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de Morais RPL, de Aguiar AWPB, da Hora Sales PH, Carvalho ADAT, Vescovi P, Meleti M, Leão JC. Is the use of Pentoxifylline and Tocopherol effective in the treatment of Osteoradionecrosis of the jaws or for the treatment of medicationosteonecrosis of the jaw? An overview. JOURNAL OF STOMATOLOGY, ORAL AND MAXILLOFACIAL SURGERY 2024; 125:101959. [PMID: 38964469 DOI: 10.1016/j.jormas.2024.101959] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/24/2024] [Accepted: 06/30/2024] [Indexed: 07/06/2024]
Abstract
PURPOSE The aim of the present study was to determine the methodological quality of systematic reviews that evaluated the effectiveness of pentoxifylline and tocopherol (PENTO) in the treatment of osteoradionecrosis of the jaw (ORNJ) and medication-related osteonecrosis of the jaw (MRONJ). METHODS Searches were performed in Databases including PubMed, Scopus, LILACS, DARE, Cochrane Library, and SIGLE through OpenGrey until March 2024, were evaluated by two independent reviewers to answer the following question: Is the use of PENTO protocol effective in the treatment of ORNJ or for the treatment of MRONJ? RESULTS A total of 256 articles were initially identified; however, following the use of appropriate inclusion and exclusion criteria, five systematic reviews were identified for detailed analysis. The final study sample comprised 588 patients: 397 patients with ORN and 197 patients with MRONJ who were treated with PENTO. The total recovery of individuals who used the PENTO protocol was 62,2 % for ORN and 100 % for MRONJ, with a follow-up period of 1 month to 10 years. The methodological quality of the studies was assessed using the AMSTAR 2 tool, in which four were of low quality and 1 moderate quality. CONCLUSION The treatment of ORN and MRONJ with pentoxifylline and tocopherol has shown good results in the studies presented, with a partial or total reduction in bone exposure. However, the low quality of the relevant reports highlights the need for primary and secondary studies with better methodological rigor to reduce bias and provide reassurance for this treatment option.
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Affiliation(s)
- Rayane Portela Lima de Morais
- Departamento de Clínica e Odontologia Preventiva, Universidade Federal de Pernambuco, Av. Prof. Moraes Rego, 1235, Recife, Brazil
| | | | | | | | - Paolo Vescovi
- Department of Medicine and Surgery, Università degli Studi di Parma, Via Gramsci 14, 43126, Parma, Italy
| | - Marco Meleti
- Department of Medicine and Surgery, Università degli Studi di Parma, Via Gramsci 14, 43126, Parma, Italy
| | - Jair Carneiro Leão
- Departamento de Clínica e Odontologia Preventiva, Universidade Federal de Pernambuco, Av. Prof. Moraes Rego, 1235, Recife, Brazil.
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Byrne H, O'Reilly S, Weadick CS, Brady P, Ríordáin RN. How we manage medication-related osteonecrosis of the jaw. Eur J Med Res 2024; 29:402. [PMID: 39095845 PMCID: PMC11297747 DOI: 10.1186/s40001-024-01912-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Accepted: 05/30/2024] [Indexed: 08/04/2024] Open
Abstract
Bone-modifying agents (BMAs) are integral to managing patients with advanced cancer. They improve quality of survival by reducing skeletal-related events, treating hypercalcaemia and chemotherapy-induced bone loss (Coleman in Clin Cancer Res 12: 6243s-6249s, 2006), (Coleman in Ann Oncol 31: 1650-1663, 2020). Two decades ago, medication-related osteonecrosis of the jaw (MRONJ) was first reported following BMA therapy (Marx in J Oral Maxillofac Surg 61: 1115-1117, 2003). The risk of MRONJ extends over a decade following BMA treatment with bisphosphonates, complicating dental care such as extractions. In addition, MRONJ has been reported following additional therapies such as antiangiogenic agents, cytotoxic agents, immunotherapy, and targeted agents. The use of BMAs in the curative and adjuvant cancer setting is increasing, consequently the implication of MRONJ is growing. Over the past 20 years, the literature has consolidated major risk factors for MRONJ, the pathophysiology and management strategies for MRONJ. Our review aims to document the development of MRONJ preventative and management strategies in cancer patients receiving a BMA. The authors advocate the incorporation of dental oncology strategies into contemporary cancer care, to optimise long-term quality of survival after cancer treatment.
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Affiliation(s)
- H Byrne
- Cork University Dental School and Hospital, University College Cork, Cork, Ireland.
| | - S O'Reilly
- Cancer Research @UCC, College of Medicine and Health, University College Cork, Cork, Ireland
- Department of Medical Oncology, Cork University Hospital, Wilton, Cork, Ireland
| | - C S Weadick
- Cancer Research @UCC, College of Medicine and Health, University College Cork, Cork, Ireland
- Department of Medical Oncology, Cork University Hospital, Wilton, Cork, Ireland
| | - P Brady
- Cork University Dental School and Hospital, University College Cork, Cork, Ireland
| | - R Ni Ríordáin
- Cork University Dental School and Hospital, University College Cork, Cork, Ireland
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Ward J, Singh A, White C, Riedel E, Lewis R, Yom SK, Halpern J, Randazzo JD, Kronstadt KL, Huryn JM, Estilo CL. Determinants of outcome in cancer patients with medication-related osteonecrosis of the jaw: A 19-year retrospective study. ORAL ONCOLOGY REPORTS 2024; 10:100488. [PMID: 38957376 PMCID: PMC11218890 DOI: 10.1016/j.oor.2024.100488] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 07/04/2024]
Affiliation(s)
- Jenna Ward
- Dental Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, 1275 York Ave, New York, NY 10065, USA
| | - Annu Singh
- Dental Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, 1275 York Ave, New York, NY 10065, USA
| | - Charlie White
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, 1275 York Ave, New York, NY 10065, USA
| | - Elyn Riedel
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, 1275 York Ave, New York, NY 10065, USA
| | - Roxanne Lewis
- Dental Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, 1275 York Ave, New York, NY 10065, USA
| | - SaeHee K. Yom
- Dental Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, 1275 York Ave, New York, NY 10065, USA
| | - Jerry Halpern
- Dental Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, 1275 York Ave, New York, NY 10065, USA
| | - Joseph D. Randazzo
- Dental Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, 1275 York Ave, New York, NY 10065, USA
| | - Kenneth L. Kronstadt
- Dental Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, 1275 York Ave, New York, NY 10065, USA
| | - Joseph M. Huryn
- Dental Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, 1275 York Ave, New York, NY 10065, USA
| | - Cherry L. Estilo
- Dental Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, 1275 York Ave, New York, NY 10065, USA
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Abdolrahmani A, Epstein JB, Samim F. Medication-related osteonecrosis of the jaw: evolving research for multimodality medical management. Support Care Cancer 2024; 32:212. [PMID: 38443685 DOI: 10.1007/s00520-024-08388-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2023] [Accepted: 02/16/2024] [Indexed: 03/07/2024]
Abstract
PURPOSE Medication-related osteonecrosis of the jaw (MRONJ) is a debilitating side effect of antiresorptive and antiangiogenic agents that can lead to progressive bone destruction in the maxillofacial region. Dental surgery, including tooth extractions, commonly trigger the onset of MRONJ. While guidelines suggest avoiding extraction when possible, complete avoidance is not always feasible, as necrosis can develop from dental and periodontal disease without dental procedures. The goal of this article is to provide an update review of current preventive and therapeutic approaches for MRONJ. METHODS A comprehensive electronic search was conducted on PubMed/MEDLINE, Embase, and Scopus databases. All English articles encompassing randomized controlled trials, systematic reviews, observational studies, and case studies were reviewed. The current medical treatments and adjuvant therapies for managing MRONJ patients were critically assessed and summarized. RESULTS Pentoxifylline and alpha tocopherol (PENT-E), teriparatide, photobiomodulation (PBM), photodynamic therapy (PDT), and the use of growth factors have shown to enhance healing in MRONJ patients. Implementing these methods alone or in conjunction with surgical treatment has been linked to reduced discomfort and improved wound healing and increased new bone formation. DISCUSSION While several adjuvant treatment modalities exhibit promising results in facilitating the healing process, current clinical practice guidelines predominantly recommend antibiotic therapy as a non-surgical approach, primarily addressing secondary infections in necrotic areas. However, this mainly addresses the potential infectious complication of MRONJ. Medical approaches including PENT-E, teriparatide, PBM, and PDT can result in successful management and should be considered prior to taking a surgical approach. Combined medical management for both preventing and managing MRONJ holds potential for achieving optimal clinical outcomes and avoiding surgical intervention, requiring further validation through larger studies and controlled trials.
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Affiliation(s)
- Ali Abdolrahmani
- Oral Medicine & Oral Pathology Clinic, Montreal General Hospital, Montreal, QC, Canada
| | - Joel B Epstein
- Department of Surgery, City of Hope National Cancer Center, Duarte, CA, USA
- Cedars-Sinai Medical Center, Samuel Oschin Comprehensive Cancer Institute, Los Angeles, CA, USA
| | - Firoozeh Samim
- Faculty of Dental Medicine and Oral Health, McGill University, Montreal, QC, Canada.
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Halpern LR, Adams DR. Treatment of Medication-Related Osteonecrosis of the Jaw: Controversies in Causality and Therapy. Dent Clin North Am 2024; 68:67-85. [PMID: 37951638 DOI: 10.1016/j.cden.2023.07.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2023]
Abstract
Medication-related osteonecrosis of the jaw (MRONJ) is a most interesting, complex and "elusive" condition seen by the oral health care provider. It is plagued by controversy and although a wealth of research has created clinical treatment databases, there is no "gold standard" algorithm to be applied in a universal fashion. The purpose of this article is to explore several controversies associated with the etiology(s), staging, treatments, and long-term resolution of MRONJ in patients who are treated by the oral health care provider. Controversies for optimizing prevention, and disease control will also be discussed from an interdisciplinary perspective.
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Affiliation(s)
- Leslie Robin Halpern
- New York Medical College/NYCHHC, Metropolitan Hospital, 100 Woods Road, Valhalla, NY 10593, USA.
| | - David Russell Adams
- Section head, Oral and Maxillofacial Surgery, University of Utah, School of Dentistry, 530 South Wakara Way, Salt Lake City, UT 84108, USA
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Correia-Neto IJ, Colafemina ACE, Faustino ISP, Santos-Silva AR, Vargas PA, Lopes MA. Medication-related osteonecrosis in torus palatinus: Report of a case and literature review. SPECIAL CARE IN DENTISTRY 2024; 44:136-142. [PMID: 37055926 DOI: 10.1111/scd.12862] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Revised: 03/27/2023] [Accepted: 04/02/2023] [Indexed: 04/15/2023]
Abstract
BACKGROUND Medication-related osteonecrosis of the jaw bones have been frequently reported. However, its occurrence in torus palatinus is very rare with only 10 cases published in the English-language literature. CASE REPORT We describe an additional case in a 79-year-old woman, who was referred for evaluation of a painful swelling with areas of suppuration on the hard palate. CONCLUSION Conservative treatment was performed and after spontaneous sequestrectomy, total healing was achieved.
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Affiliation(s)
- Ivan José Correia-Neto
- Department of Oral Diagnosis, Piracicaba Dental School, University of Campinas (UNICAMP), Piracicaba, São Paulo, Brazil
| | | | | | - Alan Roger Santos-Silva
- Department of Oral Diagnosis, Piracicaba Dental School, University of Campinas (UNICAMP), Piracicaba, São Paulo, Brazil
| | - Pablo Agustin Vargas
- Department of Oral Diagnosis, Piracicaba Dental School, University of Campinas (UNICAMP), Piracicaba, São Paulo, Brazil
| | - Márcio Ajudarte Lopes
- Department of Oral Diagnosis, Piracicaba Dental School, University of Campinas (UNICAMP), Piracicaba, São Paulo, Brazil
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Epstein JB, Arany PR, Yost SE, Yuan Y. Medication-Related Osteonecrosis of the Jaw: Successful Medical Management of Complex Maxillary Alveolus with Sinus Involvement. Case Rep Oncol 2023; 16:397-413. [PMID: 37384201 PMCID: PMC10294216 DOI: 10.1159/000529502] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Accepted: 01/31/2023] [Indexed: 06/30/2023] Open
Abstract
Medication-related osteonecrosis of the jaw (MRONJ) in cancer patients presents a considerable challenge in management. Current management is primarily based on interventions in a limited number of cases assessing a single approach. Medical management typically is reported to include antimicrobial therapy with or without surgery. Advances in the understanding of pathogenesis have led to the investigation of additional medical interventions for early-stage necrosis. We present 3 patients with advanced-stage MRONJ of the maxilla using combined medical modalities including antimicrobial therapy, photobiomodulation therapy, pentoxifylline, vitamin E, and synthetic parathyroid hormone. All patients had a good outcome and avoided surgical intervention. We also report biological and functional imaging that may assist in more effective diagnosis and management of MRONJ. The 3 patients reported suggest that combined medical management should be considered in all cases of MRONJ (including stage III) prior to determining if surgical intervention is required. Functional imaging with a technetium bone scan or positron emission tomography scan correlated with diagnosis and confirmed resolution in patients. We present 3 challenging MRONJ patients that were effectively managed with a combined medical and nonsurgical therapy that demonstrated good clinical outcomes avoiding surgical interventions.
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Affiliation(s)
- Joel B. Epstein
- Department of Surgery, City of Hope Comprehensive Cancer Center, Duarte, CA, USA
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Praveen R. Arany
- Department of Oral Biology, Surgery, and Biomedical Engineering, University at Buffalo, Buffalo, NY, USA
| | - Susan E. Yost
- Department of Medical Oncology and Therapeutics Research, City of Hope Comprehensive Cancer Center, Duarte, CA, USA
| | - Yuan Yuan
- Division of Medical Oncology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
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Medication-Related Osteonecrosis of the Mandible Treated with Marginal Resection: A Case Report. SURGERIES 2022. [DOI: 10.3390/surgeries3020016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
The aim of this report is to present a successful combined surgical and pharmaceutical treatment in the highest stage of medicine-related osteonecrosis of the jaw (MRONJ). A 70-year-old man treated for metastatic prostate cancer concomitant with hypertension and diabetes presented due to the exposure of the jawbone. Initial imaging studies suggested MRONJ, and the biopsy did not confirm bone metastasis in the oral cavity. Marginal resection of the mandible was performed after the administration of antibiotics and anticoagulants. There was no recurrence of mandibular necrosis during the 3-year follow-up. MRONJ can develop covertly, with scanty clinical symptoms, and can be easily overlooked. Radical combined treatment may, in some cases, prevent further progression of the disease, which was successful in this case.
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Delfrate G, Mroczek T, Mecca LEA, Andreis JD, Fernandes D, Lipinski LC, Claudino M, Franco GCN. Effect of pentoxifylline and α-tocopherol on medication-related osteonecrosis of the jaw in rats: Before and after dental extraction. Arch Oral Biol 2022; 137:105397. [DOI: 10.1016/j.archoralbio.2022.105397] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2021] [Revised: 02/25/2022] [Accepted: 03/06/2022] [Indexed: 11/16/2022]
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10
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Seo MH, Kim DW, Kim YS, Lee SK. Pentoxifylline-induced protein expression change in RAW 264.7 cells as determined by immunoprecipitation-based high performance liquid chromatography. PLoS One 2022; 17:e0261797. [PMID: 35333871 PMCID: PMC8956197 DOI: 10.1371/journal.pone.0261797] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Accepted: 03/07/2022] [Indexed: 11/19/2022] Open
Abstract
Although pentoxifylline (PTX) was identified as a competitive non-selective phosphodiesterase inhibitor, its pharmacological effect has not been clearly elucidated. The present study explored the effect of low dose 10 μg/mL PTX (therapeutic dose) compared to high dose 300 μg/mL PTX (experimental dose) in RAW 264.7 cells through immunoprecipitation-based high performance liquid chromatography (IP-HPLC), immunohistochemistry, and western blot. 10 μg/mL PTX increased the expression of proliferation (Ki-67, PCNA, cyclin D2, cdc25A), epigenetic modification (KDM4D, PCAF, HMGB1), protein translation (DOHH, DHPS, eIF5A1), RAS signaling (KRAS, pAKT1/2/3, PI3K), NFkB signaling (NFkB, GADD45, p38), protection (HSP70, SOD1, GSTO1/2), survival (pAKT1/2/3, SP1, sirtuin 6), neuromuscular differentiation (NSEγ, myosin-1a, desmin), osteoblastic differentiation (BMP2, RUNX2, osterix), acute inflammation (TNFα, IL-1, CXCR4), innate immunity (β-defensin 1, lactoferrin, TLR-3, -4), cell-mediated immunity (CD4, CD8, CD80), while decreased the expression of ER stress (eIF2α, eIF2AK3, ATF6α), fibrosis (FGF2, CTGF, collagen 3A1), and chronic inflammation (CD68, MMP-2, -3, COX2) versus the untreated controls. The activation of proliferation by 10 μg/mL PTX was also supported by the increase of cMyc-MAX heterodimer and β-catenin-TCF1 complex in double IP-HPLC. 10 μg/mL PTX enhanced FAS-mediated apoptosis but diminished p53-mediated apoptosis, and downregulated many angiogenesis proteins (angiogenin, VEGF-A, and FLT4), but upregulated HIF1α, VEGFR2, and CMG2 reactively. Whereas, 300 μg/mL PTX consistently decreased proliferation, epigenetic modification, RAS and NFkB signaling, neuromuscular and osteoblastic differentiation, but increased apoptosis, ER stress, and fibrosis compared to 10 μg/mL PTX. These data suggest PTX has different biological effect on RWA 264.7 cells depending on the concentration of 10 μg/mL and 300 μg/mL PTX. The low dose 10 μg/mL PTX enhanced RAS/NFkB signaling, proliferation, differentiation, and inflammation, particularly, it stimulated neuromuscular and osteoblastic differentiation, innate immunity, and cell-mediated immunity, but attenuated ER stress, fibrosis, angiogenesis, and chronic inflammation, while the high dose 300 μg/mL PTX was found to alleviate the 10 μg/mL PTX-induced biological effects, resulted in the suppression of RAS/NFkB signaling, proliferation, neuromuscular and osteoblastic differentiation, and inflammation.
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Affiliation(s)
- Mi Hyun Seo
- Department of Oral and Maxillofacial Surgery, College of Dentistry, Seoul National University, Seoul, South Korea
| | - Dae Won Kim
- Department of Oral Biochemistry, College of Dentistry, Gangneung-Wonju National University, Gangneung, Korea
| | - Yeon Sook Kim
- Department of Dental Hygiene, College of Health & Medical Sciences, Cheongju University, Cheongju, South Korea
| | - Suk Keun Lee
- Department of Oral Pathology, College of Dentistry, Gangneung-Wonju National University, Gangneung, South Korea
- Institute of Hydrogen Magnetic Reaction Gene Regulation, Dae Jeon, South Korea
- * E-mail:
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Niloy I, Burkes J. The role of endotracheal tube in medication-related osteonecrosis of the jaw - A case report. Ann Maxillofac Surg 2022; 12:99-101. [PMID: 36199473 PMCID: PMC9527827 DOI: 10.4103/ams.ams_300_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2021] [Accepted: 04/22/2022] [Indexed: 11/04/2022] Open
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Abstract
Abstract
Current therapies for Head and Neck cancer treatment are extremely advanced. Though, they cause oral complications which have deleterious effects on basic life functions, affect oral and overall health, may lead to significant morbidity and treatment discontinuation and have an impact on survivorship and quality of life. As new therapies are introduced, a new spectrum of oral complications is rising, compromising the mucosal integrity and the salivary function, that may not be recognized, reported and treated properly. Oral complications, often permanent and extremely painful, may include mucositis, xerostomia, dysgeusia, infections, trismus and fibrosis, risk of dental disease and necrosis of the jaw, neurosensory disorders and when targeted therapies and immunotherapy are involved, aphthoid and lichenoid lesions can also be reported. Increased awareness is required for the prevention and management of these complications, which can be best provided by a multidisciplinary team.
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Cilostazol and Tocopherol in the Management of Medication-Related Osteonecrosis of the Jaw: New Insights From a Case Report. J Oral Maxillofac Surg 2021; 79:2499-2506. [PMID: 34339622 DOI: 10.1016/j.joms.2021.06.036] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Revised: 06/30/2021] [Accepted: 06/30/2021] [Indexed: 11/20/2022]
Abstract
Several treatment protocols for medication-related osteonecrosis of the jaw (MRONJ) have been published. Despite the efficacy of surgical therapy of approximately 90% as primary therapy, the role of other agents, such as drug administration, should not be underestimated. Based on previous experience with osteoradionecrosis, the association of pentoxifylline and tocopherol has shown encouraging results in MRONJ patients. Despite the need for long-term use of the combination, compliance has been good. However, studies in breast cancer patients revealed that pentoxifylline can require dose reduction or discontinuation due to nausea and epigastric pain. Cilostazol has been used as a substitute for pentoxifylline in peripheral artery disease. Herein we report a case in which cilostazol replaced pentoxifylline at a dose of 100mg, 2 times/day with tocopherol 500UI, 2 times/day, in a 77-year-old female patient that could not tolerate pentoxifylline for the management of MRONJ. After an uneventful 22 months of follow-up, a cone-beam computed tomography revealed complete bone formation and no signs of recurrence. Cilostazol may be a useful and safe alternative to pentoxifylline as part of MRONJ management protocols.
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Late radiation effects in survivors of head and neck cancer: State of the science. Crit Rev Oncol Hematol 2021; 162:103335. [PMID: 33992801 DOI: 10.1016/j.critrevonc.2021.103335] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Revised: 04/03/2021] [Accepted: 04/06/2021] [Indexed: 01/15/2023] Open
Abstract
Head and neck squamous cell carcinoma is one of the most common neoplasms. Radiotherapy (RT) plays an essential role in the management of such cases. Despite advances in the technique, hyposalivation, xerostomia, dysphagia, trismus, radiation caries, and osteoradionecrosis remain significant late complications of RT. The aim of this narrative review was to summarize and update the main findings related to late side effects of radiotherapy in survivors of head and neck cancer (HNC). Such effects limit the ability to speak, ingest food and medications, and breathe and also exert a negative impact on social well-being and quality of life. This review highlights research in the field for both researchers and clinicians, assisting in the prevention and management of these adverse conditions. The findings can contribute to improving preventive management and multidisciplinary interventions for HNC patients.
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Kaibuchi N, Hoshi K, Yamazaki A, Miyamoto-Sangu N, Akagi Y, Okamoto T. The progress of medication-related osteonecrosis of the jaw with conservative initial treatment: A 12-year retrospective study of 129 patients. Bone Rep 2021; 14:101072. [PMID: 33997149 PMCID: PMC8100074 DOI: 10.1016/j.bonr.2021.101072] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Revised: 04/13/2021] [Accepted: 04/16/2021] [Indexed: 11/30/2022] Open
Abstract
This retrospective study aimed to examine the course and prognosis of medication-related osteonecrosis of the jaw (MRONJ) initially treated conservatively and the effects of various factors affecting treatment outcomes. We evaluated 129 patients with MRONJ between January 2008 and December 2018 at a university hospital. The factors examined included sex, age, stage of MRONJ (1-3), type of bone modifying agents (bisphosphonate or denosumab), primary disease (osteoporosis or malignant tumor), medical history (diabetes and rheumatoid arthritis), use of corticosteroids, the trigger of MRONJ (teeth extraction or others), and separation of sequestrum, using logistic regression analysis. Patients with MRONJ were treated conservatively as the initial treatment in accordance with the position paper of the American Association of Oral and Maxillofacial Surgeons. Of the 129 patients, 59 (45.7%) were cured, and the condition of 70 (54.3%) remained unchanged or worsened. The overall cure rates at 12, 36, and 60 months were 25.8%, 50.8%, and 72.4% respectively. The cure rate of stage 1 was lower than that of stages 2 and 3 at 80 months. In multivariate analysis, it was found that 37 (64.9%) of 57 patients with osteoporosis as a primary disease were cured (odds ratio [OR], 7.7; 95% confidence interval [CI], 2.4-24.4). In addition, 40 (69.0%) of 58 patients with separation of sequestrum were cured (OR, 8.9; 95% CI, 3.4-23.5). The cure rate was significantly higher in patients with osteoporosis than in those with cancer when the treatment outcomes of primary disease were compared using the Kaplan-Meier method (p < 0.01). It was also significantly higher in patients who had separation of sequestrum than in those who did not (p < 0.05). Our results suggest that primary disease and separation of sequestrum were associated with favorable outcomes in patients with MRONJ initially treated conservatively. MRONJ had a poor prognosis with conventional treatment carried according to the stage of the disease. This was especially prominent when conservative treatment was employed for mild cases.
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Affiliation(s)
- Nobuyuki Kaibuchi
- Department of Oral and Maxillofacial Surgery, Tokyo Women's Medical University School of Medicine, 8-1 Kawada-cho, Shinjuku-ku, Tokyo 162-8666, Japan.,Institute of Advanced Biomedical Engineering and Science, Tokyo Women's Medical University (TWIns), 8-1 Kawada-cho, Shinjuku-ku, Tokyo 162-8666, Japan
| | - Keika Hoshi
- National Institute of Public Health, Center for Public Health Informatics, 2-3-6 Minami, Wako, Saitama 351-0197, Japan.,Department of Hygiene, Kitasato University School of Medicine, 1-15-1 Kitasato, Minami-ku, Sagamihara, Kanagawa 252-0373, Japan
| | - Ayame Yamazaki
- Department of Oral and Maxillofacial Surgery, Tokyo Women's Medical University School of Medicine, 8-1 Kawada-cho, Shinjuku-ku, Tokyo 162-8666, Japan
| | - Noriko Miyamoto-Sangu
- Department of Oral and Maxillofacial Surgery, Tokyo Women's Medical University School of Medicine, 8-1 Kawada-cho, Shinjuku-ku, Tokyo 162-8666, Japan
| | - Yuichi Akagi
- Department of Oral and Maxillofacial Surgery, Tokyo Women's Medical University School of Medicine, 8-1 Kawada-cho, Shinjuku-ku, Tokyo 162-8666, Japan
| | - Toshihiro Okamoto
- Department of Oral and Maxillofacial Surgery, Tokyo Women's Medical University School of Medicine, 8-1 Kawada-cho, Shinjuku-ku, Tokyo 162-8666, Japan
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Treatment of Stage 2 Medication-Induced Osteonecrosis of the Jaw: A Case Series. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18031018. [PMID: 33498884 PMCID: PMC7908594 DOI: 10.3390/ijerph18031018] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Revised: 01/19/2021] [Accepted: 01/21/2021] [Indexed: 12/29/2022]
Abstract
Medication-induced jaw osteonecrosis (MRONJ) is a rare and serious disease with a negative impact on patients’ quality of life, whose exact cause remains unclear and which may have a multifactorial origin. Although there are different therapeutic protocols, there is still no consensus. This case series evaluated three patients diagnosed with staged 2 MRONJ treated at the University of Murcia dental clinic according to the protocols described by the Spanish Society of Oral and Maxillofacial Surgery and the American Association of Oral and Maxillofacial Surgeons. Within 12 months of the application of therapeutic protocols, the lesions were completely healed in all cases. Radiography showed slow but progressive healing with normal bone structure. Conservative treatment with antibiotics, chlorhexidine rinses and minimally invasive surgical intervention with necrotic bone resection is effective in treating stage 2 of MRONJ. In cases of refractory osteonecrosis, the application of platelet and leukocyte-rich fibrin (PRF-L) in the surgical approach improves the outcome in soft tissue healing and bone regeneration but further research is needed to confirm its effectiveness.
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Kün-Darbois JD, Fauvel F. Medication-related osteonecrosis and osteoradionecrosis of the jaws: Update and current management. Morphologie 2020; 105:170-187. [PMID: 33281055 DOI: 10.1016/j.morpho.2020.11.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Revised: 11/12/2020] [Accepted: 11/14/2020] [Indexed: 12/19/2022]
Abstract
Medication related osteonecrosis of the jaws (MRONJ) and osteoradionecrosis of the jaws (ORNJ) are two different diseases of quite similar appearance. MRONJ is mainly due to antiresorptive or antiangiogenic drug therapy and ORNJ to radiotherapy. The present work aimed at presenting and comparing the current knowledge on MRONJ and ORNJ. They both present as an exposure of necrotic bone and differ in some clinical or radiological characteristics, clinical course and mostly in treatment. They share similar risk factors. A tooth extraction is more frequently found as a triggering factor in MRONJ. The frequency of a maxillary localisation seems higher for MRONJ. On computed tomographic images, a periosteal reaction seems characteristic of MRONJ. More frequent pathological fractures seem to occur in ORNJ. It is mandatory, for ORNJ diagnosis, to exclude a residual or recurrent tumour using histological examination. Both MRONJ and ORNJ are challenging to treat and cannot be managed similarly. For both, it would still be worth to optimise awareness within the medical community, patients' oral hygiene and dental cares to improve their prevention and make their incidences decrease. Conservative therapy is more frequently achieved for MRONJ than ORNJ and surgical resection is more often performed for ORNJ. For both diseases, the last treatment possible in refractory cases is a surgical extensive resection with free flap reconstruction. A MRONJ classification is widely used today, whereas no consensus exists to date for ORNJ classification. We propose a classification that could play this role.
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Affiliation(s)
- J-D Kün-Darbois
- Department of oral and maxillofacial surgery, CHU d'Angers, 4, rue Larrey, 49933 Angers cedex, France; Groupe études remodelage osseux et bioMatériaux, GEROM, SFR 4208, UNIV Angers, IRIS-IBS institut de biologie en Santé, CHU d'Angers, 4, rue Larrey, 49933 Angers cedex, France.
| | - F Fauvel
- Department of oral and maxillofacial surgery, CHU de Nantes, 1, place Alexis-Ricordeau, 44093 Nantes cedex 1, France; Department of oral and maxillofacial surgery, CH de Saint-Nazaire, 11, boulevard Georges-Charpak, 44606 Saint-Nazaire cedex, France
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Gupta L, Dholam K, Janghel Y, Gurav SV. Osteonecrosis of the jaw associated with imatinib therapy in myeloproliferative neoplasm: a rare case report. Oral Surg Oral Med Oral Pathol Oral Radiol 2020; 131:e157-e162. [PMID: 33187944 DOI: 10.1016/j.oooo.2020.10.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Revised: 10/06/2020] [Accepted: 10/08/2020] [Indexed: 11/26/2022]
Abstract
Medication-related osteonecrosis of the jaw (MRONJ) is a relatively infrequent but very well-known adverse effect of bisphosphonates. This rare complication of bisphosphonates is rarest with the use of certain drugs. Tyrosine kinase inhibitors (TKIs), particularly used in renal cell carcinoma or gastrointestinal tumors as a chemotherapeutic agent, can precipitate this particular medical condition of bone when it is associated with either radiation or bisphosphonates, though, monodrug therapy with TKIs rarely causes MRONJ. This article describes a rare case of necrosis of the jawbone in a patient with a myeloproliferative neoplasm who was receiving the TKI imatinib and had no history of bisphosphonate or radiation therapy to head and neck region.
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Affiliation(s)
- Lokendra Gupta
- Assistant Professor, Department of Dental and Prosthetic Surgery, Mahamana Pandit Madan Mohan Malaviya Cancer Center, Unit of Tata Memorial Center, Varanasi, Uttar Pradesh, India
| | - Kanchan Dholam
- Professor, Department of Dental and Prosthetic Surgery, Tata Memorial Hospital, Tata Memorial Center (TMC), Homi Bhabha National Institute (HBNI) Mumbai, Maharashtra, India
| | - Yogesh Janghel
- Former Assistant Professor, Department of Dental and Prosthetic Surgery, Homi Bhabha Cancer Hospital and Research Center, Unit of Tata Memorial Center, Vizag, Andhra Pradesh, India
| | - Sandeep V Gurav
- Professor, Department of Dental and Prosthetic Surgery, Tata Memorial Hospital, Tata Memorial Center (TMC), Homi Bhabha National Institute (HBNI) Mumbai, Maharashtra, India.
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Risk factors for bisphosphonate-associated osteonecrosis of the jaw in the prospective randomized trial of adjuvant bisphosphonates for early-stage breast cancer (SWOG 0307). Support Care Cancer 2020; 29:2509-2517. [PMID: 32929540 DOI: 10.1007/s00520-020-05748-8] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Accepted: 09/04/2020] [Indexed: 12/11/2022]
Abstract
PURPOSE Bisphosphonates reduce bone metastases in postmenopausal women with early-stage breast cancer but carry the risk of bisphosphonate-related osteonecrosis of the jaw (BRONJ). We describe risk factors for BRONJ and compare BRONJ provoked by infection or trauma with spontaneous lesions, which carry a better prognosis. METHODS SWOG 0307 randomized women with stage I-III breast cancer to receive zoledronic acid (ZA), clodronate (CL), or ibandronate (IB) for 3 years, implemented BRONJ prevention guidelines, and collected information about dental health and development of BRONJ. All statistical tests were two-sided. RESULTS Of 6018 women, 48 developed BRONJ. Infection was present in 21 (43.8%). Median time to BRONJ was 2.1 years for ZA, 2.0 years for IB, and 3.4 years for clodronate (p = 0.04). BRONJ was associated with bisphosphonate type (28/2231 (1.26%) for ZA, 8/2235 (0.36%) for CL, 12/1552 (0.77%) for IB), dental calculus (OR 2.03), gingivitis (OR 2.11), moderate/severe periodontal disease (OR 2.87), and periodontitis > 4 mm (OR 2.20) (p < 0.05). Of 57 lesions, BRONJ occurred spontaneously in 20 (35.1%) and was provoked by dental extraction in 20 (35.1%), periodontal disease in 14 (24.6%), denture trauma in 6 (10.5%), and dental surgery in 2 (3.5%). Spontaneous BRONJ occurred more frequently at the mylohyoid ridge. There were no differences in dental disease, infection, or bisphosphonate type between spontaneous and provoked BRONJ. CONCLUSION ZA and worse dental health were associated with increased incidence of BRONJ, with a trend toward additive risk when combined. BRONJ incidence was lower than in similar studies, with prevention strategies likely linked to this. CLINICAL TRIAL NUMBER NCT00127205 REGISTRATION DATE: July 2005.
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Moraschini V, Calasans-Maia MD, Louro RS, Arantes EBR, Calasans-Maia JDA. Weak evidence for the management of medication-related osteonecrosis of the jaw: An overview of systematic reviews and meta-analyses. J Oral Pathol Med 2020; 50:10-21. [PMID: 32589782 DOI: 10.1111/jop.13083] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Revised: 06/02/2020] [Accepted: 06/09/2020] [Indexed: 01/08/2023]
Abstract
BACKGROUND Although several therapies are proposed for medication-related osteonecrosis of the jaw (MRONJ), to date there is no consensus or treatment protocol for MRONJ. This overview aims to summarize the available evidence on the management and outcomes of MRONJ. METHODS An electronic search without language or date restrictions occurred in five databases and gray literature for articles published until March 2020. This overview was performed according to the PICO format. The eligibility criteria comprised systematic reviews (RS) with or without meta-analyses that analyzed treatments outcomes for MRONJ. The methodological quality of each SR was evaluated using AMSTAR 2. RESULTS Fifteen studies published between 2014 and 2020 were included in this overview. The summary of the evidence showed that conservative treatment and low level laser therapy can yield favorable results for early stages of MRONJ whereas surgical treatment seems to be better for advanced stages. However, qualitative assessment of the SRs highlighted a global low level of quality. CONCLUSIONS There is weak evidence to support treatment protocols for MRONJ. Because of the low quality of the SRs, highlighted by this overview, no insightful therapeutic recommendations can be issued for any intervention for MRONJ.
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Affiliation(s)
- Vittorio Moraschini
- Dental Research Division, Department of Periodontology, School of Dentistry, Veiga de Almeida University, Rio de Janeiro, Brazil
| | | | - Rafael Seabra Louro
- Department of Oral Surgery, School of Dentistry, Fluminense Federal University, Niterói, Brazil
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