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Obermeier KT, Dewenter I, Malenova Y, Fliefel R, Kaeppler G, Otto S. Sclerotic bone: a sign of bone reaction in patients with medication related osteonecrosis of the jaw. Sci Rep 2024; 14:7914. [PMID: 38575664 PMCID: PMC10994931 DOI: 10.1038/s41598-024-57635-5] [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: 07/05/2023] [Accepted: 03/20/2024] [Indexed: 04/06/2024] Open
Abstract
Medication-related osteonecrosis of the jaw (MRONJ) is a serious adverse reaction associated with antiresorptive drugs such as bisphosphonates and denosumab. When dealing with advanced and/or multiple MRONJ lesions undergoing surgical therapy, the extent of surgery is often a topic of discussion. The aim of this study was to identify the differences in bone density in and around the MRONJ lesion before and after surgical treatment to evaluate the needed surgical extend of the modelling osteotomy. In this retrospective study 26 patients with MRONJ lesions that were surgically treated in our department were observed. Length, width and bone density were measured in panoramic radiograph pre and postoperatively with the Imaging processing software Sidexis and ImageJ (Fiji). The necrotic area, the surrounding sclerotic area as well as the healthy contralateral side were observed. Measurements were performed by two independent observers. Pearson correlation was calculated to determine the interobserver variability. Bone density was significantly reduced in the necrotic bone area compared to the healthy unaffected contralateral reference side. The sclerotic bone area surrounding the necrosis showed increased bone density compared to the contralateral unaffected reference side. The density of the sclerotic bone area was increased in the previously affected MRONJ area in the postoperative panoramic radiograph. The pre and postoperative density showed no significant correlation to healing behaviour. The focus of the modelling osteotomy in surgical treatment of mature MRONJ lesions should be predominantly on the parts that appear necrotic and less dense in the panoramic radiograph as sclerotic areas might be an expression of bone reaction.
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Affiliation(s)
- Katharina Theresa Obermeier
- Department of Oral and Maxillofacial Surgery and Facial Plastic Surgery, Ludwig-Maximilians-University (LMU), Lindwurmstrasse 2a, 80337, Munich, Germany
| | - Ina Dewenter
- Department of Oral and Maxillofacial Surgery and Facial Plastic Surgery, Ludwig-Maximilians-University (LMU), Lindwurmstrasse 2a, 80337, Munich, Germany.
| | - Yoana Malenova
- Department of Oral and Maxillofacial Surgery and Facial Plastic Surgery, Ludwig-Maximilians-University (LMU), Lindwurmstrasse 2a, 80337, Munich, Germany
| | - Riham Fliefel
- Department of Oral and Maxillofacial Surgery and Facial Plastic Surgery, Ludwig-Maximilians-University (LMU), Lindwurmstrasse 2a, 80337, Munich, Germany
- Department of Orthopaedics and Trauma Surgery, Musculoskeletal University Center Munich (MUM), Ludwig-Maximilians-University (LMU), Fraunhoferstrasse 20, 82152, Planegg/Martinsried, Germany
- Department of Oral and Maxillofacial Surgery, Alexandria University, Alexandria, Egypt
| | - Gabriele Kaeppler
- Department of Oral and Maxillofacial Surgery and Facial Plastic Surgery, Ludwig-Maximilians-University (LMU), Lindwurmstrasse 2a, 80337, Munich, Germany
| | - Sven Otto
- Department of Oral and Maxillofacial Surgery and Facial Plastic Surgery, Ludwig-Maximilians-University (LMU), Lindwurmstrasse 2a, 80337, Munich, Germany
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Muttanahally KS, Sheppard S, Yadav S, Tadinada A. The Utility of Cone Beam Computed Tomography Scans in Diagnosing and Treating Anterior Lesions of the Maxilla and Mandible. Cureus 2024; 16:e52804. [PMID: 38389599 PMCID: PMC10883409 DOI: 10.7759/cureus.52804] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/23/2024] [Indexed: 02/24/2024] Open
Abstract
BACKGROUND The standard screening protocol for radiographic examination in dentistry as per the American Dental Association recommendations is a panoramic radiograph (PAN) and four horizontal bitewings. PAN inherently suffers from several shortcomings like the superimposition of anatomic structures, especially of the cervical spine that obscures a significant portion of the anterior maxilla and mandible. This region has a significant amount of pathology that is not adequately imaged. Three-dimensional (3D) imaging provides circumferential information on the area of interest and adds value to the diagnosis and treatment planning of pathology, especially in the anterior maxilla and mandible. However, there is not an adequate number of well-designed studies that articulate the true value addition of 3D imaging for the evaluation of this region. OBJECTIVES The objective of this study is to evaluate the value addition of 3D imaging in diagnosing pathologies in the anterior maxilla and mandible when compared to two-dimensional PAN. MATERIALS AND METHODS A total of 25 cases that had a diagnosis of anterior pathology and had both a PAN and a cone beam computed tomography (CBCT) scan were collected for this study. An institutional review board approval to retrospectively evaluate these data was obtained. The PAN and CBCT scans were randomly evaluated by a second-year dental student, an oral and maxillofacial radiology resident in training, and a board-certified oral radiologist. The scans were evaluated using a three-point modified Likert scale, where 1 represents "not visible or clear," 2 represents "visible but not clear," and 3 represents "visible and clear." The lesions were evaluated for characteristics like lesion location, size & shape, internal contents, borders of the lesion, cortical integrity, locularity, and effect on adjacent structures like root resorption. After the evaluation was completed, a comparison of the lesion diagnosis was done with histopathology to confirm the diagnosis. The evaluators were also asked to comment on the specific feature that 3D imaging provided that added value to the case. Kappa analysis was done to evaluate inter-operator reliability. RESULTS PAN demonstrated significantly lower efficacy in identifying and diagnosing lesions. Only 56% of cases were analyzed using PAN, with 44% deemed undetectable or poorly visualized. These challenging cases necessitated CBCT scans for accurate diagnosis, which successfully diagnosed all 25 cases. The p-value of 0.0002 for PAN implies a highly significant difference from histopathology, suggesting the distinctions are not due to chance. Conversely, the p-value of 0.3273 for CBCT implies that observed differences may be random, lacking sufficient evidence to reject the null hypothesis. CBCT scans consistently outperformed PAN in visualizing various lesion characteristics, underscoring their superior diagnostic capabilities. CONCLUSIONS In this study, with a small sample size, 3D imaging provided a significant value addition to the diagnosis and treatment planning by providing additional information regarding the location, extent, internal content, and effect on adjacent structures. The practical implications for clinical settings, along with comparisons to current literature, underscore the study's distinctiveness.
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Affiliation(s)
- Kavya Shankar Muttanahally
- Oral and Maxillofacial Radiology, Department of Growth and Development, University of Nebraska Medical Center, Lincoln, USA
| | - Samantha Sheppard
- Department of General Dentistry, University of Connecticut, Farmington, USA
| | - Sumit Yadav
- Department of Growth and Development, University of Nebraska Medical Center, Lincoln, USA
| | - Aditya Tadinada
- Department of Oral and Maxillofacial Radiology, University of Connecticut, Farmington, USA
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Moreno Rabie C, Cavalcante Fontenele R, Oliveira Santos N, Nogueira Reis F, Van den Wyngaert T, Jacobs R. Three-dimensional clinical assessment for MRONJ risk in oncologic patients following tooth extractions. Dentomaxillofac Radiol 2023; 52:20230238. [PMID: 37874081 DOI: 10.1259/dmfr.20230238] [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: 10/25/2023] Open
Abstract
OBJECTIVES To identify clinical and local radiographic predictors for medication-related osteonecrosis of the jaws (MRONJ) by the assessment of pre-operative CBCT images of oncologic patients treated with anti-resorptive drugs (ARDs) undergoing tooth extractions. METHODS This retrospective, longitudinal, case-control study included clinical and imaging data of 97 patients, divided into study and control group. Patients in the study group (n = 47; 87 tooth extractions) had received at least one dose of ARD, undergone tooth extraction(s), and had a pre-operative CBCT. An age-, gender-, and tooth extraction-matched control group (n = 50; 106 tooth extractions) was selected. Three calibrated, blinded, and independent examiners evaluated each tooth extraction site. Statistical analysis used χ2/Fisher's exact/Mann-Whitney U test to contrast control and study group, ARD type used, and sites with or without MRONJ development. p-value ≤ 0.05 was considered significant. RESULTS From the study group, 15 patients (32%) and 33 sites (38%) developed MRONJ after tooth extraction. When controls were compared to study sites, the latter showed significantly more thickening of the lamina dura, widened periodontal ligament space, osteosclerosis, osteolysis, and sequestrum formation. In the study group, MRONJ risk significantly increased in patients who had multiple tooth extractions, were smokers, and had shorter drug holidays. Periosteal reaction and sequestrum formation may indicate latent MRONJ lesions. Additionally, patients given bisphosphonates showed considerably more osteosclerosis than those given denosumab. CONCLUSIONS Periosteal reaction and sequestrum formation are suspected to be pre-clinical MRONJ lesions. Furthermore, ARD induced bony changes and radiographic variations between ARD types were seen.
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Affiliation(s)
- Catalina Moreno Rabie
- OMFS-IMPATH Research Group, Department of Imaging and Pathology, Faculty of Medicine, University of Leuven, Leuven, Belgium
- Department of Oral and Maxillofacial Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Rocharles Cavalcante Fontenele
- OMFS-IMPATH Research Group, Department of Imaging and Pathology, Faculty of Medicine, University of Leuven, Leuven, Belgium
- Department of Oral and Maxillofacial Surgery, University Hospitals Leuven, Leuven, Belgium
- Department of Oral Diagnosis, Division of Oral Radiology, Piracicaba Dental School, University of Campinas, Piracicaba, São Paulo, Brazil
| | - Nicolly Oliveira Santos
- OMFS-IMPATH Research Group, Department of Imaging and Pathology, Faculty of Medicine, University of Leuven, Leuven, Belgium
- Department of Oral and Maxillofacial Surgery, University Hospitals Leuven, Leuven, Belgium
- Department of Oral Diagnosis, Division of Oral Radiology, Piracicaba Dental School, University of Campinas, Piracicaba, São Paulo, Brazil
| | - Fernanda Nogueira Reis
- OMFS-IMPATH Research Group, Department of Imaging and Pathology, Faculty of Medicine, University of Leuven, Leuven, Belgium
- Department of Oral and Maxillofacial Surgery, University Hospitals Leuven, Leuven, Belgium
- Department of Oral Diagnosis, Division of Oral Radiology, Piracicaba Dental School, University of Campinas, Piracicaba, São Paulo, Brazil
| | - Tim Van den Wyngaert
- Department of Nuclear Medicine, Antwerp University Hospital, Edegem, Belgium
- Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
| | - Reinhilde Jacobs
- OMFS-IMPATH Research Group, Department of Imaging and Pathology, Faculty of Medicine, University of Leuven, Leuven, Belgium
- Department of Oral and Maxillofacial Surgery, University Hospitals Leuven, Leuven, Belgium
- Department of Dental Medicine, Karolinska Institutet, Stockholm, Sweden
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Moreno Rabie C, García-Larraín S, Contreras Diez de Medina D, Cabello-Salazar I, Fontenele RC, Van den Wyngaert T, Jacobs R. How does the clinical and tomographic appearance of MRONJ influences its treatment prognosis? Dentomaxillofac Radiol 2023; 52:20230304. [PMID: 37870051 DOI: 10.1259/dmfr.20230304] [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: 10/24/2023] Open
Abstract
OBJECTIVES To identify clinical and tomographic prognostic factors for conservative and surgical treatment of medication-related osteonecrosis of the jaws (MRONJ). METHODS A retrospective search identified patients treated with antiresorptive drugs (ARDs), diagnosed with Stage 1, 2 or 3 MRONJ, and having CBCT scans previous to conservative or surgical treatment. Following data collection, imaging assessment of the following parameters on each MRONJ site was performed: involvement of teeth and/or implants, presence of osteosclerosis, osteolysis, sequestrum formation, periosteal reaction, and pathological fractures. For statistical analysis, patients and lesions were divided into conservative and surgical treatment. Comparisons were made between successful and unsuccessful outcomes. Significance was set at p ≤ 0.05. RESULTS 115 ARD-treated patients who developed 143 osteonecrosis lesions were selected. 40 patients and 58 lesions received conservative treatment, of which 14 patients (35%) and 25 lesions (43%) healed. Additionally, 75 patients and 85 lesions underwent surgery, with 48 patients (64%) and 55 lesions (65%) that healed. Clinical and tomographic risk factors for conservative treatment were MRONJ staging, tooth involvement, extensive osteosclerosis, and deep sequestrum formation (p < 0.05). Complementarily, poor prognostic indicators for surgical therapy were a short bisphosphonate (BP) holiday, MRONJ staging, absence of sequestrum formation, and presence of periosteal reaction (p < 0.05). CONCLUSIONS Lesions at Stage 3 MRONJ, with tooth involvement, or sequestrum formation showed poor outcomes when conservative treatment is chosen. Alternatively, surgical treatment is most effective when BPs are discontinued, in Stage 1 lesions, in the presence of sequestrum formation, and absence of periosteal reaction.
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Affiliation(s)
- Catalina Moreno Rabie
- OMFS-IMPATH Research Group, Department of Imaging and Pathology, Faculty of Medicine, University of Leuven, Leuven, Belgium
- Department of Oral and Maxillofacial Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Santiago García-Larraín
- OMFS-IMPATH Research Group, Department of Imaging and Pathology, Faculty of Medicine, University of Leuven, Leuven, Belgium
- Department of Oral and Maxillofacial Surgery, University Hospitals Leuven, Leuven, Belgium
- Department of Oral and Maxillofacial Radiology, Facultad de Odontología, Universidad de los Andes, Santiago, Chile
| | - David Contreras Diez de Medina
- OMFS-IMPATH Research Group, Department of Imaging and Pathology, Faculty of Medicine, University of Leuven, Leuven, Belgium
- Department of Oral and Maxillofacial Surgery, University Hospitals Leuven, Leuven, Belgium
- Department of Oral and Maxillofacial Radiology, Facultad de Odontología, Universidad de los Andes, Santiago, Chile
| | - Isadora Cabello-Salazar
- OMFS-IMPATH Research Group, Department of Imaging and Pathology, Faculty of Medicine, University of Leuven, Leuven, Belgium
- Department of Oral and Maxillofacial Surgery, University Hospitals Leuven, Leuven, Belgium
- Department of Oral and Maxillofacial Radiology, Facultad de Odontología, Universidad de los Andes, Santiago, Chile
| | - Rocharles Cavalcante Fontenele
- OMFS-IMPATH Research Group, Department of Imaging and Pathology, Faculty of Medicine, University of Leuven, Leuven, Belgium
- Department of Oral and Maxillofacial Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Tim Van den Wyngaert
- Department of Nuclear Medicine, Antwerp University Hospital, Edegem, Belgium
- Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
| | - Reinhilde Jacobs
- OMFS-IMPATH Research Group, Department of Imaging and Pathology, Faculty of Medicine, University of Leuven, Leuven, Belgium
- Department of Oral and Maxillofacial Surgery, University Hospitals Leuven, Leuven, Belgium
- Department of Dental Medicine, Karolinska Institutet, Stockholm, Sweden
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Novel modified quantitative index for cone-beam CT assessment of Medication-Related Osteonecrosis of the Jaw - comparative analysis with original index. Saudi Dent J 2023; 35:310-316. [DOI: 10.1016/j.sdentj.2023.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2023] [Revised: 03/04/2023] [Accepted: 03/09/2023] [Indexed: 03/17/2023] Open
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Badabaan G, Creanga AG, Singer SR, Strickland M, Subramanian G. Quantitative indices for cone-beam CT assessment of Medication-Related Osteonecrosis of the Jaw - a scoping review. Saudi Dent J 2023; 35:133-140. [PMID: 36942207 PMCID: PMC10024109 DOI: 10.1016/j.sdentj.2022.12.012] [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: 07/14/2022] [Revised: 12/20/2022] [Accepted: 12/21/2022] [Indexed: 12/31/2022] Open
Abstract
Objectives It is not unusual for Medication-related osteonecrosis of the jaw (MRONJ) lesions that have similar clinical presentation and staging to have dissimilar radiographic extent of disease. The aim of this review was to explore the published scientific literature for quantitative indices that describe the cone-beam computerized tomography (CBCT) radiographic features of MRONJ lesions and assess their clinical utility. Method and Materials A scoping review of the literature was performed to identify quantitative indices developed to describe the CBCT radiographic features of MRONJ lesions. Five electronic databases were included in the review: PubMed, Scopus, Web of Science, Trip medical database, and Cochrane Library. Articles published from the year 2003 onward were included in the review. Results 367 articles were initially included in the review. 39 abstracts were screened for full-text assessment. The scoping review yielded 12 full length articles with169 cases reported. The Composite Radiographic Index score (CRI score) was identified as the most meaningful index in published literature that attempted to quantify qualitative radiographic changes (Walton, Grogan et al. 2019). However, lesions with similar CRI scores that corresponded to intermediate severity (3-5) may be very dissimilar radiographically in both nature and extent of radiographic changes, undercutting its clinical value. Conclusion The CRI index score was the only relevant index for cross-sectional (one-time) assessment of established MRONJ lesions (non-stage 0). This scoping review yielded several critical questions regarding the clinical significance and prognostic implications of various radiographic changes in MRONJ, thereby identifying focus areas for future research.
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Affiliation(s)
- Ghaidaa Badabaan
- Master of Dental Science, Rutgers School of Dental Medicine, Faculty of Dentistry, Umm Al-Qura University, Saudi Arabia
- Department of Diagnostic Science, Rutgers School of Dental Medicine, NJ, USA
- Corresponding author.
| | - Adriana G. Creanga
- Department of Diagnostic Science, Rutgers School of Dental Medicine, NJ, USA
| | - Steven R. Singer
- Department of Diagnostic Science, Rutgers School of Dental Medicine, NJ, USA
| | - Maxine Strickland
- Department of Diagnostic Science, Rutgers School of Dental Medicine, NJ, USA
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Evaluation of Medication-Related Osteonecrosis of the Jaw (MRONJ) in Terms of Staging and Treatment Strategies by Dental Students at Different Educational Levels. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:medicina59020252. [PMID: 36837455 PMCID: PMC9962432 DOI: 10.3390/medicina59020252] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Revised: 01/15/2023] [Accepted: 01/23/2023] [Indexed: 02/03/2023]
Abstract
Background: The role of medication-related osteonecrosis of the jaw (MRONJ) as a dento-maxillo-facial pathology is becoming increasingly important due to its growing prevalence. The success of preventive and therapeutic measures relies mainly on the dentist's ability to correctly diagnose the disease. Methods: The aim of this study was to evaluate the skills of dental students of different educational levels in choosing the correct stage, diagnostics, and treatment option for MRONJ based on clinical and radiographic imaging (panoramic radiograph, CBCT). The study was designed as a cross-sectional cohort study. Twenty dental students were asked to complete a questionnaire in their third and fifth year of studies in which they had to correctly stage the disease, choose the radiological diagnostics and recommend the treatment. The control group contained experienced oral and maxillofacial surgeons. Results: With an overall performance of 59% (third year: 145.2/248 points; fifth year: 145.3/248 points), no statistically significant difference between the educational levels could be observed. The classification based on CBCT imaging was significantly more often correct compared to panoramic radiographs (p < 0.001). Conclusions: This study highlights students' lack of knowledge in staging, diagnostics, and treatment of MRONJ, even though the CBCT positively affected decision-making. No significant increase in knowledge could be confirmed through clinical education. This study highlights the need for students to catch up on MRONJ diagnostics and treatment planning. Further expansion of teaching in this disease's context and X-ray diagnostics is needed.
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Beck MT, Rugel G, Reinfelder J, Kuwert T, Ritt P, Kreissel S, Schlittenbauer T. Quantitative Analysis of Multimodal Skeletal SPECT/CT Reconstructions in Diagnosing Medication-related Osteonecrosis of the Jaw. NUKLEARMEDIZIN. NUCLEAR MEDICINE 2021; 60:403-410. [PMID: 34380154 DOI: 10.1055/a-1525-7621] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
AIM Our goal was to assess visual and quantitative aspects of multimodal skeletal SPECT/CT reconstructions (recon) in differentiating necrotic and healthy bone of patients with suspected MRONJ. METHODS Prior to surgery, 20 patients with suspected MRONJ underwent SPECT/CT of the jaw 3-4 hours after injection of Tc-99m-DPD (622±112.4 MBq). SPECT/CT data were reconstructed using the multimodal xSPECT Bone and xSPECT Quant algorithms as well as the OSEM-algorithm FLASH 3D. For analysis, we divided the jaw into 12 separate regions. Both xSPECT Bone and FLASH 3D datasets were scored on a four-point scale (VIS xSPECT; VIS F3D), based on the intensity of localized tracer uptake. In F3D and xSPECT Quant datasets, local tracer uptake of each region was recorded as semi-quantitative uptake ratio (SQR F3D) or SUVs, respectively. ROC analysis was performed. Postoperative histologic results served as gold standard. RESULTS VIS F3D, VIS xSPECT and SQR F3D did not differ significantly in diagnostic accuracy (VIS xSPECT sensitivity=0.64; specificity=0.89). Of the quantitative parameters, SUVpeak yielded the best interobserver reproducibility. SUVpeak was 9.9±7.1 (95%CI: 7.84-11.95) in MRONJ regions, as opposed 3.6±1.8 (95% CI:3.36-3.88) elsewhere, with a cutpoint of 4.5 (sensitivity=0.83; specificity=0.80). Absolute quantitation significantly surpassed VIS and SQR (p<0.05) in accuracy and interobserver agreement (SUVpeak: κ=0.92; VIS xSPECT: κ=0.61; SQR F3D κ=0.66). CONCLUSION Absolute quantitation proved significantly more accurate than visual and semi-quantitative assessment in diagnosing MRONJ, with higher interobserver agreement.
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Affiliation(s)
| | - Gregor Rugel
- Universitätsklinikum Erlangen Nuklearmedizinische Klinik, Erlangen, Germany
| | - Julia Reinfelder
- Universitätsklinikum Erlangen Nuklearmedizinische Klinik, Erlangen, Germany
| | - Torsten Kuwert
- Universitätsklinikum Erlangen Nuklearmedizinische Klinik, Erlangen, Germany
| | - Philipp Ritt
- Universitätsklinikum Erlangen Nuklearmedizinische Klinik, Erlangen, Germany
| | - Sebastian Kreissel
- Klinik für Mund- Kiefer- und Gesichtschirurgie, Universitätsklinikum Erlangen, Erlangen, Germany
| | - Tilo Schlittenbauer
- Abteilung Mund- Kiefer- und Gesichtschirurgie, Universitätsklinikum Augsburg, Augsburg, Germany.,Klinik für Mund- Kiefer- und Gesichtschirurgie, Universitätsklinikum Erlangen, Erlangen, Germany
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A Comparison of the Clinical and Radiological Extent of Denosumab (Xgeva ®) Related Osteonecrosis of the Jaw: A Retrospective Study. J Clin Med 2021; 10:jcm10112390. [PMID: 34071481 PMCID: PMC8197814 DOI: 10.3390/jcm10112390] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Revised: 05/25/2021] [Accepted: 05/26/2021] [Indexed: 01/19/2023] Open
Abstract
Medication-related osteonecrosis of the jaw (MRONJ) is a severe side effect of antiresorptive medication. The aim of this study was to evaluate the incidence of denosumab-related osteonecrosis of the jaw and to compare the clinical and radiological extent of osteonecrosis. A retrospective study of patients who received Xgeva® at the Institut de Cancérologie de Lorraine (ICL) was performed. Patients for whom clinical and radiological (CBCT) data were available were divided into two groups: “exposed” for patients with bone exposure and “fistula” when only a fistula through which the bone could be probed was observed. The difference between clinical and radiological extent was assessed. The p-value was set at 0.05, and a total of 246 patients were included. The cumulative incidence of osteonecrosis was 0.9% at 6 months, 7% at 12 months, and 15% from 24 months. The clinical extent of MRONJ was significantly less than their radiological extent: in the “exposed” group, 17 areas (45%) were less extensive clinically than radiologically (p < 0.001) and respectively 6 (67%) for the “fistula” group (p < 0.031). It would seem that a CBCT is essential to know the real extent of MRONJ. Thus, it would seem interesting to systematically perform a CBCT during the diagnosis of MRONJ, exploring the entire affected dental arch.
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Ogura I, Minami Y, Ono J, Kanri Y, Okada Y, Igarashi K, Haga-Tsujimura M, Nakahara K, Kobayashi E. CBCT imaging and histopathological characteristics of osteoradionecrosis and medication-related osteonecrosis of the jaw. Imaging Sci Dent 2021; 51:73-80. [PMID: 33828964 PMCID: PMC8007393 DOI: 10.5624/isd.20200230] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Revised: 10/14/2020] [Accepted: 10/28/2020] [Indexed: 12/12/2022] Open
Abstract
Purpose The purpose of this study was to evaluate the cone-beam computed tomographic (CBCT) imaging and histopathological characteristics of osteoradionecrosis (ORN) and medication-related osteonecrosis of the jaw (MRONJ). Materials and Methods Ten surgical specimens from segmental mandibulectomy (3 ORN and 7 MRONJ) were analyzed using CBCT. The CBCT parameters were as follows: high-resolution mode (tube voltage, 90.0 kV; tube current, 4.00 mA; rotation time, 16.8 s; field of view, 56 mm×56 mm; thickness, 0.099 mm). Histopathological characteristics were evaluated using histological slides of the surgical specimens. The Pearson chi-square test was used to compare ORN and MRONJ in terms of CBCT findings (internal texture, sequestrum, periosteal reaction and cortical perforation) and histopathological characteristics (necrotic bone, inflammatory cells, reactive bone formation, bacteria, Actinomyces, and osteoclasts). A P value less than 0.05 was considered to indicate statistical significance. Results MRONJ showed periosteal reaction on CBCT more frequently than ORN (7 of 7 [100%] vs. 0 of 3 [0%], P<0.05). Regarding histopathological characteristics, MRONJ showed osteoclasts more frequently than ORN (6 of 7 [85.7%] vs. 0 of 3 [0%], P<0.05). Conclusion This study evaluated the CBCT imaging and histopathological characteristics of ORN and MRONJ, and the findings suggest that CBCT could be useful for the evaluation of ORN and MRONJ.
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Affiliation(s)
- Ichiro Ogura
- Department of Oral and Maxillofacial Radiology, The Nippon Dental University School of Life Dentistry at Niigata, Niigata, Japan
| | - Yoshiyuki Minami
- Department of Oral and Maxillofacial Radiology, The Nippon Dental University School of Life Dentistry at Niigata, Niigata, Japan
| | - Junya Ono
- Department of Pathology, The Nippon Dental University School of Life Dentistry at Niigata, Niigata, Japan
| | - Yoriaki Kanri
- Department of Pathology, The Nippon Dental University School of Life Dentistry at Niigata, Niigata, Japan
| | - Yasuo Okada
- Department of Pathology, The Nippon Dental University School of Life Dentistry at Niigata, Niigata, Japan
| | - Kensuke Igarashi
- Department of Dental Materials Science, The Nippon Dental University School of Life Dentistry at Niigata, Niigata, Japan
| | - Maiko Haga-Tsujimura
- Department of Histology, The Nippon Dental University School of Life Dentistry at Niigata, Niigata, Japan.,Advanced Research Center, The Nippon Dental University School of Life Dentistry at Niigata, Niigata, Japan
| | - Ken Nakahara
- Advanced Research Center, The Nippon Dental University School of Life Dentistry at Niigata, Niigata, Japan
| | - Eizaburo Kobayashi
- Department of Oral and Maxillofacial Surgery, The Nippon Dental University School of Life Dentistry at Niigata, Niigata, Japan
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Wongratwanich P, Shimabukuro K, Konishi M, Nagasaki T, Ohtsuka M, Suei Y, Nakamoto T, Verdonschot RG, Kanesaki T, Sutthiprapaporn P, Kakimoto N. Do various imaging modalities provide potential early detection and diagnosis of medication-related osteonecrosis of the jaw? A review. Dentomaxillofac Radiol 2021; 50:20200417. [PMID: 33411572 DOI: 10.1259/dmfr.20200417] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
OBJECTIVE Patients with medication-related osteonecrosis of the jaw (MRONJ) often visit their dentists at advanced stages and subsequently require treatments that greatly affect quality of life. Currently, no clear diagnostic criteria exist to assess MRONJ, and the definitive diagnosis solely relies on clinical bone exposure. This ambiguity leads to a diagnostic delay, complications, and unnecessary burden. This article aims to identify imaging modalities' usage and findings of MRONJ to provide possible approaches for early detection. METHODS Literature searches were conducted using PubMed, Web of Science, Scopus, and Cochrane Library to review all diagnostic imaging modalities for MRONJ. RESULTS Panoramic radiography offers a fundamental understanding of the lesions. Imaging findings were comparable between non-exposed and exposed MRONJ, showing osteolysis, osteosclerosis, and thickened lamina dura. Mandibular cortex index Class II could be a potential early MRONJ indicator. While three-dimensional modalities, CT and CBCT, were able to show more features unique to MRONJ such as a solid type periosteal reaction, buccal predominance of cortical perforation, and bone-within-bone appearance. MRI signal intensities of vital bones are hypointense on T1WI and hyperintense on T2WI and STIR when necrotic bone shows hypointensity on all T1WI, T2WI, and STIR. Functional imaging is the most sensitive method but is usually performed in metastasis detection rather than being a diagnostic tool for early MRONJ. CONCLUSION Currently, MRONJ-specific imaging features cannot be firmly established. However, the current data are valuable as it may lead to a more efficient diagnostic procedure along with a more suitable selection of imaging modalities.
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Affiliation(s)
- Pongsapak Wongratwanich
- Department of Oral and Maxillofacial Radiology, Graduate School of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima 734-8553, Japan
| | - Kiichi Shimabukuro
- Department of Oral and Maxillofacial Radiology, Graduate School of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima 734-8553, Japan
| | - Masaru Konishi
- Department of Oral and Maxillofacial Radiology, Hiroshima University Hospital, 1-2-3 Kasumi, Minami-ku, Hiroshima 734-8553, Japan
| | - Toshikazu Nagasaki
- Department of Oral and Maxillofacial Radiology, Graduate School of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima 734-8553, Japan
| | - Masahiko Ohtsuka
- Department of Oral and Maxillofacial Radiology, Graduate School of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima 734-8553, Japan
| | - Yoshikazu Suei
- Department of Oral and Maxillofacial Radiology, Hiroshima University Hospital, 1-2-3 Kasumi, Minami-ku, Hiroshima 734-8553, Japan
| | - Takashi Nakamoto
- Department of Oral and Maxillofacial Radiology, Graduate School of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima 734-8553, Japan
| | - Rinus G Verdonschot
- Department of Oral and Maxillofacial Radiology, Graduate School of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima 734-8553, Japan
| | - Tomohiko Kanesaki
- Department of Oral and Maxillofacial Surgery, Saiseikai Senri Hospital, 1 Chome-1-6 Tsukumodai, Suita, Osaka 565-0862, Japan
| | - Pipop Sutthiprapaporn
- Department of Preventive Dentistry, Faculty of Dentistry, Khon Kaen University, Amphur Muang, Khon Kaen 40002, Thailand
| | - Naoya Kakimoto
- Department of Oral and Maxillofacial Radiology, Graduate School of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima 734-8553, Japan
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Differences between bisphosphonate-related and denosumab-related osteonecrosis of the jaws: a systematic review. Support Care Cancer 2020; 29:2811-2820. [PMID: 33140246 DOI: 10.1007/s00520-020-05855-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Accepted: 10/23/2020] [Indexed: 01/07/2023]
Abstract
OBJECTIVE Bisphosphonates and denosumab are both antiresorptive medications, each with their own mechanism of action; yet both may result in the same adverse effect: medication-related osteonecrosis of the jaw (ONJ). The present systematic review aims to answer the following question: "Are bisphosphonate-related ONJ and denosumab-related ONJ any different, regarding clinical and imaging aspects?" METHODS This review followed the Joanna Briggs Review's Manual, and the searches were performed on PubMed, Cochrane, Scopus, Web of Science, and Lilacs databases and on the grey literature (ProQuest, Open Grey, and Google Scholar). RESULTS The searches resulted in 7535 articles that were critically assessed. Based on the selection criteria, seven studies were included in the review: five cross-sectional studies and two randomized clinical trials. A total of 7755 patients composed the final population. An increase in bone sequestra, cortical bone lysis, and bone density was observed in bisphosphonate-related ONJ, while larger bone sequestra, more frequent periosteal reactions, and mandibular canal enhancement were noted in denosumab-related ONJ. CONCLUSION This systematic review demonstrated that the imaging characteristics of bisphosphonate-related and denosumab-related ONJ are not similar. Although clinically similar conditions, they were found to be radiographically distinct. More studies are necessary to further elucidate these differences.
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13
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Simpione G, Caldas RJ, Soares MQS, Rubira-Bullen IRF, Santos PSS. Tomographic study of Jaw bone changes in patients with bisphosphonate-related osteonecrosis. J Clin Exp Dent 2020; 12:e285-e290. [PMID: 32190200 PMCID: PMC7071540 DOI: 10.4317/jced.56265] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Accepted: 01/08/2020] [Indexed: 11/11/2022] Open
Abstract
Background Bisphosphonates (BP) are synthetic pyrophosphate-like substances with antiresorptive properties and specifically affect osteoclastic activity. In 2007, the American Association of Oral and Maxillofacial Surgeons (AAOMS) defined diagnostic criteria for Osteonecrosis of the Jaws Associated with Bisphosponates (BRONJ). BRONJ is mainly diagnosed by clinical features, but the detection of early bone changes by imaging may help prevent and better understand the disease. The objective of this study was to evaluate maxillary changes in CBCT in patients using BP.
Material and Methods All included patients were diagnosed with osteonecrosis and received bisphosphonate drugs in the last ten years. All imaging examinations were obtained by I-CAT and 3D Accuitomo. The multiplanar reconstructions were analyzed by an examiner without knowledge of the clinical aspects and location of the lesions.
Results The study sample consisted of 21 patients, the majority of the sample represented patients with cancer (76.2%), the other patients had osteoporosis (23.8%). Only four patients (19.04%) received alendronate, while intravenous bisphosphonates, such as zoledronate and pamidronate, represented the treatment of most of our sample. Most of our patients presented stage 1 and 2 MRONJ (85.7%), whose lesions were mainly observed in the mandible (52.4%). Fifty-seven percent of the patients had at least one bone change.
Conclusions In BRONJ, bone changes vary between exposed and non-exposed areas and one aspect of the study was: persistent extraction cavities in the BRONJ lesion region and high frequency of periodontal ligament space widening in areas that are not involved in BRONJ lesions. This reflects the very important role of dental and periodontal diseases in the pathophysiology of BRONJ. Thus, preventive measures should be prioritized for patients exposed to anti-resorptive drugs. Key words:Cone-Beam computed tomography, osteonecrosis, bisphosphonate-associated osteonecrosis of the jaw.
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Affiliation(s)
- Guilherme Simpione
- Master student, Bauru School of Dentistry, University of Sao Paulo, Brazil
| | | | - Mariana Q S Soares
- Post-doctoral student Bauru School of Dentistry, University of Sao Paulo, Brazil
| | - Izabel R F Rubira-Bullen
- Associate Professor, Department of Surgery, Stomatology, Radiology and Pathology, Faculty of Dentistry of Bauru - USP
| | - Paulo S S Santos
- Associate Professor, Department of Surgery, Stomatology, Radiology and Pathology, Faculty of Dentistry of Bauru - USP
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14
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Feitosa ÉF, Vasconcellos MM, Magalhães RJP, Domingos-Vieira AC, Visconti MA, Guedes FR, Maiolino A, Torres SR. Bisphophonate alterations of the jaw bones in individuals with multiple myeloma. Dentomaxillofac Radiol 2019; 49:20190155. [PMID: 31670576 DOI: 10.1259/dmfr.20190155] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
OBJECTIVES To verify quantitative differences of the mandibular cortical and trabecular bone between patients with multiple myeloma (MM) under bisphosphonate (BP) therapy and a control group never exposed to BP. METHODS Clinical and demographic characteristics were collected through medical records and interviews. Mandibular cortical thickness (MCT) and fractal dimension (FD) were measured on cone beam computed tomography (CBCT) images, on the molar region, in both groups. Additionally, FD was measured on periapical digital intraoral radiography and results were compared to CBCT measurements. RESULTS There were 33 patients with MM under BP therapy and 28 controls, with no significant differences in gender and age between groups. Pamidronate was used by all MM patients, either associated or not to other types of BP. The median MCT was higher in MM group exposed to BP (5.20 mm) than in controls (3.50 mm, p < 0.001). There were no significant differences in the median FD between patients in the MM group and controls, on CBCT (0.95 vs 0.90, p = 0.814) and periapical digital intraoral radiography (0.98 vs 0.96, p = 0.963), respectively, even when more than one type of BP was used. CONCLUSIONS The MCT represents an useful tool in the detection of bone dimensional changes caused by BP, in patients with MM. Additional studies are necessary to improve the knowledge on the quantitative evaluation of trabecular jaw bone, in individuals with MM, under BP therapy.
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Affiliation(s)
- Édila Figuerêdo Feitosa
- Department of Internal Medicine, Clementino Fraga Filho University Hospital, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Mariana Monteiro Vasconcellos
- Department of Oral Pathology and Diagnosis, Dental School, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Roberto José Pessoa Magalhães
- Department of Internal Medicine, Clementino Fraga Filho University Hospital, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Andrea Castro Domingos-Vieira
- Department of Oral Pathology and Diagnosis, Dental School, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Maria Augusta Visconti
- Department of Oral Pathology and Diagnosis, Dental School, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Fabio Ribeiro Guedes
- Department of Oral Pathology and Diagnosis, Dental School, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Angelo Maiolino
- Department of Internal Medicine, Clementino Fraga Filho University Hospital, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Sandra Regina Torres
- Department of Oral Pathology and Diagnosis, Dental School, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
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15
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Weiss R, Read-Fuller A. Cone Beam Computed Tomography in Oral and Maxillofacial Surgery: An Evidence-Based Review. Dent J (Basel) 2019; 7:dj7020052. [PMID: 31052495 PMCID: PMC6631689 DOI: 10.3390/dj7020052] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Revised: 04/09/2019] [Accepted: 04/11/2019] [Indexed: 12/24/2022] Open
Abstract
Cone Beam Computed Tomography (CBCT) is a valuable imaging technique in oral and maxillofacial surgery (OMS) that can help direct a surgeon’s approach to a variety of conditions. A 3-dimensional analysis of head and neck anatomy allows practitioners to plan appropriately, operate with confidence, and assess results post-operatively. CBCT imaging has clear indications and limitations. CBCT offers the clinician 3-dimensional and multi-planar views for a more accurate diagnosis and treatment without the financial burden and radiation exposure of conventional computed tomography (CT) scans. Furthermore, CBCT overcomes certain limitations of 2-dimensional imaging, such as distortion, magnification, and superimposition. However, CBCT lacks the detailed depiction of soft tissue conditions for evaluation of pathologic conditions, head and neck infections, and temporomandibular joint (TMJ) disc evaluation. This review evaluates the evidence-based research supporting the application of CBCT in the various fields of oral and maxillofacial surgery, including dentoalveolar surgery, dental implants, TMJ, orthognathic surgery, trauma, and pathology, and will assess the value of CBCT in pre-operative assessment, surgical planning, and post-operative analysis when applicable. Additionally, the significant limitations of CBCT and potential areas for future research will be discussed.
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Affiliation(s)
- Robert Weiss
- Department of Oral and Maxillofacial Surgery, Texas A&M University College of Dentistry, Dallas, TX 75246, USA.
- Baylor Scott and White Health, Baylor University Medical Center-Dallas, Dallas, TX 75246, USA.
| | - Andrew Read-Fuller
- Department of Oral and Maxillofacial Surgery, Texas A&M University College of Dentistry, Dallas, TX 75246, USA.
- Attending Physician, Baylor Scott and White Health, Baylor University Medical Center-Dallas, Dallas, TX 75246, USA.
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16
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Hingst V, Weber MA. Bildgebende Diagnostik bei medikamenteninduzierten Kiefernekrosen. Radiologe 2018; 58:935-948. [DOI: 10.1007/s00117-018-0443-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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17
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Soundia A, Hadaya D, Mallya SM, Aghaloo TL, Tetradis S. Radiographic predictors of bone exposure in patients with stage 0 medication-related osteonecrosis of the jaws. Oral Surg Oral Med Oral Pathol Oral Radiol 2018; 126:537-544. [PMID: 30266375 DOI: 10.1016/j.oooo.2018.08.005] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2018] [Revised: 06/27/2018] [Accepted: 08/14/2018] [Indexed: 10/28/2022]
Abstract
OBJECTIVE The aim of this study was to explore the radiographic appearance of stage 0 medication-related osteonecrosis of the jaws (MRONJ) and examine 5 radiographic parameters (trabecular sclerosis, cortical erosion, periosteal reaction, sequestration, and crater-like defect) as predictors of progression to bone exposure. STUDY DESIGN Twenty-three patients with a history of antiresorptive therapy, no bone exposure, and nonspecific signs and symptoms were included. Intraoral photographs, panoramic and cone beam computed tomography (CBCT) images at initial visit, and follow-up intraoral photographs were reviewed. Three patients had dental disease (DD), 10 patients with stage 0 MRONJ did not progress to bone exposure (NBE), and 10 patients progressed to bone exposure (BE). Radiographic parameters were scored as absent (0), localized (1), or extensive (2), and their sum formed the composite radiographic index (CRI). RESULTS DD patients demonstrated minimal radiographic findings, and their CRI was significantly lower than that of NBE and BE patients. Additionally, BE patients demonstrated a higher radiographic index compared with NBE patients. Intriguingly, sequestration was observed in the initial CBCT of 9 (90%) of 10 BE patients, whereas 80% of NBE patients showed absence of sequestration at initial CBCT examination. CONCLUSIONS CBCT imaging can aid in the differentiation of stage 0 MRONJ from dental disease. Radiographic sequestration at initial presentation can serve as a predictor of future bone exposure in patients with stage 0 MRONJ.
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Affiliation(s)
- Akrivoula Soundia
- Section of Oral and Maxillofacial Radiology, Division of Diagnostic and Surgical Sciences, UCLA School of Dentistry, Los Angeles, CA, USA
| | - Danny Hadaya
- Section of Oral and Maxillofacial Surgery, Division of Diagnostic and Surgical Sciences, UCLA School of Dentistry, Los Angeles, CA, USA
| | - Sanjay M Mallya
- Section of Oral and Maxillofacial Radiology, Division of Diagnostic and Surgical Sciences, UCLA School of Dentistry, Los Angeles, CA, USA
| | - Tara L Aghaloo
- Section of Oral and Maxillofacial Surgery, Division of Diagnostic and Surgical Sciences, UCLA School of Dentistry, Los Angeles, CA, USA.
| | - Sotirios Tetradis
- Section of Oral and Maxillofacial Radiology, Division of Diagnostic and Surgical Sciences, UCLA School of Dentistry, Los Angeles, CA, USA.
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18
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Walton K, Grogan TR, Eshaghzadeh E, Hadaya D, Elashoff DA, Aghaloo TL, Tetradis S. Medication related osteonecrosis of the jaw in osteoporotic vs oncologic patients-quantifying radiographic appearance and relationship to clinical findings. Dentomaxillofac Radiol 2018; 48:20180128. [PMID: 29952657 DOI: 10.1259/dmfr.20180128] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
OBJECTIVES To explore whether differences exist in the clinical and radiographic presentation of oncologic vs osteoporotic patients with medication-related osteonecrosis of the jaw (MRONJ). METHODS We retrospectively assessed panoramic radiographs and CBCT examinations of 70 MRONJ patients receiving antiresorptive medications for the management of either osteoporosis or bone malignancy. Radiographic features of MRONJ were documented and categorized according to severity. A composite radiographic index (CRI) was constructed to account for the heterogeneity in radiographic manifestations of MRONJ and further stratify extent of osseous changes. RESULTS Patients with osteoporosis were mostly older females and presented more frequently with Stage 2 MRONJ, while patients with malignancy were equally distributed between males and females, and presented mostly with Stage 1 MRONJ. Most MRONJ lesions in oncologic patients occurred in the mandible, whereas the maxilla and mandible were equally affected in osteoporotic patients. Patients with minimal radiographic changes (low CRI score) often presented with MRONJ in dentate areas, while most patients in medium and high CRI groups presented with MRONJ after recent tooth extraction. The low CRI group consisted of primarily oncologic patients, while osteoporotic vs oncologic patients were divided more evenly in the other CRI groups (p = 0.083). While CRI scores increased with clinical staging, a Spearman's rank correlation coefficient of 0.49 suggests that clinical appearance does not reliably predict osseous changes. CONCLUSIONS Our data identify differences in the MRONJ appearance of patients with osteoporosis vs malignancy and emphasize the significance of detailed radiographic assessment, in addition to the clinical appearance, in characterizing the osseous changes of the disease.
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Affiliation(s)
- Kaycee Walton
- Division of Diagnostic and Surgical Sciences, UCLA School of Dentistry, Los Angeles, CA, USA.,Midwestern University College of Dental Medicine, Glendale, CA, USA
| | - Tristan R Grogan
- Department of Medicine Statistics, Core David Geffen School of Medicine, Los Angeles, CA, USA
| | - Edwin Eshaghzadeh
- Division of Diagnostic and Surgical Sciences, UCLA School of Dentistry, Los Angeles, CA, USA
| | - Danny Hadaya
- Division of Diagnostic and Surgical Sciences, UCLA School of Dentistry, Los Angeles, CA, USA
| | - David A Elashoff
- Department of Medicine Statistics, Core David Geffen School of Medicine, Los Angeles, CA, USA
| | - Tara L Aghaloo
- Division of Diagnostic and Surgical Sciences, UCLA School of Dentistry, Los Angeles, CA, USA
| | - Sotirios Tetradis
- Division of Diagnostic and Surgical Sciences, UCLA School of Dentistry, Los Angeles, CA, USA
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19
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Alves DBM, Tuji FM, Alves FA, Rocha AC, Santos-Silva ARD, Vargas PA, Lopes MA. Evaluation of mandibular odontogenic keratocyst and ameloblastoma by panoramic radiograph and computed tomography. Dentomaxillofac Radiol 2018; 47:20170288. [PMID: 29791200 DOI: 10.1259/dmfr.20170288] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
OBJECTIVES: The purpose of this study was to describe and compare the main imagenological features of mandibular ameloblastomas and odontogenic keratocyst (OKC) using panoramic radiograph (PR) and CT. METHODS: The sample consisted of nine cases of ameloblastomas and nine cases of OKC. PR and CT images were analyzed according to shape, internal structure, borders, associated unerupted tooth, root resorption, expansion and perforation of cortical bones. RESULTS: PR evaluation allowed the identification of the lesion's location, presence of sclerosis in the periphery, presence of associated non-erupted tooth and expansion of the mandible's lower border cortical bone. CT was more accurate than PR in the assessment of the lesion shape, presence of inner bone septa, root resorption, buccolingual expansion and rupture of cortical bone. Most cases of ameloblastoma and OKC presented buccolingual expansion and erosion of cortical bone. Only ameloblastomas showed tooth root resorption. CONCLUSIONS: Although PR is very helpful and widely used, CT provides more precise information on buccolingual expansion, calcification, bone septa, perforation of cortical bones and tooth resorption, features that are frequently underdescribed in the literature, particularly in OKC.
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Affiliation(s)
- Daniel Berretta Moreira Alves
- 1 Department of Oral Diagnosis, Piracicaba Dental School, University of Campinas (UNICAMP) , Campinas , Brazil.,2 Department of Oral Diagnosis, Esperança Institute of Higher Learning , Santarém, Pará , Brazil
| | - Fabrício Mesquita Tuji
- 3 Department of Oral Radiology, School of Dentistry, Federal University of Pará , Belém , Brazil
| | - Fábio Abreu Alves
- 4 Stomatology Department, A. C. Camargo Hospital , São Paulo , Brazil
| | | | - Alan Roger Dos Santos-Silva
- 1 Department of Oral Diagnosis, Piracicaba Dental School, University of Campinas (UNICAMP) , Campinas , Brazil
| | - Pablo Agustin Vargas
- 1 Department of Oral Diagnosis, Piracicaba Dental School, University of Campinas (UNICAMP) , Campinas , Brazil
| | - Márcio Ajudarte Lopes
- 1 Department of Oral Diagnosis, Piracicaba Dental School, University of Campinas (UNICAMP) , Campinas , Brazil
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20
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Lim LZ, Padilla RJ, Reside GJ, Tyndall DA. Comparing panoramic radiographs and cone beam computed tomography: Impact on radiographic features and differential diagnoses. Oral Surg Oral Med Oral Pathol Oral Radiol 2018; 126:S2212-4403(18)30888-5. [PMID: 29748039 DOI: 10.1016/j.oooo.2018.03.019] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2017] [Revised: 03/13/2018] [Accepted: 03/26/2018] [Indexed: 10/17/2022]
Abstract
OBJECTIVES The aims of this study were to determine whether lesion features appear differently on panoramic radiography (PAN) and cone beam computed tomography (CBCT), and whether the use of CBCT affects diagnostic accuracy and observers' confidence in comparison with PAN. STUDY DESIGN Three oral and maxillofacial radiologists reviewed 33 sets of PAN images and CBCT volumes of biopsy-proven lesions. They described 12 different lesion features and provided up to 3 ranked differential diagnoses, as well as their confidence with respect to those diagnoses. Their confidence was weighted by the rank at which the correct diagnosis was provided. RESULTS Odds ratios (ORs) were statistically significant for border definition (OR = 5.45; P = .004), continuity of border cortication (OR = 0.34; P = .035), effect on neurovascular canals (OR = 6.38; P = .043), expansion (OR = 18.56; P < .001), cortical thinning (OR = 30.22; P < .001), and cortical destruction (OR = 9.80; P < .001). There was no association between the 2 modalities and the rank at which the correct differential diagnoses were made or the observers' weighted confidence. CONCLUSIONS Before acquiring a CBCT scan to aid in the diagnosis of an intraosseous lesion, clinicians should consider the diagnostic information that is expected to be gained. In this study, although there were differences between PAN and CBCT with respect to some lesion features, CBCT did not help improve diagnostic accuracy.
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Affiliation(s)
- Li Zhen Lim
- Department of Diagnostic Sciences, University of North Carolina at Chapel Hill School of Dentistry, Chapel Hill, NC, USA.
| | - Ricardo J Padilla
- Department of Diagnostic Sciences, University of North Carolina at Chapel Hill School of Dentistry, Chapel Hill, NC, USA
| | - Glenn J Reside
- Department of Oral and Maxillofacial Surgery, University of North Carolina at Chapel Hill School of Dentistry, Chapel Hill, NC, USA
| | - Donald A Tyndall
- Department of Diagnostic Sciences, University of North Carolina at Chapel Hill School of Dentistry, Chapel Hill, NC, USA
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21
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Shimamoto H, Grogan TR, Tsujimoto T, Kakimoto N, Murakami S, Elashoff D, Aghaloo TL, Tetradis S. Does CBCT alter the diagnostic thinking efficacy, management and prognosis of patients with suspected Stage 0 medication-related osteonecrosis of the jaws? Dentomaxillofac Radiol 2017; 47:20170290. [PMID: 29168936 DOI: 10.1259/dmfr.20170290] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
OBJECTIVES To evaluate the impact of cone beam CT (CBCT) in the diagnostic thinking efficacy, management and prognosis of patients with suspected Stage 0 medication-related osteonecrosis of the jaw (MRONJ). METHODS For 15 patients with suspected Stage 0 MRONJ, clinical photographs, a panoramic radiograph and selected CBCT sections were identified. 13 oral surgeons reviewed the material and answered 10 questions in two different sessions. First session included clinical photographs and panoramic radiographs, while second session also included CBCT images. Questions (Qs) referred to dental disease and bone abnormalities (Qs 1, 2 and 3), differential diagnosis (Qs 4 and 5), patient management (Qs 6 and 7) and prognosis (Qs 8 and 9). Q 10 queried indication (first session) and usefulness (second session) of CBCT images. RESULTS Qs 2, 3, 5, 7 and 9 scores increased between sessions, with statistical differences for Qs 2, 3, 5 and 7 (<0.05). Patients 2, 8 and 11 showed a significant increase in the average score of all Qs between sessions, while scores for patient 10 nearly reached statistical significance (p = 0.055). For Q 10, 57.4% of answers reported that CBCT was needed (first session) and was beneficial (second session). CONCLUSIONS CBCT had a significant impact in differential diagnosis and management of patients with suspected Stage 0 MRONJ.
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Affiliation(s)
- Hiroaki Shimamoto
- 1 Department of Oral and Maxillofacial Radiology, Osaka University Graduate School of Dentistry , Suita, Osaka , Japan.,2 Section of Oral and Maxillofacial Radiology, UCLA School of Dentistry , Los Angeles, CA , USA
| | - Tristan R Grogan
- 3 Statistics Core, David Geffen School of Medicine, University of California Los Angeles , Los Angeles, CA , USA
| | - Tomomi Tsujimoto
- 1 Department of Oral and Maxillofacial Radiology, Osaka University Graduate School of Dentistry , Suita, Osaka , Japan
| | - Naoya Kakimoto
- 4 Department of Oral and Maxillofacial Radiology, Institute of Biomedical & Health Sciences, Hiroshima University , Minami-ku, Hiroshima , Japan
| | - Shumei Murakami
- 1 Department of Oral and Maxillofacial Radiology, Osaka University Graduate School of Dentistry , Suita, Osaka , Japan
| | - David Elashoff
- 3 Statistics Core, David Geffen School of Medicine, University of California Los Angeles , Los Angeles, CA , USA
| | - Tara L Aghaloo
- 5 Section of Oral and Maxillofacial Surgery, UCLA, School of Dentistry , Los Angeles, CA , USA
| | - Sotirios Tetradis
- 2 Section of Oral and Maxillofacial Radiology, UCLA School of Dentistry , Los Angeles, CA , USA
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22
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Gönen ZB, Yillmaz Asan C, Zararsiz G, Kiliç E, Alkan A. Osseous changes in patients with medication-related osteonecrosis of the jaws. Dentomaxillofac Radiol 2017; 47:20170172. [PMID: 28871814 DOI: 10.1259/dmfr.20170172] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVES Medication-related osteonecrosis of the jaw (MRONJ) is a severe side effect of antiresorptive agents. The aim of this study was to investigate the osseous changes in patients with MRONJ. METHODS Cone beam CT (CBCT) images of 25 patients with MRONJ and controls were retrospectively evaluated. Buccal, lingual, apical cortical bone thicknesses; buccal, lingual, apical intracortical and cancellous bone density; diameter of mental foramen and incisive canal, and width of mental foramen were measured. RESULTS Buccal and apical cortical bone thicknesses were increased; however intracortical radiodensity values decreased in the Study Group when compared with the Control Group (p = 0.007, p = 0.001). Narrowing of incisive canal was observed in patients with MRONJ (p = 0.000). CONCLUSIONS Clinician should have awareness about narrowing of incisive canal, apical and buccal cortical bone thickening, decreasing in cancellous bone radiodensity, and the lingual cortex destruction in patients with MRONJ.
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Affiliation(s)
- Zeynep Burcin Gönen
- 1 Department of Oral and Maxillofacial Surgery, Faculty of Dentistry and Genome - Stem Cell Center, Erciyes University, Kayseri, Turkey
| | - Canay Yillmaz Asan
- 2 Department of Oral and Maxillofacial Surgery, Ministry of Dental Health Hospital, Kayseri, Turkey
| | - Gökmen Zararsiz
- 3 Department of Biostatistics, Faculty of Medicine, Erciyes University and Turcosa Analytics Solutions Ltd. Co, Erciyes Teknopark, Kayseri, Turkey
| | - Erdem Kiliç
- 4 Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Bezmialem University, Istanbul, Turkey
| | - Alper Alkan
- 4 Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Bezmialem University, Istanbul, Turkey
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Voss P, Poxleitner P, Schmelzeisen R, Stricker A, Semper-Hogg W. Update MRONJ and perspectives of its treatment. JOURNAL OF STOMATOLOGY, ORAL AND MAXILLOFACIAL SURGERY 2017; 118:232-235. [DOI: 10.1016/j.jormas.2017.06.012] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/07/2017] [Accepted: 06/20/2017] [Indexed: 11/16/2022]
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Vilarinho JLP, Ferrare N, Moreira AMR, Moura HF, Acevedo AC, Chaves SB, Melo NS, Leite AF, Macedo SB, de Souza MP, Guimarães ATB, Figueiredo PT. Early bony changes associated with bisphosphonate-related osteonecrosis of the jaws in rats: A longitudinal in vivo study. Arch Oral Biol 2017. [PMID: 28622548 DOI: 10.1016/j.archoralbio.2017.06.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECTIVE To evaluate early bony changes in an animal model of Medication-Related Osteonecrosis of the Jaw (MRONJ) at the side of the local trauma and at the contralateral side, comparing with a control group. Bony changes were evaluated by Microcomputed Tomography (MicroCT) at three times points: at baseline (T0), after drug administration (T1) and after dental extraction (T2). DESIGN Two groups were compared: the experimental group in which zoledronic acid (ZA) was administered (17 rats) and the control group (13 rats). Dental extractions of the lower left first molars were performed in all animals. The left side was considered as the supposed affected area in the ZA group, and the right side was considered as the unaffected area. In these areas, the following structural microtomographic bone parameters were calculated: Bone Mineral Density (BMD), Trabecular Thickness (Tb.Th), and Bone Volume Proportion (BV/TV). The comparison of quantitative bone parameters among the different sides and experimental phases of both studied groups were performed by ANOVA-factorial. RESULTS None of the animals of the control group developed MRONJ. In the ZA group, 76% presented bone exposure. From T0 to T1, Tb.Th and BV/TV increased, and in T2, the mean values were higher in ZA group than in the control group. BMD increased throughout the different phases of both groups. CONCLUSIONS Structural bony changes occurred in the ZA group at both mandibular sides before the dental extraction (T1). Tb.Th and BV/TV should be further investigated as potential early bone markers of MRONJ.
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Affiliation(s)
- Josy Lorena Peres Vilarinho
- Department of Dentistry, Faculty of Health Sciences, University of Brasília, Campus Universitário Darcy Ribeiro, Asa Norte, Zip Code: 70910-900, Brasília, Brazil.
| | - Nathália Ferrare
- Department of Dentistry, Faculty of Health Sciences, University of Brasília, Campus Universitário Darcy Ribeiro, Asa Norte, Zip Code: 70910-900, Brasília, Brazil.
| | - Andreia Maria Rocha Moreira
- Department of Dentistry, Faculty of Health Sciences, University of Brasília, Campus Universitário Darcy Ribeiro, Asa Norte, Zip Code: 70910-900, Brasília, Brazil.
| | - Helora Freitas Moura
- Department of Dentistry, Faculty of Health Sciences, University of Brasília, Campus Universitário Darcy Ribeiro, Asa Norte, Zip Code: 70910-900, Brasília, Brazil.
| | - Ana Carolina Acevedo
- Oral Care Center for Inherited Diseases, Faculty of Health Sciences, University of Brasília, Campus Universitário Darcy Ribeiro, Asa Norte, Zip Code: 70910-900, Brasília, Brazil.
| | - Sacha Braun Chaves
- Biology Institute University of Brasília, Campus Universitário Darcy Ribeiro, Asa Norte, Zip Code: 70910-900, Brasília, Brazil.
| | - Nilce Santos Melo
- Department of Dentistry, Faculty of Health Sciences, University of Brasília, Campus Universitário Darcy Ribeiro, Asa Norte, Zip Code: 70910-900, Brasília, Brazil.
| | - André Ferreira Leite
- Department of Dentistry, Faculty of Health Sciences, University of Brasília, Campus Universitário Darcy Ribeiro, Asa Norte, Zip Code: 70910-900, Brasília, Brazil.
| | - Sérgio Bruzadelli Macedo
- Department of Dentistry, Faculty of Health Sciences, University of Brasília, Campus Universitário Darcy Ribeiro, Asa Norte, Zip Code: 70910-900, Brasília, Brazil.
| | - Melissa Paoletti de Souza
- Biological Sciences Department, State University of West Paraná, Rua Universitária 2069, Cascavel, Zip Code: 85819-110, Paraná, Brazil.
| | - Ana Tereza Bittencourt Guimarães
- Biological Sciences Department, State University of West Paraná, Rua Universitária 2069, Cascavel, Zip Code: 85819-110, Paraná, Brazil.
| | - Paulo Tadeu Figueiredo
- Department of Dentistry, Faculty of Health Sciences, University of Brasília, Campus Universitário Darcy Ribeiro, Asa Norte, Zip Code: 70910-900, Brasília, Brazil.
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Koth VS, Figueiredo MA, Salum FG, Cherubini K. Interrelationship of clinical, radiographic and haematological features in patients under bisphosphonate therapy. Dentomaxillofac Radiol 2017; 46:20160260. [PMID: 28107028 DOI: 10.1259/dmfr.20160260] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVES To analyze the clinical, radiographic and haematological aspects of patients under bisphosphonate therapy. METHODS A retrospective study was conducted where the records of patients taking bisphosphonates were analyzed considering the occurrence of bisphosphonate-related osteonecrosis of the jaw (BRONJ). Evaluation included panoramic and periapical radiographies, haematological examinations and clinical features. Radiographies were analyzed determining the presence or absence of bone sclerosis, osteolysis, persisting alveolar socket, narrowing of the mandibular canal, widening of the periodontal ligament space, periradicular radiolucency, sequestrum and thickening of the lamina dura. Laboratory tests consisted of complete blood count, fasting serum glucose, erythrocyte sedimentation rate (ESR) and serum levels of calcium, phosphorus, alkaline phosphatase, parathormone (PTH) and C-terminal telopeptide of collagen I (CTX). RESULTS Alkaline phosphatase and ESR were significantly higher in the BRONJ group, whereas fasting serum glucose, CTX, PTH, calcium and phosphorus did not significantly differ. BRONJ showed association with smoking, tooth extraction, anaemia and leukocytosis. On radiographic analysis, persisting alveolar socket, osteolysis, bone sclerosis and narrowing of the mandibular canal were significantly more prevalent in the BRONJ group. Thickening of the lamina dura, periapical radiolucencies, widening of the periodontal ligament space and sequestrum did not significantly differ between the groups. CONCLUSIONS BRONJ is a multifactorial disease with high morbidity, which requires experimental studies to clarify the role of the reported risk factors and clinical radiographic signs to improve its diagnosis.
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Affiliation(s)
- Valesca S Koth
- Dental College, Pontifical Catholic University of Rio Grande do Sul, Porto Alegre, Brazil
| | - Maria A Figueiredo
- Dental College, Pontifical Catholic University of Rio Grande do Sul, Porto Alegre, Brazil
| | - Fernanda G Salum
- Dental College, Pontifical Catholic University of Rio Grande do Sul, Porto Alegre, Brazil
| | - Karen Cherubini
- Dental College, Pontifical Catholic University of Rio Grande do Sul, Porto Alegre, Brazil
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Bagan L, Leopoldo-Rodado M, Poveda-Roda R, Murillo-Cortes J, Diaz-Fernández J, Bagan J. Grade of sclerosis in the contralateral mandibular area in osteonecrosis of the jaws. Int J Oral Maxillofac Surg 2017; 46:167-172. [DOI: 10.1016/j.ijom.2016.09.025] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2016] [Revised: 08/03/2016] [Accepted: 09/29/2016] [Indexed: 11/29/2022]
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Identifying MRONJ-affected bone with digital fusion of functional imaging (FI) and cone-beam computed tomography (CBCT): case reports and hypothesis. Oral Surg Oral Med Oral Pathol Oral Radiol 2016; 123:e106-e116. [PMID: 28108142 DOI: 10.1016/j.oooo.2016.11.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2016] [Revised: 11/11/2016] [Accepted: 11/21/2016] [Indexed: 01/26/2023]
Abstract
Surgical debridement of medication-related osteonecrosis of the jaw (MRONJ) lesions is far less predictable than lesion resection. Margins for surgical debridement are guided by surrogate markers of bone viability, such as bleeding and bone fluorescence, which limit debridement to visibly necrotic bone. In contrast, surgical resection is extensive, including a substantial portion of surrounding bone. The concept that the MRONJ lesion is a composite of affected but viable ("compromised") and necrotic bone is supported by histopathological data. Hence, removing only the necrotic bone during lesion debridement could inadvertently leave behind residual compromised bone in the lesion, subsequently contributing to persistence or reestablishment of the lesion. Using 2 case reports, this manuscript illustrates a novel assessment of the MRONJ lesion to enable demarcation of both the compromised and necrotic portions of the lesion. This assessment uses tumor-surveillance functional bone imaging data that may already be available for cancer patients with MRONJ and fuses these data digitally with computed tomography/cone-beam computed tomography imaging of the jaw obtained during MRONJ assessment. If validated, preoperative functional imaging-based assessment of the MRONJ lesion could enable surgeons to eliminate both the compromised and nonviable portions of the lesion precisely with conservative debridement, matching surgical resection in outcome.
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Berg BI, Mueller AA, Augello M, Berg S, Jaquiéry C. Imaging in Patients with Bisphosphonate-Associated Osteonecrosis of the Jaws (MRONJ). Dent J (Basel) 2016; 4:E29. [PMID: 29563471 PMCID: PMC5806936 DOI: 10.3390/dj4030029] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2016] [Revised: 08/11/2016] [Accepted: 08/17/2016] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Bisphosphonate-associated osteonecrosis of the jaws (MRONJ/BP-ONJ/BRONJ) is a commonly seen disease. During recent decades, major advances in diagnostics have occurred. Once the clinical picture shows typical MRONJ features, imaging is necessary to determine the size of the lesion. Exposed bone is not always painful, therefore a thorough clinical examination and radiological imaging are essential when MRONJ is suspected. METHODS In this paper we will present the latest clinical update on the imaging options in regard to MRONJ: X-ray/Panoramic Radiograph, Cone Beam Computed Tomography (CBCT) and Computed Tomography (CT), Magnetic Resonance Imaging (MRI), Nuclear Imaging, Fluorescence-Guided Bone Resection. CONCLUSION Which image modality is chosen depends not only on the surgeon's/practitioner's preference but also on the available imaging modalities. A three-dimensional imaging modality is desirable, and in severe cases necessary, for extended resections and planning of reconstruction.
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Affiliation(s)
- Britt-Isabelle Berg
- Department of Cranio-Maxillofacial Surgery, University Hospital Basel, 4056 Basel, Switzerland.
- Division of Oral and Maxillofacial Radiology, Columbia University Medical Center, New York, NY 10032, USA.
| | - Andreas A Mueller
- Department of Cranio-Maxillofacial Surgery, University Hospital Basel, 4056 Basel, Switzerland.
| | - Marcello Augello
- Clinic of Cranio-Maxillofacial Surgery, Kantonsspital Aarau, 5001 Aarau, Switzerland.
| | - Scott Berg
- Private Practice, 25524 Itzehoe, Germany.
| | - Claude Jaquiéry
- Department of Cranio-Maxillofacial Surgery, University Hospital Basel, 4056 Basel, Switzerland.
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Wolff C, Mücke T, Wagenpfeil S, Kanatas A, Bissinger O, Deppe H. Do CBCT scans alter surgical treatment plans? Comparison of preoperative surgical diagnosis using panoramic versus cone-beam CT images. J Craniomaxillofac Surg 2016; 44:1700-1705. [PMID: 27567358 DOI: 10.1016/j.jcms.2016.07.025] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2016] [Revised: 06/16/2016] [Accepted: 07/27/2016] [Indexed: 02/07/2023] Open
Abstract
Cone beam CT and/or panoramic images are often required for a successful diagnosis in oral and maxillofacial surgery. The aim of this study was to evaluate if 3D diagnostic imaging information had a significant impact on the decision process in six different classes of surgical indications. MATERIAL AND METHODS Records of all patients who had undergone both panoramic X-ray and CBCT imaging due to surgical indications between January 2008 and December 2012 were examined retrospectively. In February 2013, all surgically relevant diagnoses of both conventional panoramic radiographs and CBCT scans were retrieved from the patient's charts. It was recorded whether (1) 3D imaging presented additional surgically relevant information and (2) if the final decision of surgical therapy had been based on 2D or 3D imaging. RESULTS A total of 253 consecutive patients with both panoramic radiographs and CBCT analysis were eligible for the study. 3D imaging provided significantly more surgically relevant information in cases of implant dentistry, maxillary sinus diagnosis and in oral and maxillofacial traumatology. However, surgical strategies had not been influenced to any significant extent by 3D imaging. CONCLUSION Within the limitations of this study it may be concluded that CBCT imaging results in significantly more surgically relevant information in implant dentistry, maxillary sinus diagnosis and in cases of oral and maxillofacial trauma. However, 3D imaging information did not alter significantly the surgical plan that was based on 2D panoramic radiography. Further studies are necessary to define indications for CBCT in detail.
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Affiliation(s)
- Carolina Wolff
- Department of Oral and Craniomaxillofacial Surgery, Technical University of Munich, Klinikum rechts der Isar, Germany.
| | - Thomas Mücke
- Department of Oral and Craniomaxillofacial Surgery, Technical University of Munich, Klinikum rechts der Isar, Germany.
| | - Stefan Wagenpfeil
- Institute for Medical Biometry, Epidemiology and Medical Informatics, University of Saarland, Homburg/Saar, Germany.
| | - Anastasios Kanatas
- Leeds Teaching Hospitals and St James Institute of Oncology, Leeds General Infirmary, LS1 3EX, UK.
| | - Oliver Bissinger
- Department of Oral and Craniomaxillofacial Surgery, Technical University of Munich, Klinikum rechts der Isar, Germany.
| | - Herbert Deppe
- Department of Oral and Craniomaxillofacial Surgery, Technical University of Munich, Klinikum rechts der Isar, Germany.
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Koth VS, Figueiredo MA, Salum FG, Cherubini K. Bisphosphonate-related osteonecrosis of the jaw: from the sine qua non condition of bone exposure to a non-exposed BRONJ entity. Dentomaxillofac Radiol 2016; 45:20160049. [PMID: 27167455 DOI: 10.1259/dmfr.20160049] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
The present work aimed to review the literature focusing on the diagnostic criteria for bisphosphonate-related osteonecrosis of the jaw (BRONJ) and its implications regarding the management of the disease. Since the report of the first cases, BRONJ concepts, diagnostic criteria and guidelines have been changed. The presence of bone exposure in the oral cavity was at first a sine qua non condition for diagnosis. However, it seems that the great concern now is the possibility of occurrence of BRONJ without this feature. Some authors warn that the bone exposure criterion leads to late diagnosis and poor response to treatment. Meanwhile, some radiographic features, such as bone sclerosis, have been postulated as early signs of the disease. Criticisms have also been raised about the clinical staging system of BRONJ. While there is no consensus on the subject, common sense recommends treating symptomatic patients taking bisphosphonate as having BRONJ despite the absence of bone exposure; and asymptomatic patients must be kept under dental follow-up, since all of them are at risk for BRONJ.
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Affiliation(s)
- Valesca Sander Koth
- 1 Post-Graduate Program, Dental College, Pontifical Catholic University of Rio Grande do Sul, Porto Alegre, Brazil
| | - Maria Antonia Figueiredo
- 1 Post-Graduate Program, Dental College, Pontifical Catholic University of Rio Grande do Sul, Porto Alegre, Brazil
| | - Fernanda Gonçalves Salum
- 1 Post-Graduate Program, Dental College, Pontifical Catholic University of Rio Grande do Sul, Porto Alegre, Brazil
| | - Karen Cherubini
- 1 Post-Graduate Program, Dental College, Pontifical Catholic University of Rio Grande do Sul, Porto Alegre, Brazil
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Kämmerer PW, Thiem D, Eisenbeiß C, Dau M, Schulze RKW, Al-Nawas B, Draenert FG. Surgical evaluation of panoramic radiography and cone beam computed tomography for therapy planning of bisphosphonate-related osteonecrosis of the jaws. Oral Surg Oral Med Oral Pathol Oral Radiol 2015; 121:419-24. [PMID: 26876493 DOI: 10.1016/j.oooo.2015.11.012] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2015] [Revised: 11/02/2015] [Accepted: 11/18/2015] [Indexed: 11/29/2022]
Abstract
OBJECTIVES The purpose of this retrospective study was to compare the clinical significance of panoramic radiography (orthopantomography [OPTG]) and cone beam computed tomography (CBCT) for therapy planning of bisphosphonate-related osteonecrosis of the jaw (BRONJ) by surgeons. STUDY DESIGN Using standardized questionnaire, eight maxillofacial surgeons evaluated intraoral photographs of the clinical situation of 14 patients with BRONJ as well as the corresponding radiographic images (OPTG, CBCT). The presence of five typical BRONJ signs (bone-remodeling, periosteal reaction, osteosclerosis, sequestra, and continuity of cortical bone) was evaluated with OPTG and CBCT. The influence of radiologic information on therapy decision was examined as well. RESULTS On the basis of the information from intraoral photographs only, seven of the eight surgeons indicated that an additional radiographic examination was necessary for further therapy planning. For evaluation of the five radiographic BRONJ signs, CBCT provided significantly better values compared with OPTG (all P < .05). A before-and-after comparison showed that four of the eight surgeons changed their therapy concept after having three-dimensional CBCT information. The majority (6 of 8) of the surgeons considered that an additional CBCT was required for therapy planning, even after having studied the clinical photographs and OPTG images. CONCLUSION These data demonstrate a significant advantage of CBCT over OPTG for surgeons with regard to therapeutic planning for BRONJ.
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Affiliation(s)
- Peer W Kämmerer
- Department of Oral and Maxillofacial Surgery, Facial Plastic Surgery, Medical Centre of the University of Rostock, Rostock, Mecklenburg-Vorpommern, Germany.
| | - Daniel Thiem
- Department of Oral and Maxillofacial Surgery, Facial Plastic Surgery, Medical Centre of the University of Rostock, Rostock, Mecklenburg-Vorpommern, Germany
| | - Christoph Eisenbeiß
- Department of Oral and Maxillofacial Surgery, Plastic Surgery, University Medical Centre of the Johannes Gutenberg-University Mainz, Mainz, Rheinland-Pfalz, Germany
| | - Michael Dau
- Department of Oral and Maxillofacial Surgery, Facial Plastic Surgery, Medical Centre of the University of Rostock, Rostock, Mecklenburg-Vorpommern, Germany
| | - Ralf K W Schulze
- Department of Oral Surgery, University Medical Centre Mainz, Mainz, Rheinland-Pfalz, Germany
| | - Bilal Al-Nawas
- Department of Oral and Maxillofacial Surgery, Plastic Surgery, University Medical Centre of the Johannes Gutenberg-University Mainz, Mainz, Rheinland-Pfalz, Germany
| | - Florian G Draenert
- Department of Oral and Maxillofacial Surgery, Plastic Surgery, University Medical Centre of the Johannes Gutenberg-University Mainz, Mainz, Rheinland-Pfalz, Germany
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Diagnosis and Staging of Medication-Related Osteonecrosis of the Jaw. Oral Maxillofac Surg Clin North Am 2015; 27:479-87. [DOI: 10.1016/j.coms.2015.06.008] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Reich W, Bilkenroth U, Schubert J, Wickenhauser C, Eckert AW. Surgical treatment of bisphosphonate-associated osteonecrosis: Prognostic score and long-term results. J Craniomaxillofac Surg 2015; 43:1809-22. [PMID: 26321065 DOI: 10.1016/j.jcms.2015.07.035] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2015] [Revised: 07/19/2015] [Accepted: 07/29/2015] [Indexed: 12/24/2022] Open
Abstract
Over a century after the first synthesis of bisphosphonates (1897) and a decade (2003) since the initial report on bisphosphonate-related osteonecrosis of the jaw (ONJ), this osteopathy remains a serious clinical challenge. A single center longitudinal study (2005-2014) was carried out to prospectively characterize inpatients with manifest ONJ and to evaluate their outcomes. The data recorded were: medical history, bisphosphonate treatment, localization, imaging, treatment, histomorphological features, and complications. A prognostic score (modified UCONN-Score) was adopted to predict outcomes. Eighty patients were included (mean age 69.4 years; 40 male, 40 female). Breast cancer (n = 25), multiple myeloma (n = 16), and prostate cancer (n = 15) were the three most common malignancies; and cardiovascular disease (n = 31), diabetes mellitus (16), and renal disorders (6) were the most important comorbidities. The severity of ONJ was stage I in three patients, stage II in 37, and stage III in 40, being predominantly localized in the posterior mandible and needing gradual resection. The average duration of bisphosphonate treatment was 38.3 months. The typical histological aspects of ONJ were predominantly osteonecrosis, bone marrow fibrosis, and bacterial colonization (Actinomyces) with suppurative inflammation. Within the resected jawbone a primary malignancy was diagnosed in two cases. The overall success rate was 83.6% (follow-up 23.5 months), with a UCONN-Score ≥15 predicting unfavorable treatment results (OR = 5.2). The past decade has enhanced experience with ONJ treatment and knowledge about its pathogenesis, which seems to be a multistep process. This study demonstrates the importance of bone and multilayer soft tissue management, preferably as an early intervention. The UCONN-Score might help to assess individual prognosis in ONJ surgery and the potential benefit of an antiresorptive drug holiday. To our knowledge it is the first use of a prognostic score in ONJ surgery.
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Affiliation(s)
- Waldemar Reich
- Department of Oral and Plastic Maxillofacial Surgery (Temporary Head: Prof. Dr. Dr. Alexander Walter Eckert, MD, DMD, PhD), Martin Luther University Halle-Wittenberg, Ernst-Grube Str. 40, 06120 Halle (Saale), Germany.
| | - Udo Bilkenroth
- Institute of Pathology Lutherstadt Eisleben (Head: Dr. Udo Bilkenroth, MD, PhD), Hohetorstr. 25, 06295 Lutherstadt, Eisleben, Germany
| | - Johannes Schubert
- Department of Oral and Plastic Maxillofacial Surgery (Temporary Head: Prof. Dr. Dr. Alexander Walter Eckert, MD, DMD, PhD), Martin Luther University Halle-Wittenberg, Ernst-Grube Str. 40, 06120 Halle (Saale), Germany
| | - Claudia Wickenhauser
- Institute of Pathology (Head: Prof. Dr. Claudia Wickenhauser, MD, PhD), Martin Luther University Halle-Wittenberg, Magdeburger Str. 14, 06112 Halle (Saale), Germany.
| | - Alexander Walter Eckert
- Department of Oral and Plastic Maxillofacial Surgery (Temporary Head: Prof. Dr. Dr. Alexander Walter Eckert, MD, DMD, PhD), Martin Luther University Halle-Wittenberg, Ernst-Grube Str. 40, 06120 Halle (Saale), Germany.
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Bagan JV, Cibrian RM, Lopez J, Leopoldo-Rodado M, Carbonell E, Bagán L, Utrilla J, Scully C. Sclerosis in bisphosphonate-related osteonecrosis of the jaws and its correlation with the clinical stages: study of 43 cases. Br J Oral Maxillofac Surg 2015; 53:257-62. [PMID: 25560326 DOI: 10.1016/j.bjoms.2014.12.004] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2014] [Accepted: 12/07/2014] [Indexed: 12/20/2022]
Abstract
We analysed the degree of sclerosis in the different stages of bisphosphonate-related osteonecrosis of the jaws (BRONJ) and studied the relation between the grade of sclerosis, the clinical symptoms, and the depth of lucency. We compared 43 patients with mandibular BRONJ with a control group of 40 cases with no bony lesions. The presence of sclerotic bone, cortical irregularities, radiolucency, fragmentation or sequestration, periostitis, and narrowing of the mandibular canal were studied from computed tomographic (CT) scans using the program ImageJ 1.47v (National Institute of Health, Bethesda, USA) to measure the radiolucency, width of the cortices, and degree of sclerosis. Patients with BRONJ had more severe sclerosis than controls (p<0.01). There was also a significant difference among the different stages of BRONJ, with the highest values found in stage III (p=0.02). The degree of sclerosis differed according to sex, type of bisphosphonate, and the clinical characteristics such as pain, or suppuration, but not significantly so (p>0.05). We conclude that the degree of sclerosis increases with the clinical stage of BRONJ, and is correlated with the depth of lucency.
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Affiliation(s)
- J V Bagan
- Oral Medicine, Valencia University, Spain; Department of Oral and Maxillofacial Surgery, University General Hospital, Valencia, Spain.
| | - R M Cibrian
- Department of Physiology, Valencia University, Spain
| | - J Lopez
- Department of Physiology, Valencia University, Spain
| | - M Leopoldo-Rodado
- Oral and Maxillofacial Surgery, University General Hospital, Valencia, Spain
| | - E Carbonell
- Stomatology, University General Hospital, Valencia, Spain
| | - L Bagán
- Oral Medicine, Valencia University, Spain; University Cardenal Herrera Valencia, Spain
| | - J Utrilla
- Oral Medicine, Valencia University, Spain
| | - C Scully
- University College London [UCL], UK
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Khan AA, Morrison A, Hanley DA, Felsenberg D, McCauley LK, O'Ryan F, Reid IR, Ruggiero SL, Taguchi A, Tetradis S, Watts NB, Brandi ML, Peters E, Guise T, Eastell R, Cheung AM, Morin SN, Masri B, Cooper C, Morgan SL, Obermayer-Pietsch B, Langdahl BL, Al Dabagh R, Davison KS, Kendler DL, Sándor GK, Josse RG, Bhandari M, El Rabbany M, Pierroz DD, Sulimani R, Saunders DP, Brown JP, Compston J. Diagnosis and management of osteonecrosis of the jaw: a systematic review and international consensus. J Bone Miner Res 2015; 30:3-23. [PMID: 25414052 DOI: 10.1002/jbmr.2405] [Citation(s) in RCA: 814] [Impact Index Per Article: 90.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2014] [Revised: 11/03/2014] [Accepted: 11/05/2014] [Indexed: 11/08/2022]
Abstract
This work provides a systematic review of the literature from January 2003 to April 2014 pertaining to the incidence, pathophysiology, diagnosis, and treatment of osteonecrosis of the jaw (ONJ), and offers recommendations for its management based on multidisciplinary international consensus. ONJ is associated with oncology-dose parenteral antiresorptive therapy of bisphosphonates (BP) and denosumab (Dmab). The incidence of ONJ is greatest in the oncology patient population (1% to 15%), where high doses of these medications are used at frequent intervals. In the osteoporosis patient population, the incidence of ONJ is estimated at 0.001% to 0.01%, marginally higher than the incidence in the general population (<0.001%). New insights into the pathophysiology of ONJ include antiresorptive effects of BPs and Dmab, effects of BPs on gamma delta T-cells and on monocyte and macrophage function, as well as the role of local bacterial infection, inflammation, and necrosis. Advances in imaging include the use of cone beam computerized tomography assessing cortical and cancellous architecture with lower radiation exposure, magnetic resonance imaging, bone scanning, and positron emission tomography, although plain films often suffice. Other risk factors for ONJ include glucocorticoid use, maxillary or mandibular bone surgery, poor oral hygiene, chronic inflammation, diabetes mellitus, ill-fitting dentures, as well as other drugs, including antiangiogenic agents. Prevention strategies for ONJ include elimination or stabilization of oral disease prior to initiation of antiresorptive agents, as well as maintenance of good oral hygiene. In those patients at high risk for the development of ONJ, including cancer patients receiving high-dose BP or Dmab therapy, consideration should be given to withholding antiresorptive therapy following extensive oral surgery until the surgical site heals with mature mucosal coverage. Management of ONJ is based on the stage of the disease, size of the lesions, and the presence of contributing drug therapy and comorbidity. Conservative therapy includes topical antibiotic oral rinses and systemic antibiotic therapy. Localized surgical debridement is indicated in advanced nonresponsive disease and has been successful. Early data have suggested enhanced osseous wound healing with teriparatide in those without contraindications for its use. Experimental therapy includes bone marrow stem cell intralesional transplantation, low-level laser therapy, local platelet-derived growth factor application, hyperbaric oxygen, and tissue grafting.
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Imaging findings of bisphosphonate-related osteonecrosis of the jaws: a critical review of the quantitative studies. Int J Dent 2014; 2014:784348. [PMID: 25018769 PMCID: PMC4075086 DOI: 10.1155/2014/784348] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2014] [Accepted: 05/09/2014] [Indexed: 01/25/2023] Open
Abstract
Objectives. This paper offers a critical review of published information on the imaging strategies used for diagnosing bisphosphonate-associated osteonecrosis of the jaw (BRONJ) in patients taking intravenous bisphosphonates, pointing at the different methodologies and results of existing literature. Methods. Electronic literature search was performed in order to identify as many quantitative studies that discussed the imaging findings of BRONJ up to February 2014. Initially, the search for articles was based on the following four types of imaging modalities for evaluating BRONJ: computed tomography, plain film radiographs, magnetic resonance imaging, and nuclear bone scanning. Results. Eleven out of the 79 initially selected articles met the inclusion criteria. Most of the selected articles were cross-sectional studies. Regarding the selected studies, 54.5% have used plain films radiographs and 54.5% were based on computed tomography findings. All of the selected studies showed a small number of patients and none of the selected studies have tested the accuracy of the imaging examination for evaluating BRONJ. Conclusions. This critical review showed a scarcity of quantitative studies that analyzed the typical imaging findings related to BRONJ. Further studies are necessary in order to analyze the role of different imaging techniques in the assessment of BRONJ.
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Kaptan F, Kazandag MK, Iseri U. Treatment of bisphosphonate related osteonecrosis following root canal therapy at the 1-year follow-up: report of two cases. Ther Clin Risk Manag 2013; 9:477-82. [PMID: 24353427 PMCID: PMC3861363 DOI: 10.2147/tcrm.s52630] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
The objective of this report was to use topical gaseous ozone as an adjunct to conventional treatment methods and to describe the multidisciplinary management of bisphosphonate associated bone necrosis, which developed following endodontic treatment. No complaints were noted by the patients at their 1-year follow-up and the treatment showed favorable prognosis.
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Affiliation(s)
- Figen Kaptan
- Yeditepe University, Faculty of Dentistry, Department of Endodontics, Istanbul, Turkey
| | | | - Ufuk Iseri
- Department of Prosthodontics, Istanbul, Turkey
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Thumbigere-Math V, Michalowicz BS, de Jong EP, Griffin TJ, Basi DL, Hughes PJ, Tsai ML, Swenson KK, Rockwell L, Gopalakrishnan R. Salivary proteomics in bisphosphonate-related osteonecrosis of the jaw. Oral Dis 2013; 21:46-56. [PMID: 24286378 DOI: 10.1111/odi.12204] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2013] [Revised: 09/15/2013] [Accepted: 10/17/2013] [Indexed: 01/01/2023]
Abstract
OBJECTIVE The objective of this study was to identify differentially expressed salivary proteins in bisphosphonate-related osteonecrosis of the jaw (BRONJ) patients that could serve as biomarkers for BRONJ diagnosis. SUBJECTS AND METHODS Whole saliva obtained from 20 BRONJ patients and 20 controls were pooled within groups. The samples were analyzed using iTRAQ-labeled two-dimensional liquid chromatography-tandem mass spectrometry. RESULTS Overall, 1340 proteins were identified. Of these, biomarker candidates were selected based on P-value (<0.001), changes in protein expression (≥1.5-fold increase or decrease), and unique peptides identified (≥2). Three comparisons made between BRONJ and control patients identified 200 proteins to be differentially expressed in BRONJ patients. A majority of these proteins were predicted to have a role in drug metabolism and immunological and dermatological diseases. Of all the differentially expressed proteins, we selected metalloproteinase-9 and desmoplakin for further validation. Immunoassays confirmed increased expression of metalloproteinase-9 in individual saliva (P = 0.048) and serum samples (P = 0.05) of BRONJ patients. Desmoplakin was undetectable in saliva. However, desmoplakin levels tended to be lower in BRONJ serum than controls (P = 0.157). CONCLUSIONS Multiple pathological reactions are involved in BRONJ development. One or more proteins identified by this study may prove to be useful biomarkers for BRONJ diagnosis. The role of metalloproteinase-9 and desmoplakin in BRONJ requires further investigation.
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Affiliation(s)
- V Thumbigere-Math
- Division of Periodontology, University of Minnesota School of Dentistry, Minneapolis, MN, USA
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Beninati F, Pruneti R, Ficarra G. Bisphosphonate-related osteonecrosis of the jaws (Bronj). Med Oral Patol Oral Cir Bucal 2013; 18:e752-8. [PMID: 23722119 PMCID: PMC3790648 DOI: 10.4317/medoral.18076] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2011] [Accepted: 08/15/2012] [Indexed: 11/24/2022] Open
Abstract
Bisphosphonate-related osteonecrosis of the jaws (BRONJ) is an extremely therapy resistant osteomyelitis-like disease exclusively involving the jaw bones of patients in treatment with bisphosphonates (BPs).
Objectives: The aim of this study was to evaluate the radiological and clinical findings and management of 51 patients with BRONJ diagnosed from 2004 to 2009 in our Reference Center.
Study Design: A prospective study was performed. The patients were examined every 2-6 months, depending on their clinical conditions. Outcome variables were the resolution of symptoms, persistence of bone exposure and /or fistula and the status of the lesional mucosa.
Results: The higher prevalence of the disease was noted in 2006 and 2007 and at the time of diagnosis 90% of patients had been treated with iv BPs. The main precipitating event leading to BRONJ was an invasive dental procedure in 61% of patients while no traumatic event could be identified in 16% of patients. The median time of follow-up was 19 months (range: 2-57), during which 31% of patients healed and 39% succumbed. In 78% of patients the therapy was medical, in 16% it consisted in surgical deep curettage and only in 6% it was necessary to perform an osteotomy to avoid a mandibular pathological fracture. All the patients in treatment with oral BPs healed from BRONJ with a median time of conservative treatment of 19 months.
Conclusions: Prevention has lead to a progressive reduction in the prevalence of BRONJ. In our experience medical treatment is often sufficient to keep the disease under control and to lead to the healing of the lesions by spontaneous loss of the sequestrum.
This approach seems to be very effective in patients who were in treatment with oral Bps preparations; BRONJ seems to have a more benign clinical behaviour in these patients.
Key words:Bisphosphonates, osteonecrosis, treatment, follow-up.
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Affiliation(s)
- Francesco Beninati
- Reference Center for the Study of Oral Diseases, University of Florence and Azienda Ospedaliero-Universitaria Careggi, Viale Morgagni 85, Florence 50134, Italy,
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Ruggiero SL. An office-based approach to the diagnosis and management of osteonecrosis. Atlas Oral Maxillofac Surg Clin North Am 2013; 21:167-173. [PMID: 23981492 DOI: 10.1016/j.cxom.2013.05.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Affiliation(s)
- Salvatore L Ruggiero
- Division of Oral and Maxillofacial Surgery, Hofstra North Shore/LIJ School of Medicine, 270-05 76th Avenue, New Hyde Park, Hempstead, NY 11040, USA.
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Rugani P, Luschin G, Jakse N, Kirnbauer B, Lang U, Acham S. Prevalence of bisphosphonate-associated osteonecrosis of the jaw after intravenous zoledronate infusions in patients with early breast cancer. Clin Oral Investig 2013; 18:401-7. [PMID: 23749244 DOI: 10.1007/s00784-013-1012-5] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2012] [Accepted: 05/28/2013] [Indexed: 10/26/2022]
Abstract
OBJECTIVES The definite incidence rate of bisphosphonate-related osteonecrosis of the jaws (BRONJ) is still unknown. The aim of this study was to investigate prevalence of BRONJ in a group of breast cancer patients applying the classification of the Association of Oral and Maxillofacial Surgeons 2009. PATIENTS AND METHODS Between 2000 and 2008, 63 premenopausal early breast cancer patients who were free of metastases were treated with 4 mg zoledronic acid every 6 months over 3 years as participants of a multicenter, randomized, controlled, adjuvant breast cancer medication trial. Patients were not informed about the risk of jaw necrosis. None reported tooth or jaw complaints during the breast cancer follow-up examinations. In 2010, 48 patients of this cohort were investigated concerning BRONJ by clinical and radiological examinations. RESULTS No advanced stages (AAOMS 2009)were detected. However, five patients (10.4%) presented purulent (2) and nonpurulent (3) fistulas and radiological signs correlating to BRONJ stage 0. CONCLUSION Although no case of advanced BRONJ was detected, the study revealed a high prevalence of BRONJ stage 0. This supports the need for tight cooperation between dentists and medical specialists prescribing bisphosphonates including dental pre-therapeutic and follow-up examinations. Adaption of the BRONJ classification taking account to bone exposure via fistulas is recommended. CLINICAL RELEVANCE BRONJ is said to be a complication linked to high-dosage bisphosphonate therapy. The study demonstrates that even after application of zoledronate in a low-dose protocol, early BRONJ occurred. Radiological signs solely are not sufficient to confirm BRONJ; clinical signs are mandatory.
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Affiliation(s)
- Petra Rugani
- Department of Oral Surgery and Radiology, Medical University of Graz, Auenbruggerplatz 12, 8036, Graz, Austria,
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Suei Y. Radiographic findings of bisphosphonate-related osteomyelitis of the jaw: investigation of the diagnostic points by comparison with radiation osteomyelitis, suppurative osteomyelitis, and diffuse sclerosing osteomyelitis. Oral Radiol 2013. [DOI: 10.1007/s11282-013-0135-3] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Radiologic bone loss in patients with bisphosphonate-associated osteonecrosis of the jaws: a case-control study. Clin Oral Investig 2013; 18:385-90. [PMID: 23525860 DOI: 10.1007/s00784-013-0974-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2012] [Accepted: 03/14/2013] [Indexed: 02/06/2023]
Abstract
OBJECTIVES Most patients with bisphosphonate-associated osteonecrosis of the jaws (BP-ONJ) report a previous tooth extraction at the necrosis site before the diagnosis was made. At older ages, most teeth are extracted due to periodontal disease, which is per se another BP-ONJ trigger factor. The aim of this study was to evaluate the periodontal status of BP-ONJ patients using panoramic radiographs compared to a control. MATERIALS AND METHODS All patients treated for BP-ONJ up to January 1, 2010 comprised the study. The very first panoramic radiograph was analyzed. The number of remaining teeth and the radiographic bone loss from the cemento-enamel junction to the crestal bone were measured. For each patient, one control was analyzed (matching for gender and age). RESULTS One hundred twenty-nine BP-ONJ panoramic radiographs and 129 controls were analyzed (68 women, 61 men; 67.3 ± 9.7 years; osteoporosis [n = 11], breast cancer [n = 33], multiple myeloma [n = 61], prostate cancer [n = 24]). The average number of remaining teeth was 12.9 ± 8.4 for BP-ONJ and 16.4 ± 9.4 for the control (p = 0.02). The average radiographic bone loss was 5.5 ± 2.3 mm for BP-ONJ and 3.1 ± 1.1 mm for the control (p < 0.001); 96.6 % of BP-ONJ and 77.5 % had radiographic bone loss of more than 5 mm. Radiographic bone loss in the molar region was the highest for both groups (BP-ONJ 6.0 ± 2.3 mm; control 3.6 ± 1.4 mm). CONCLUSION Prevalence and severity of periodontal disease in patients with BP-ONJ is higher compared to healthy controls. CLINICAL RELEVANCE Patients with periodontal disease might be at a higher risk of developing BP-ONJ; therefore, periodontal disease therapy in patients who are about to receive bisphosphonates should be undertaken.
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Prevalence of cone beam computed tomography imaging findings according to the clinical stage of bisphosphonate-related osteonecrosis of the jaw. Oral Surg Oral Med Oral Pathol Oral Radiol 2012; 114:804-11. [DOI: 10.1016/j.oooo.2012.08.458] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2011] [Revised: 05/06/2012] [Accepted: 08/27/2012] [Indexed: 11/20/2022]
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Ruggiero SL. Emerging concepts in the management and treatment of osteonecrosis of the jaw. Oral Maxillofac Surg Clin North Am 2012; 25:11-20, v. [PMID: 23159218 DOI: 10.1016/j.coms.2012.10.002] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Since the first description of bone necrosis in patients receiving bisphosphonate therapy in 2004, there have been multiple retrospective, prospective, and case-control studies that have served to characterize the diagnosis, associated risk factors, and treatment of this new complication. Bisphosphonate-related osteonecrosis of the jaw is at present associated with several risk factors that are identified across several disciplines in medicine and dentistry. With this level of broad-based recognition, new clinical and basic science research initiatives have begun and are likely to elucidate the etiopathogenesis of this disease process, significantly improving the level of disease management and prevention.
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Affiliation(s)
- Salvatore L Ruggiero
- New York Center for Orthognathic and Maxillofacial Surgery, 2001 Marcus Avenue, Suite N10, Lake Success, NY 11042, USA.
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Ahmad M, Jenny J, Downie M. Application of cone beam computed tomography in oral and maxillofacial surgery. Aust Dent J 2012; 57 Suppl 1:82-94. [PMID: 22376100 DOI: 10.1111/j.1834-7819.2011.01661.x] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
In the past decade, the utility of cone beam computed tomography (CBCT) images in oral and maxillofacial surgery has seen continuous increase. However, CBCT images are not always able to replace other imaging modalities. Based on the current published knowledge, this paper discusses advantages and limitations of CBCT images in the diagnosis and surgical planning of dentoalveolar procedures, odontogenic cysts, benign and malignant tumours, inflammatory changes, orthognathic surgery, maxillofacial trauma, sinus disorders, and systemic and osseous conditions that manifest in the maxillofacial area. This paper also suggests alternative imaging modalities when CBCT images are not adequate for surgical planning.
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Affiliation(s)
- Mansur Ahmad
- Division of Oral and Maxillofacial Radiology, School of Dentistry, University of Minnesota, Minneapolis, Minnesota, USA.
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Abstract
Bisphosphonate use has increased in veterinary medicine over the last decade. During this time, bisphosphonate related osteonecrosis of the jaws (BRONJ) in human patients has been identified. Only recently was a dog model for BRONJ developed for human oral surgery and medicine. Veterinary patients treated with bisphosphonates may be at an increased risk for BRONJ There has been little, to no, investigation of potential long term side-effects of bisphosphonate use in veterinary patients; potential sequelae are unknown. The history of bisphosphonates, their use, and BRONJ in veterinary patients are discussed.
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Affiliation(s)
- Kevin Stepaniuk
- College of Veterinary Medicine, University of Minnesota, St. Paul, MN 55108, USA.
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Migliorati CA, Epstein JB, Abt E, Berenson JR. Osteonecrosis of the jaw and bisphosphonates in cancer: a narrative review. Nat Rev Endocrinol 2011; 7:34-42. [PMID: 21079615 DOI: 10.1038/nrendo.2010.195] [Citation(s) in RCA: 83] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Bisphosphonate-associated osteonecrosis (BON) is a complication that almost exclusively affects the jaw bones. The clinical presentation of BON often mimics that of other conditions, such as routine dental disease, osteoradionecrosis or avascular necrosis; therefore, diagnosis can be difficult. As this complication has only been recognized within the past 10 years, management strategies for patients with BON are poorly defined. Physicians must choose between continuing the bisphosphonate therapy (to reduce the risk of skeletal complications in patients with metastatic bone disease or osteoporosis) and discontinuing the drug (to possibly improve the odds for tissue healing). A conservative or aggressive management strategy must be chosen with limited evidence that the outcome of either strategy will be successful. BON is most prevalent in patients with cancer using intravenous nitrogen-containing bisphosphonates. The pathobiology of this complication is not fully understood and the diagnosis relies on the clinical manifestations of the condition. Future research should focus on the pathobiological mechanisms involved in the development of BON, which could help explain why this complication affects only a small number of those who use bisphosphonates, and also suggest strategies for prevention and management.
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Affiliation(s)
- Cesar A Migliorati
- University of Tennessee Health Science Center, College of Dentistry, 875 Union Avenue, Memphis, TN 38163, USA.
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