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Miles E, Arya R, Sproat C, Patel V. Clinical status of established MRONJ in oncology patients continuing bone-modifying agents. Br Dent J 2024; 236:683-687. [PMID: 38730156 DOI: 10.1038/s41415-024-7340-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2023] [Revised: 01/10/2024] [Accepted: 01/19/2024] [Indexed: 05/12/2024]
Abstract
The continuation of bone-modifying agents (BMAs) in patients with established medication-related osteonecrosis of the jaw (MRONJ) is a common concern among dentists and oncologists. There is little evidence supporting or refuting the continued use of BMAs or drug holidays and their impact on established MRONJ. This paper evaluates the outcome of continued BMAs use on the patient's MRONJ status. A retrospective review of 29 oncology patients undergoing active cancer care for either metastatic disease or multiple myeloma was conducted. Data on demographics, oncological status, BMA history and MRONJ status were collected. In total, 90% of patients were judged to have healed or stable MRONJ while continuing BMAs. Most patients (69%) continued the same BMA regime (three- or four-weekly) that they were on before developing MRONJ. The average number of BMAs doses received after an MRONJ diagnosis was 12 (range 1-48). Three patients (10.3%) were found to have MRONJ progression, with two patients developing new sites of necrosis. This real-world dataset suggests that the majority of MRONJ cases remain stable and will not worsen with the continuation of BMAs.
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Affiliation(s)
- Elizabeth Miles
- Specialist Registrar in Oral Surgery, Floor 23, Oral Surgery Department, Guy´s and St Thomas´ Hospital, London, SE1 9RT, UK
| | - Richa Arya
- Speciality Dentist in Oral Surgery, Floor 23, Oral Surgery Department, Guy´s and St Thomas´ Hospital, London, SE1 9RT, UK
| | - Christopher Sproat
- Consultant in Oral Surgery, Floor 23, Oral Surgery Department, Guy´s and St Thomas´ Hospital, London, SE1 9RT, UK
| | - Vinod Patel
- Consultant in Oral Surgery, Floor 23, Oral Surgery Department, Guy´s and St Thomas´ Hospital, London, SE1 9RT, UK.
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2
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Abukhder M, Nasri Elmi S, Van Der Lith S, Hawesa N, Abukhder D, Abid H, Liu L. Bisphosphonate therapy in the management of diffuse sclerosing osteomyelitis of the mandible: a systematic review and narrative synthesis. Ann Med Surg (Lond) 2024; 86:950-957. [PMID: 38333319 PMCID: PMC10849439 DOI: 10.1097/ms9.0000000000001561] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Accepted: 11/18/2023] [Indexed: 02/10/2024] Open
Abstract
Background Diffuse sclerosing osteomyelitis (DSO) affecting the mandible is an uncommon condition characterised by recurrent pain and functional disturbances. Traditional treatments involving antibiotics, steroids, and analgesics have generally yielded unsatisfactory results. Numerous articles have proposed the utilisation of bisphosphonate therapy as an alternative approach to achieve sustained symptom relief. This study aims to consolidate the available evidence on the effectiveness of bisphosphonate therapy in managing DSO. Methods A systematic review protocol was registered with PROSPERO and reported in accordance with the Preferred Reporting for Items for Systematic Reviews and Meta-Analyses. Comprehensive electronic search strategies were devised, and studies were screened based on predefined inclusion and exclusion criteria. Results Ten articles met the eligibility criteria, encompassing a total of 135 patients diagnosed with DSO who received bisphosphonate treatment. All included studies consistently reported a reduction in pain levels and swelling, along with a decrease in the cumulative use of analgesics. The majority of patients reported long-lasting symptom improvement with bisphosphonate therapy. Notably, four studies documented improvements in maximal mouth opening, with one study reporting a mean increase of 9.6mm. Furthermore, six studies observed improvements in panoramic radiographs and cone beam computed tomography scans, with one publication describing two patients exhibiting near-normal bone architecture. Importantly, all studies reported the absence of long-term complications. Conclusions Bisphosphonate therapy emerges as a promising treatment modality for DSO, exhibiting efficacy in symptom alleviation and radiological enhancement while conferring lasting benefits. Nevertheless, further prospective studies are warranted to refine treatment protocols and substantiate these findings.
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Affiliation(s)
| | | | | | | | | | - Husnain Abid
- Sandwell General Hospital, Lyndon, West Bromwich, West Midlands, B71 4HJ, UK
| | - Linda Liu
- Northwick Park Hospita, Harrow HA1 3UJ
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3
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DuVal M, Alkhraisat MH. Adjunctive Plasma Rich in Growth Factors in the Treatment of Osteomyelitis and Large Odontogenic Cysts Prior to Successful Implant Rehabilitation: Case Report. Dent J (Basel) 2023; 11:184. [PMID: 37623280 PMCID: PMC10453440 DOI: 10.3390/dj11080184] [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: 06/15/2023] [Revised: 07/06/2023] [Accepted: 07/25/2023] [Indexed: 08/26/2023] Open
Abstract
Osteomyelitis of the jaws presents a clinical challenge to conventional treatment, often requiring multiple surgical interventions resulting in significant deformity and presenting significant problems to satisfactory rehabilitation. While benign odontogenic cysts, such as the radicular cyst, are generally predictably treated, they can cause significant localized bone destruction and thus can present significant problems in satisfactory rehabilitation. In this case report, patients were treated combining conventionally appropriate surgical debridement and oral antibiotics with adjunctive plasma rich in growth factors (PRGF). Patients showed a complete soft tissue and osseous regeneration to their pre-pathologic state, with successful implant rehabilitation. PRGF appears to be highly successful in minimizing or eliminating osseous deformities normally associated with conventional treatment of osteomyelitis of the jaw and treatment of large odontogenic cysts. Future trials must be performed to confirm these results in comparison to controls using conventional treatment alone.
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Affiliation(s)
- Marc DuVal
- Department of Dentistry, McGill University, Montreal, QC H3A 0C7, Canada
- Montreal Jewish General Hospital, Department of Dentistry and Oral and Oral and Maxillofacial Surgery, Montreal, QC H3T 1E2, Canada
- Santa Cabrini Hospital, Department of Surgery, Division of Plastics, Montreal, QC H1T 1P7, Canada
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Leerling AT, Dekkers OM, Appelman-Dijkstra NM, Winter EM. Clinical and therapeutic diversity in adult chronic nonbacterial osteomyelitis (CNO) of the sternocostoclavicular region: a meta-analysis. Rheumatology (Oxford) 2023; 62:512-522. [PMID: 35961032 PMCID: PMC9891421 DOI: 10.1093/rheumatology/keac443] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Revised: 07/14/2022] [Accepted: 07/22/2022] [Indexed: 02/04/2023] Open
Abstract
OBJECTIVES Chronic nonbacterial osteomyelitis (CNO) is a rare inflammatory bone disease. The distinct CNO subtype that affects the anterior chest wall is descriptively named sternocostoclavicular hyperostosis (SCCH) and mainly occurs in adults. Literature on CNO/SCCH is scattered and lacks diagnostic and therapeutic consensus. METHODS Systematic review and meta-analysis aiming to characterize clinical presentation and therapeutic modalities applied in adult CNO/SCCH patients. Untransformed numerical data and double-arcsine transformed proportional data were pooled in a random effects model in R-4.0.5; proportions were reported with 95% CI. RESULTS Forty studies were included, containing data on 2030 and 642 patients for aim 1 and 2, respectively. A female predisposition (67%, 95% CI 60, 73) and major diagnostic delay (5 years 95% CI 3, 7) were noted. Clinical presentation included chest pain (89%, 95% CI 79, 96) and swelling (79%, 95% CI 62, 91). Patients suffered from pustulosis palmoplantaris (53%, 95% CI 37, 68), arthritis (24%, 95% CI 11, 39) and acne (8%, 95% CI 4, 13). Inflammatory markers were inconsistently elevated. Autoantibody and HLA-B27 prevalence was normal, and histopathology unspecific. Increased isotope uptake (99%, 95% CI 96, 100) was a consistent imaging finding. Among manifold treatments, pamidronate and biologicals yielded good response in 83%, 95% CI 60, 98 and 56%, 95% CI 26, 85, respectively. CONCLUSION CNO/SCCH literature proves heterogeneous regarding diagnostics and treatment. Timely diagnosis is challenging and mainly follows from increased isotope uptake on nuclear examination. Biopsies, autoantibodies and HLA status are non-contributory, and biochemical inflammation only variably detected. Based on reported data, bisphosphonates and biologicals seem reasonably effective, but due to limitations in design and heterogeneity between studies the precise magnitude of their effect is uncertain. Fundamentally, international consensus seems imperative to advance clinical care for CNO/SCCH.
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Affiliation(s)
- Anne T Leerling
- Department of Internal Medicine, Division of Endocrinology.,Center for Bone Quality, Leiden University Medical Center, Leiden, The Netherlands
| | - Olaf M Dekkers
- Department of Internal Medicine, Division of Endocrinology
| | - Natasha M Appelman-Dijkstra
- Department of Internal Medicine, Division of Endocrinology.,Center for Bone Quality, Leiden University Medical Center, Leiden, The Netherlands
| | - Elizabeth M Winter
- Department of Internal Medicine, Division of Endocrinology.,Center for Bone Quality, Leiden University Medical Center, Leiden, The Netherlands
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5
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Hua H, Wang X, Guo J, Zhang L, Guo Z, Chen J. A comparison of the vancomycin calcium sulfate implantation versus fenestration decompression for the treatment of sclerosing osteomyelitis. BMC Musculoskelet Disord 2021; 22:993. [PMID: 34844579 PMCID: PMC8630894 DOI: 10.1186/s12891-021-04881-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Accepted: 11/16/2021] [Indexed: 11/10/2022] Open
Abstract
OBJECTIVE To compare the clinical efficacy of vancomycin calcium sulfate implantation and fenestration decompression in the treatment of sclerosing osteomyelitis. METHOD A retrospective analysis for 46 cases of sclerosing osteomyelitis were admitted to our department between June 2010 to June 2020. Twenty-one patients were treated with fenestration decompression, twenty-five patients were treated with vancomycin calcium sulfate implantation. The postoperative hospital stay, days of drainage tube placement, visual analogue scale scores, C-reactive protein and erythrocyte sedimentation rate were compared between the two groups. RESULTS The visual analogue scale scores of both groups were significantly lower than before treatment (p < 0.05), but the difference between them was not statistically significant. Patients treated by vancomycin calcium sulfate implantation had shorter postoperative hospital stay and days of drainage tube placement compared to those treated by fenestration decompression (p < 0.05). C-reactive protein and erythrocyte sedimentation rate in both groups were significantly lower than before treatment, but the improvement effect of vancomycin calcium sulfate implantation was better (p < 0.05). CONCLUSION Both treatment methods can relieve pain effectively. Compared with fenestration decompression, vancomycin calcium sulfate implantation can shorten the treatment time effectively, control the infection better.
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Affiliation(s)
- Haotian Hua
- Henan University of Traditional Chinese Medicine, Zhengzhou, China
| | - Xinwei Wang
- Research and Treatment Center of Bone and Joint Infections, Luoyang Orthopedic Hospital of Henan Province, Orthopedics Hospital of Henan Province, Luoyang, China.
| | - Jiangang Guo
- Research and Treatment Center of Bone and Joint Infections, Luoyang Orthopedic Hospital of Henan Province, Orthopedics Hospital of Henan Province, Luoyang, China
| | - Lei Zhang
- Research and Treatment Center of Bone and Joint Infections, Luoyang Orthopedic Hospital of Henan Province, Orthopedics Hospital of Henan Province, Luoyang, China
| | - Zairan Guo
- Research and Treatment Center of Bone and Joint Infections, Luoyang Orthopedic Hospital of Henan Province, Orthopedics Hospital of Henan Province, Luoyang, China
| | - Jiangfei Chen
- Research and Treatment Center of Bone and Joint Infections, Luoyang Orthopedic Hospital of Henan Province, Orthopedics Hospital of Henan Province, Luoyang, China
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Robertsson C, Sävendahl L, Cardemil C. Primary chronic osteomyelitis of the jaw: Rapid improvement after hormonal suppression in a girl with precocious puberty. Bone Rep 2021; 14:101089. [PMID: 34026952 PMCID: PMC8131392 DOI: 10.1016/j.bonr.2021.101089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Revised: 04/09/2021] [Accepted: 05/01/2021] [Indexed: 11/11/2022] Open
Abstract
Primary chronic osteomyelitis (PCO) of the jaw is a non-infectious, inflammatory state of the jawbone of unknown etiology. In recurrent periods, these patients often exhibit swelling of the cheek, impaired ability to open their mouth as well as pain. Available treatments today include anti-inflammatory or antiresorptive drugs, hyperbaric oxygen, surgical decortication or resection followed by reconstruction where none of them have been described to lead to restored anatomy and complete relief of symptoms. We here report the unexpected complete regression of all clinical symptoms of PCO within three months after initiating pubertal suppression therapy with a gonadotropin-releasing hormone analogue in a 9-year-old girl with PCO of the jaw and early onset of pubertal development. Radiology of the jawbone confirmed complete PCO remission when performed 18 months after starting the hormone suppression therapy. To our knowledge, total regression of PCO in such a short period of time has not been described earlier suggesting an effect of the anti-hormonal therapy per se. In this case report, we discuss possible underlying mechanisms and hypothesize that anti-hormonal treatment could be a potential effective treatment in patients with PCO of the jaw.
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Affiliation(s)
- Caroline Robertsson
- Unit of Cranio- & Maxillofacial Surgery, Karolinska University Hospital, Stockholm, Sweden
| | - Lars Sävendahl
- Unit of Pediatric Endocrinology, Karolinska University Hospital, Stockholm, Sweden.,Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
| | - Carina Cardemil
- Unit of Cranio- & Maxillofacial Surgery, Karolinska University Hospital, Stockholm, Sweden.,Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden.,Department of Biomaterials, Institute of Clinical Sciences, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
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Abstract
Two early observations about the first generation bisphosphonate, clodronate, suggested that it would likely have clinical utility; specifically, it was a more potent anti-resorptive but a less potent inhibitor of mineralisation than its predecessor etidronate. The known mechanism of action differs from that of the later nitrogen-containing bisphosphonates, as clodronate is metabolised intracellularly to a toxic analog of adenosine triphosphate, AppCCl2p, which causes mitochondrial dysfunction, impaired cellular energy metabolism and osteoclast apoptosis. For pre-clinical studies in a variety of disease models, liposomal clodronate has become the agent of choice for macrophage depletion, for example in a recent study to enhance haematopoietic chimerism and donor-specific skin allograft tolerance in a mouse model. For clinical use, clodronate was developed in oral and injectable formulations; while poorly absorbed from the gastro-intestinal tract, its absorption at 1-3% of the administered dose is approximately three-fold higher than for nitrogen-containing bisphosphonates. Following an early setback due to an erroneous association with toxic adverse events, a number of successful clinical studies have established clodronate, predominantly in its oral formulations, as a highly successful treatment in Paget's disease, hypercalcaemia (benign and malignant), multiple myeloma, and early or metastatic breast cancer. Novel uses in other disease areas, including veterinary use, continue to be explored.
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Affiliation(s)
- Eugene McCloskey
- Centre for Metabolic Bone Diseases, University of Sheffield, Sheffield, UK; Centre for Integrated Research in Musculoskeletal Ageing (CIMA), Mellanby Centre for Bone Research, University of Sheffield, Sheffield, UK.
| | | | - Trevor Powles
- Cancer Centre London, 49 Parkside, Wimbledon, London SW19 5NB, UK
| | - John A Kanis
- Centre for Metabolic Bone Diseases, University of Sheffield, Sheffield, UK; Mary McKillop Institute for Health Research, Australian Catholic University, Melbourne, Australia
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Jia K, Li X, An J, Zhang Y. Comparing Clinical and Radiographic Characteristics of Chronic Diffuse Sclerosing Osteomyelitis and Craniofacial Fibrous Dysplasia in the Mandible. J Oral Maxillofac Surg 2020; 79:1053-1061. [PMID: 33345814 DOI: 10.1016/j.joms.2020.11.014] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Revised: 11/17/2020] [Accepted: 11/17/2020] [Indexed: 01/19/2023]
Abstract
PURPOSE Differential diagnosis of chronic diffuse sclerosing osteomyelitis of the mandible (DSOM) and craniofacial fibrous dysplasia (CFD) involving the mandible is challenging. The purpose of this study was to explore the differences of the clinical and radiographic characteristics between these 2 conditions. PATIENTS AND METHODS In this retrospective cross-sectional, blinded, comparative study, clinical and imaging data of patients with DSOM and CFD at the Peking University Hospital of Stomatology from 2012 to 2018 were retrieved. Clinical characteristics, mainly pain, swelling, and trismus, and radiographic findings, including sclerosis, lysis, and subperiosteal bone formation, were evaluated. The t test, χ2 test, and Fisher-Freeman-Halton test were used to determine differences. RESULTS Thirty-seven patients with DSOM and 32 patients with CFD were included (mean ages, 24.2 and 28.4 years, respectively); both groups showed a female predilection. DSOM (91.9%) and CFD (84.4%) were mainly unilateral. Patients with DSOM mainly presented with pain (94.6%), soft-tissue swelling (100.0%), and trismus (54.1%), whereas those with CFD did not experience pain (90.6%) and showed bone enlargement (87.5%) without trismus (6.3%). Panoramic radiographs and computed tomography scans of patients with DSOM showed subperiosteal bone formation, cortex lysis, and poorly demarcated cortex, whereas those patients with CFD mainly showed moderate-to-severe bone expansion, well-demarcated cortex, and tooth and mandibular canal displacement. CONCLUSIONS These findings emphasize the importance of clinical and radiographic features in differentiating between DSOM and CFD. Pain, soft-tissue or bone-tissue swelling, subperiosteal bone formation, clarity of the boundary of the cortex and medulla, and continuity of the cortical bone are key points facilitating differentiation.
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Affiliation(s)
- Kuankuan Jia
- Resident, Department of Oral and Maxillofacial Surgery, Peking University School and Hospital of Stomatology, Beijing, China
| | - Xiaoli Li
- Resident, Department of Oral and Maxillofacial Surgery, Peking University School and Hospital of Stomatology, Beijing, China
| | - Jingang An
- Associate Professor, Department of Oral and Maxillofacial Surgery, Peking University School and Hospital of Stomatology, Beijing, China.
| | - Yi Zhang
- Professor, Department of Oral and Maxillofacial Surgery, Peking University School and Hospital of Stomatology, Beijing, China
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