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Gera I, Szücs N. [The recombinant human parathyroid hormone, teriparatide as an alternative remedy for the medication-related osteonecrosis of the jaw]. Orv Hetil 2023; 164:1406-1415. [PMID: 37695713 DOI: 10.1556/650.2023.32861] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Accepted: 06/30/2023] [Indexed: 09/13/2023]
Abstract
In developed countries, osteoporosis is one of the most common debilitating conditions in the population over the age of 50. Unfortunately, the pathomechanism of the disease is still not fully understood. Nowadays, the administration of antiresorptive drugs blocking osteoclastic activity is the most commonly used medication to slow down the speed of the bone loss. One of the uncommon side effects of such drugs is the medication-related osteonecrosis of the jaw (MRONJ). Recently, a number of alternative therapeutic approaches has been tested and published, amongst them the recombinant human parathyroid hormone (rhPTH, teriparatide) use, which is turning into a promising treatment modality. According to certain meta-analyses, its pharmacological effect on increasing bone mineral density and controlling pathological vertebral fractures is superior to antiresorptive drugs; however, the so-called "off-label" application of teriparatide remains controversial. As intermittent administration of teriparatide stimulates bone formation, several animal and clinical studies indicated that systemic application of teriparatide shortened fracture healing time and improved quality of the callus and the newly formed bone. Furthermore, recently several clinical studies showed the beneficial effect of the intermittent rhPTH administration in the management of MRONJ. This article reviews the history of the anabolic effect of the low-dose rhPTH discovery, provides evidence-based data from animal and human studies, summarizes its biological mechanisms and the clinical benefits of the anabolic therapy and also their possible role in the management of MRONJ. The majority of the clinical data indicates that, in the case of therapy-resistant osteonecrosis, it may be worthwhile to apply short-term intermittent teriparatide therapy. Notwithstanding, more randomized clinical trials are necessary in order to confirm the efficacy and the safety of the use of teriparatide in the treatment of MRONJ. Orv Hetil. 2023; 164(36): 1406-1415.
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Affiliation(s)
- István Gera
- 1 Semmelweis Egyetem, Fogorvostudományi Kar, Parodontológiai Klinika Budapest, Szentkirályi u. 47., 1088 Magyarország
| | - Nikolette Szücs
- 2 Semmelweis Egyetem, Általános Orvostudományi Kar, Belgyógyászati és Onkológiai Klinika Budapest Magyarország
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2
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Anastasilakis AD, Pepe J, Napoli N, Palermo A, Magopoulos C, Khan AA, Zillikens MC, Body JJ. Osteonecrosis of the Jaw and Antiresorptive Agents in Benign and Malignant Diseases: A Critical Review Organized by the ECTS. J Clin Endocrinol Metab 2022; 107:1441-1460. [PMID: 34922381 PMCID: PMC9016445 DOI: 10.1210/clinem/dgab888] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Indexed: 11/19/2022]
Abstract
CONTEXT Antiresorptive therapy significantly reduces fracture risk in patients with benign bone disease and skeletal-related events (SREs) in patients with bone metastases (BM). Osteonecrosis of the jaw (ONJ) is a rare but severe condition manifested as necrotic bone lesion or lesions of the jaws. ONJ has been linked to the use of potent antiresorptive agents, termed medication-related ONJ (MRONJ). OBJECTIVE We aimed to identify the differences various aspects of MRONJ among distinct patient categories and provide recommendations on how to mitigate the risk and optimally manage MRONJ in each of them. METHODS A working group of the European Calcified Tissue Society (ECTS) and 2 experts performed an updated detailed review of existing literature on MRONJ incidence, characteristics, and treatment applied in bone diseases with variable severity of skeletal insult, ranging from osteoporosis to prevention of cancer treatment-induced bone loss and SREs in cancer patients with BM. RESULTS The risk for MRONJ is much higher in patients with advanced malignancies compared to those with benign bone diseases because of the higher doses and more frequent administration of antiresorptive agents in individuals with compromised general health, along with coadministration of other medications that predispose to MRONJ. The overall risk for MRONJ is considerably lower than the benefits in all categories of patients. CONCLUSION The risk for MRONJ largely depends on the underlying bone disease and the relevant antiresorptive regimen applied. Physicians and dentists should keep in mind that the benefits of antiresorptive therapy far outweigh the risk for MRONJ development.
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Affiliation(s)
- Athanasios D Anastasilakis
- Department of Endocrinology, 424 General Military Hospital, 564 29 N Efkarpia Thessaloniki, Greece
- Correspondence: Athanasios D. Anastasilakis, PhD, Department of Endocrinology, 424 General Military Hospital, Ring Rd, 564 29 N Efkarpia, Thessaloniki, Greece.
| | - Jessica Pepe
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, “Sapienza” University of Rome, 00185 Rome, Italy
| | - Nicola Napoli
- Unit of Endocrinology and Diabetes, Departmental Faculty of Medicine and Surgery, Campus Bio-Medico University of Rome, 00128 Rome, Italy
| | - Andrea Palermo
- Unit of Endocrinology and Diabetes, Departmental Faculty of Medicine and Surgery, Campus Bio-Medico University of Rome, 00128 Rome, Italy
| | - Christos Magopoulos
- Department of Oral and Maxillofacial Surgery, 424 General Military Hospital, 56429 Thessaloniki, Greece
| | - Aliya A Khan
- Division of Endocrinology and Metabolism and Geriatrics, McMaster University, L8N3Z5 Hamilton, Ontario, Canada
| | - M Carola Zillikens
- Bone Center, Department of Internal Medicine, Erasmus MC, 2040 Rotterdam, the Netherlands
| | - Jean-Jacques Body
- Department of Medicine, CHU Brugmann, Université Libre de Bruxelles, 1050 Brussels, Belgium
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Current Trends in Adjuvant Therapies for Medication-Related Osteonecrosis of the Jaw. APPLIED SCIENCES-BASEL 2022. [DOI: 10.3390/app12084035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
Medication-related osteonecrosis of the jaw (MRONJ) is a refractory disease, and a standard protocol for its treatment has not yet been established. In addition, owing to the old age of MRONJ patients and various complications, treatment goals focus on relieving the symptoms and improving the quality of life. For this reason, different treatments such as conservative, surgical, and adjunctive treatments have been attempted. In particular, adjunctive treatment, which is effective for promoting healing and reducing recurrence, is gaining increasing interest, and several studies and clinical trials related to it have been published. Representative adjuvant therapies include teriparatide, recombinant human bone morphogenetic protein-2, hyperbaric oxygen, photobiomodulation and platelet concentrates. All have generally shown beneficial effects; however, no standard protocol for adjunctive treatment exists. Therefore, in this literature review, we briefly summarized the different adjuvant therapies and reviewed clinical reports to help decide whether to use adjuvant therapies in treating patients with MRONJ.
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Park JH, Cho S, Kim SJ, Jeong TD, Mun YC, Kim JW. Serum biomarkers for bisphosphonate-related osteonecrosis of the jaw: a prospective clinical study. Osteoporos Int 2022; 33:367-377. [PMID: 34471956 DOI: 10.1007/s00198-021-06137-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Accepted: 08/26/2021] [Indexed: 02/08/2023]
Abstract
UNLABELLED In this prospective study, serum levels of 12 possible biomarkers were compared between osteonecrosis of the jaw (ONJ) and control groups, before and after dentoalveolar surgery. The results suggest that patients with abnormal serum levels of specific biomarkers should be monitored closely for the prevention and early diagnosis of ONJ. INTRODUCTION Bisphosphonate-related osteonecrosis of the jaw (ONJ) is an adverse effect of long-term bisphosphonate therapy. This study aimed to identify bone biomarkers for ONJ risk assessment and diagnosis. METHODS This prospective study included patients with histories of bisphosphonate therapy without current ONJ who were in need of dentoalveolar surgery of the jaw area. Serum levels of 12 possible bone markers, selected based on their involvement in ONJ pathogenesis, were compared between ONJ and control groups before dentoalveolar surgery (T0), at 8 postoperative weeks (T1), and at 4 months after diagnosis(T2). RESULTS Seventy-six patients who met the inclusion criteria were included in the study; 33 were assigned to the ONJ group, and 43 patients without ONJ signs or symptoms after dentoalveolar surgery were assigned to the control group. In the ONJ group, at both T0 and T1, the mean tartrate-resistant acid phosphatase isoform 5b (TRACP 5b) levels were significantly lower and the mean Dickkopf-related protein 1 (DKK1) levels were significantly higher than the corresponding values for the control group. Linear mixed model analysis revealed significant group effects over time for serum TRACP 5b and DKK1 after adjusting for demographic, pharmacological, and diagnostic variables. Lower serum levels of TRACP 5b under a specified cut-off value (≤ 2.899 U/L) at T0 indicated a 20.40-fold increased risk of ONJ development. CONCLUSION Patients with abnormally low serum levels of TRACP 5b and high serum levels of DKK1 should be monitored closely before and after dentoalveolar surgery for the prevention and early diagnosis of ONJ.
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Affiliation(s)
- Jung-Hyun Park
- Department of Oral and Maxillofacial Surgery, Research Institute for Intractable Osteonecrosis of the Jaw, College of Medicine, Ewha Womans University, Anyangcheon-ro 1071, Yangcheon-gu, Seoul, 07985, Republic of Korea
| | - Sura Cho
- Department of Oral and Maxillofacial Surgery, Research Institute for Intractable Osteonecrosis of the Jaw, College of Medicine, Ewha Womans University, Anyangcheon-ro 1071, Yangcheon-gu, Seoul, 07985, Republic of Korea
| | - Sun-Jong Kim
- Department of Oral and Maxillofacial Surgery, Research Institute for Intractable Osteonecrosis of the Jaw, College of Medicine, Ewha Womans University, Anyangcheon-ro 1071, Yangcheon-gu, Seoul, 07985, Republic of Korea
| | - Tae-Dong Jeong
- Department of Laboratory Medicine, College of Medicine, Ewha Womans University, Seoul, Republic of Korea
| | - Yeung-Chul Mun
- Department of Hemato-Oncology, College of Medicine, Ewha Womans University, Seoul, Republic of Korea
| | - Jin-Woo Kim
- Department of Oral and Maxillofacial Surgery, Research Institute for Intractable Osteonecrosis of the Jaw, College of Medicine, Ewha Womans University, Anyangcheon-ro 1071, Yangcheon-gu, Seoul, 07985, Republic of Korea.
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Sharma D, Hamlet S, Vaquette C, Petcu EB, Ramamurthy P, Ivanovski S. Local delivery of hydrogel encapsulated vascular endothelial growth factor for the prevention of medication-related osteonecrosis of the jaw. Sci Rep 2021; 11:23371. [PMID: 34862395 PMCID: PMC8642483 DOI: 10.1038/s41598-021-02637-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Accepted: 11/17/2021] [Indexed: 11/16/2022] Open
Abstract
The anti-angiogenic effects of bisphosphonates have been hypothesized as one of the major etiologic factors in the development of medication-related osteonecrosis of the jaw (MRONJ), a severe debilitating condition with limited treatment options. This study evaluated the potential of a gelatine-hyaluronic acid hydrogel loaded with the angiogenic growth factor, vascular endothelial growth factor (VEGF), as a local delivery system to aid in maintaining vascularization in a bisphosphonate-treated (Zoledronic Acid) rodent maxillary extraction defect. Healing was assessed four weeks after implantation of the VEGF-hydrogel into extraction sockets. Gross examination and histological assessment showed that total osteonecrosis and inflammatory infiltrate was significantly reduced in the presence of VEGF. Also, total vascularity and specifically neovascularization, was significantly improved in animals that received VEGF hydrogel. Gene expression of vascular, inflammatory and bone specific markers within the defect area were also significantly altered in the presence of VEGF. Furthermore, plasma cytokine levels were assessed to determine the systemic effect of locally delivered VEGF and showed similar outcomes. In conclusion, the use of locally delivered VEGF within healing extraction sockets assists bone healing and prevents MRONJ via a pro-angiogenic and immunomodulatory mechanism.
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Affiliation(s)
- Dileep Sharma
- College of Medicine and Dentistry, James Cook University, Cairns Campus, PO Box 6811, Cairns, 4870, Australia. .,Australian Institute of Tropical Health and Medicine, James Cook University, Cairns, Australia.
| | - Stephen Hamlet
- Menzies Health Institute Queensland, School of Medicine and Dentistry, Griffith University, Gold Coast Campus, Gold Coast, 4222, Australia
| | - Cedryck Vaquette
- School of Dentistry, Faculty of Health and Behavioral Sciences, The University of Queensland, Herston Campus, Brisbane, 4006, Australia
| | - Eugen Bogdan Petcu
- New York Institute of Technology College of Osteopathic Medicine (NYIT), Old Westbury, NY, 11545, USA.,School of Dentistry and Oral Health, Griffith University, Gold Coast, Australia
| | - Poornima Ramamurthy
- College of Medicine and Dentistry, James Cook University, Cairns Campus, PO Box 6811, Cairns, 4870, Australia
| | - Saso Ivanovski
- School of Dentistry, Faculty of Health and Behavioral Sciences, The University of Queensland, Herston Campus, Brisbane, 4006, Australia.
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Conservative Management of Severe Medication-Related Osteonecrosis of the Jaw With Pathological Fracture. J Craniofac Surg 2021; 33:e329-e333. [PMID: 34593744 DOI: 10.1097/scs.0000000000008222] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
ABSTRACT Medication-related osteonecrosis of the jaw (MRONJ) is a well-known risk following dental extraction in patients taking certain medications. Pathological fracture secondary to MRONJ often requires complex operative intervention.This case demonstrates the conservative management of pathological fracture secondary to MRONJ in a patient with multiple comorbidities. The patient developed MRONJ with pathological fracture following extraction of the mandibular second molar. The patient presented with significant surgical risk factors, having hypertension and a recent stroke, causing dense left hemiparesis, subsequently resulting in transition to high-level nursing care. Given the high risk of reconstructive surgery, nonoperative management was undertaken. Following a course of long-term antibiotics with resolution of signs of infection, the case was managed conservatively with chlorhexidine-based mouthwash and soft diet.With routine clinico-radiographic assessment and optimal oral health care, the pathological fracture did not require operative intervention. Healing progressed well with no clinical complications and radiographic evidence of good healing at 6- and 12-month follow-up on orthopantomogram.A role for conservative management of pathological fractures secondary to MRONJ yet exists, especially in the elderly population. This case highlights the importance of developing treatment plans based on individual patient context and clinical assessment.
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George EL, Truesdell SL, Magyar AL, Saunders MM. The effects of mechanically loaded osteocytes and inflammation on bone remodeling in a bisphosphonate-induced environment. Bone 2019; 127:460-473. [PMID: 31301402 DOI: 10.1016/j.bone.2019.07.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Revised: 07/03/2019] [Accepted: 07/08/2019] [Indexed: 12/23/2022]
Abstract
Bisphosphonate-related osteonecrosis of the jaw is a disease appearing after tooth removal in patients undergoing bisphosphonate treatment for metastasizing cancers and osteoporosis. The complexity of the condition requires a multicellular model to address the net effects of two key risk factors: mechanical trauma (pathologic overload) and inflammation. In this work, a system comprised of a polydimethylsiloxane chip and mechanical loading device is used to expose bisphosphonate-treated osteocytes to mechanical trauma. Specifically, osteocytes are treated with the potent nitrogen-containing bisphosphonate, zoledronic acid, and exposed to short-term pathologic overload via substrate stretch. During bone remodeling, osteocyte apoptosis plays a role in attracting pre-osteoclasts to sites of damage; as such, lactate dehydrogenase activity, cell death and protein expression are evaluated as functions of load. Additionally, the effects of osteocyte soluble factors on osteoclast and osteoblast functional activity are quantified. Osteoclast activity and bone resorption are quantified in the presence and absence of inflammatory components, lipopolysaccharide and interferon gamma. Results suggest that inflammation associated with bacterial infection may hinder bone resorption by osteoclasts. In addition, osteocytes may respond to overload by altering expression of soluble signals that act on osteoblasts to attenuate bone formation. These findings give insight into the multicellular interactions implicated in bisphosphonate-related osteonecrosis of the jaw.
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Affiliation(s)
- Estee L George
- The University of Akron, Olson Research Center 319, 302 E. Buchtel Ave., Akron, OH 44325-0302, USA.
| | - Sharon L Truesdell
- The University of Akron, Olson Research Center 319, 302 E. Buchtel Ave., Akron, OH 44325-0302, USA.
| | - Alexandria L Magyar
- The University of Akron, Olson Research Center 319, 302 E. Buchtel Ave., Akron, OH 44325-0302, USA.
| | - Marnie M Saunders
- The University of Akron, Olson Research Center 319, 302 E. Buchtel Ave., Akron, OH 44325-0302, USA.
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Kim JW, Alfafara AMD, Kim HY, Kim SY, Kim SJ. Effects of pH alteration on the pathogenesis of medication-related osteonecrosis of the jaw. Bone 2019; 122:45-51. [PMID: 30738857 DOI: 10.1016/j.bone.2019.02.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2018] [Revised: 01/09/2019] [Accepted: 02/06/2019] [Indexed: 01/04/2023]
Abstract
INTRODUCTION An acidic environment has been recognized to increase catabolic activities and inhibit osteoblastic deposition, and also exhibited in the pathogenesis of various bone diseases. The aim of the study was to investigate the role of systemic and local pH alteration in the pathogenesis of medication-related osteonecrosis of the jaw (MRONJ). MATERIAL AND METHODS Initially, MRONJ was induced in 54 Sprague-Dawley rats via subcutaneous bisphosphonate injections, once a week for 8 weeks. A week prior to bisphosphonate termination, surgical intervention was performed and rats were divided into 3 groups-alkalotic, acidic and control group, wherein each received NaHCO3, NH4Cl and normal saline, respectively for 8 weeks. Upon sacrifice, blood was sent for arterial blood pH analysis and their mandibles were subjected to histomorphometric and μCT analyses. ONJ was histologically defined as necrotic bone persisting for eight weeks after surgical intervention. RESULTS Each intervention exemplified its expected outcome wherein each group exhibited a borderline alkalotic (7.43 ± 0.05) and acidic state (7.27 ± 37), respectively (P < 0.05). Acidic group showed a higher occurrence of MRONJ (95%) compared to that of alkalotic group (60%) and control (76.9%). Histomorphometric and microstructural evaluation revealed that acidic group presented deteriorated bone architectures with significantly higher necrotic bone fraction, clusters of empty lacunae, N.Oc/B.Pm and lower B.Ar./T.Ar, BV/TV, Tb.Th (P < 0.05). Alkalotic group showed possible protective effects against ONJ versus acidic group, however these trends were not statistically significant. CONCLUSIONS An acidic milieu aggravated ONJ development in an animal model. Further investigations are needed to elucidate the exact role of acid-base balance in MRONJ pathogenesis and possible benefits of alkali supplementation for the prevention.
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Affiliation(s)
- Jin-Woo Kim
- Department of Oral and Maxillofacial Surgery, Ewha Womans University Medical Center, Seoul, Republic of Korea; Research Institute for Intractable Osteonecrosis of the Jaw, School of Medicine, Ewha Womans University, Seoul, Republic of Korea
| | - Angenine Marie D Alfafara
- Department of Oral and Maxillofacial Surgery, Ewha Womans University Medical Center, Seoul, Republic of Korea; Research Institute for Intractable Osteonecrosis of the Jaw, School of Medicine, Ewha Womans University, Seoul, Republic of Korea
| | - Hye-Yeon Kim
- Research Institute for Intractable Osteonecrosis of the Jaw, School of Medicine, Ewha Womans University, Seoul, Republic of Korea; Department of Family Medicine, Graduate School of Medicine, Ewha Womans University, Seoul, Republic of Korea
| | - Seon-Yeong Kim
- Department of Oral and Maxillofacial Surgery, Ewha Womans University Medical Center, Seoul, Republic of Korea; Research Institute for Intractable Osteonecrosis of the Jaw, School of Medicine, Ewha Womans University, Seoul, Republic of Korea
| | - Sun-Jong Kim
- Department of Oral and Maxillofacial Surgery, Ewha Womans University Medical Center, Seoul, Republic of Korea; Research Institute for Intractable Osteonecrosis of the Jaw, School of Medicine, Ewha Womans University, Seoul, Republic of Korea.
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Mizohata K, Sano T, Oishi K, Morita S. Successful treatment of MRONJ in the palatal torus with teriparatide. JOURNAL OF ORAL AND MAXILLOFACIAL SURGERY MEDICINE AND PATHOLOGY 2018. [DOI: 10.1016/j.ajoms.2018.05.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Lee CH, Son SH, Hong CM, Jeong JH, Jeong SY, Lee SW, Lee J, Kwon TG, Ahn BC. Prevalence and Risk Factors of Atypical Femoral Fracture Bone Scintigraphic Feature in Patients Experiencing Bisphosphonate-Related Osteonecrosis of the Jaw. Nucl Med Mol Imaging 2018; 52:311-317. [PMID: 30100944 DOI: 10.1007/s13139-018-0533-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2018] [Revised: 06/05/2018] [Accepted: 06/29/2018] [Indexed: 12/13/2022] Open
Abstract
Purpose Bisphosphonate (BP) is the first-line therapy for the management of osteoporosis. BP-related osteonecrosis of the jaw (BRONJ) and atypical femoral fracture (AFF) are increasingly common comorbidities in patients with osteoporosis under long-term BP treatment. The aim of this study was to evaluate the incidence and risk factors for AFF features on bone scintigraphy in patients with BRONJ. Methods Among total of 373 BRONJ patients treated between September 2005 and July 2014, 237 (220 women, 17 men; median age 73 years) who underwent three-phase bone scintigraphy were enrolled for this retrospective study. AFF features on bone scintigraphy and the related clinical factors were assessed. Results Among 237 patients with BRONJ, 11 (4.6%) showed AFF features on bone scintigraphy. BP medication duration (p = 0.049) correlated significantly with AFF features on bone scintigraphy in patients with BRONJ. BP intake duration of 34 months was the cutoff value for predicting the presence of AFF features on bone scintigraphy. Among the patients with BRONJ, all those with AFF features on bone scintigraphy were female patients with osteoporosis who were on oral BP medication; however, these factors were not significantly different along with AFF features on bone scintigraphy. Conclusion The incidence of AFF features on bone scintigraphy was relatively high in patients with BRONJ. A careful observation of patients presenting with the AFF features on bone scintigraphy may be needed, particularly for female BRONJ patients with osteoporosis who have been on BP medication for over 34 months.
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Affiliation(s)
- Chang-Hee Lee
- 1Department of Nuclear Medicine, School of Medicine, Kyungpook National University, Daegu, Republic of Korea.,2Department of Nuclear Medicine, Kyungpook National University Hospital, Daegu, Republic of Korea
| | - Seung Hyun Son
- 1Department of Nuclear Medicine, School of Medicine, Kyungpook National University, Daegu, Republic of Korea
| | - Chae Moon Hong
- 1Department of Nuclear Medicine, School of Medicine, Kyungpook National University, Daegu, Republic of Korea.,2Department of Nuclear Medicine, Kyungpook National University Hospital, Daegu, Republic of Korea
| | - Ju Hye Jeong
- 1Department of Nuclear Medicine, School of Medicine, Kyungpook National University, Daegu, Republic of Korea.,2Department of Nuclear Medicine, Kyungpook National University Hospital, Daegu, Republic of Korea
| | - Shin Young Jeong
- 1Department of Nuclear Medicine, School of Medicine, Kyungpook National University, Daegu, Republic of Korea.,2Department of Nuclear Medicine, Kyungpook National University Hospital, Daegu, Republic of Korea
| | - Sang-Woo Lee
- 1Department of Nuclear Medicine, School of Medicine, Kyungpook National University, Daegu, Republic of Korea.,2Department of Nuclear Medicine, Kyungpook National University Hospital, Daegu, Republic of Korea
| | - Jaetae Lee
- 1Department of Nuclear Medicine, School of Medicine, Kyungpook National University, Daegu, Republic of Korea.,2Department of Nuclear Medicine, Kyungpook National University Hospital, Daegu, Republic of Korea
| | - Tae-Geon Kwon
- 3Department of Oral & Maxillofacial Surgery, School of Dentistry, Kyungpook National University, Daegu, South Korea
| | - Byeong-Cheol Ahn
- 1Department of Nuclear Medicine, School of Medicine, Kyungpook National University, Daegu, Republic of Korea.,2Department of Nuclear Medicine, Kyungpook National University Hospital, Daegu, Republic of Korea
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Role of nutritional vitamin D in osteoporosis treatment. Clin Chim Acta 2018; 484:179-191. [PMID: 29782843 DOI: 10.1016/j.cca.2018.05.035] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2018] [Revised: 05/15/2018] [Accepted: 05/15/2018] [Indexed: 01/02/2023]
Abstract
Osteoporosis is a systemic skeletal disorder characterized by a decrease in bone mass and microarchitectural deterioration of bone tissue. The World Health Organization has defined osteoporosis as a decrease in bone mass (50%) and bony quality (50%). Vitamin D, a steroid hormone, is crucial for skeletal health and in mineral metabolism. Its direct action on osteoblasts and osteoclasts and interaction with nonskeletal tissues help in maintaining a balance between bone turnover and bone growth. Vitamin D affects the activity of osteoblasts, osteoclasts, and osteocytes, suggesting that it affects bone formation, bone resorption, and bone quality. At physiological concentrations, active vitamin D maintains a normal rate of bone resorption and formation through the RANKL/OPG signal. However, active vitamin D at pharmacological concentration inhibits bone resorption at a higher rate than that of bone formation, which influences the bone quality and quantity. Nutritional vitamin D rather than active vitamin D activates osteoblasts and maintains serum 25(OH)D3 concentration. Despite many unanswered questions, much data support nutritional vitamin D use in osteoporosis patients. This article emphasizes the role of nutritional vitamin D replacement in different turnover status (high or low bone turnover disorders) of osteoporosis together with either anti-resorptive (Bisphosphonate, Denosumab et.) or anabolic (Teriparatide) agents when osteoporosis persists.
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Subramanian G, Rinaggio J, Schneider L, Quek SY. The MRONJ Lesion—Dead or Dynamic? J Oral Maxillofac Surg 2017; 75:1309. [DOI: 10.1016/j.joms.2017.02.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2017] [Accepted: 02/16/2017] [Indexed: 10/19/2022]
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Does the Addition of Bone Morphogenetic Protein 2 to Platelet-Rich Fibrin Improve Healing After Treatment for Medication-Related Osteonecrosis of the Jaw? J Oral Maxillofac Surg 2017; 75:1176-1184. [DOI: 10.1016/j.joms.2016.12.005] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2016] [Revised: 12/01/2016] [Accepted: 12/02/2016] [Indexed: 11/19/2022]
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Svejda B, Muschitz C, Gruber R, Brandtner C, Svejda C, Gasser RW, Santler G, Dimai HP. [Position paper on medication-related osteonecrosis of the jaw (MRONJ)]. Wien Med Wochenschr 2017; 166:68-74. [PMID: 26847441 DOI: 10.1007/s10354-016-0437-2] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
It is now 12 years since the first article on medication-related osteonecrosis of the jaw (MRONJ) was reported in 2003. The recognition of MRONJ is still inconsistent between physicians and dentists but it is without doubt a severe disease with impairment of oral health-related quality of life. This position paper was developed by three Austrian societies for dentists, oral surgeons and osteologists involved in this topic. This update contains amendments on the incidence, pathophysiology, diagnosis, staging and treatment and provides recommendations for management based on a multidisciplinary international consensus. The MRONJ can be a medication-related side effect of treatment of malignant and benign bone diseases with bisphosphonates (Bp), bevacizumab and denosumab (Dmab) as antiresorptive therapy. The incidence of MRONJ is highest in the oncology patient population (range 1-15 %), where high doses of these medications are used at frequent intervals. In the osteoporosis patient population, the incidence of MRONJ is estimated to be 0.001-0.01 %, marginally higher than the incidence in the general population (< 0.001 %). Other risk factors for MRONJ 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 MRONJ 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 MRONJ, 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 MRONJ is based on the stage of the disease, extent of the lesions and the presence of contributing drug therapy and comorbidity. Conservative therapy includes topical antibiotic oral rinses and systemic antibiotic therapy. Early data have suggested enhanced osseous wound healing with teriparatide in those patients without contraindications for its use. The MRONJ related to denosumab may resolve more quickly with a drug holiday than MRONJ related to bisphosphonates. Localized surgical debridement is indicated in advanced nonresponsive disease and has proven successful. More invasive surgical techniques are becoming increasingly more important. Prevention is the key for the management of MRONJ. This requires a close teamwork for the treating physician and the dentist. It is necessary that this information is disseminated to other relevant health care professionals and organizations.
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Affiliation(s)
- B Svejda
- Frauenarztpraxis, Stauderplatz 5, 9020, Klagenfurt, Österreich.
| | - Ch Muschitz
- II. Medizinische Abteilung mit Osteologie, Rheumatologie & Gastroenterologie, Krankenhaus der Barmherzigen Schwestern, Stumpergasse 13, 1060, Wien, Österreich
| | - R Gruber
- Universitätszahnklinik Wien, Division für Orale Biologie, Medizinische Universität Wien, Sensengasse 2a, 1090, Wien, Österreich
| | - Ch Brandtner
- Paracelsus Medizinische Privatuniversität, Univ.-Klinik für Mund-, Kiefer- und Gesichtschirurgie, Landeskliniken Salzburg, Müllner Hauptstraße 48, 5020, Salzburg, Österreich
| | - Ch Svejda
- Zahnarztpraxis, 9640, Kötschach-Mauthen, Österreich
| | - R W Gasser
- Universitätsklinik für Innere Medizin I, Medizinische Universität Innsbruck, Anichstraße 35, 6020, Innsbruck, Österreich
| | - G Santler
- Abteilung für Mund-, Kiefer- und Gesichtschirurgie, Klinikum Klagenfurt am Wörthersee, Feschnigstraße 11, 9020, Klagenfurt, Österreich
| | - H P Dimai
- Universitätsklinik für Innere Medizin, Klinische Abteilung für Endokrinologie und Stoffwechsel, Medizinische Universität Graz, Auenbruggerplatz 2, 8036, Graz, Österreich
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Khan AA, Morrison A, Kendler DL, Rizzoli R, 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, Dabagh RA, Davison KS, Sándor GK, Josse RG, Bhandari M, El Rabbany M, Pierroz DD, Sulimani R, Saunders DP, Brown JP, Compston J. Case-Based Review of Osteonecrosis of the Jaw (ONJ) and Application of the International Recommendations for Management From the International Task Force on ONJ. J Clin Densitom 2017; 20:8-24. [PMID: 27956123 DOI: 10.1016/j.jocd.2016.09.005] [Citation(s) in RCA: 138] [Impact Index Per Article: 19.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Osteonecrosis of the jaw (ONJ) has been associated with antiresorptive therapy in both oncology and osteoporosis patients. This debilitating condition is very rare and advances in diagnosis and management may now effectively reduce the risk of its development and offer valuable treatment options for affected patients. This paper provides a case-based review of ONJ and application of the International Task Force on ONJ (referred to as the "Task Force") recommendations for the diagnosis and management of ONJ. The Task Force was supported by 14 international societies and achieved consensus from representatives of these multidisciplinary societies on key issues pertaining to the diagnosis and management of ONJ. The frequency of ONJ in oncology patients receiving oncology doses of bisphosphonate (BP) or denosumab is estimated at 1%-15%, and the frequency in the osteoporosis patient population receiving much lower doses of BP or denosumab is estimated at 0.001%-0.01%. Although the diagnosis of ONJ is primarily clinical, imaging may be helpful in confirming the diagnosis and staging. In those with multiple risk factors for ONJ for whom major invasive oral surgery is being planned, interruption of BP or denosumab therapy (in cancer patients) is advised, if possible, before surgery, until the surgical site heals. Major oral surgery in this context could include multiple extractions if surgical extractions are required, not simple forceps extractions. ONJ development may be reduced by optimizing oral hygiene and postoperatively using topical and systemic antibiotics as appropriate. Periodontal disease should be managed before starting oncology doses of BP or denosumab. Local debridement may be successful in disease unresponsive to conservative therapy. Successful surgical intervention has been reported in those with stage 3 disease; less severe disease is best managed conservatively. Teriparatide may be helpful in healing ONJ lesions and may be considered in osteoporosis patients at a high fracture risk in the absence of contraindications. Resumption of BP or denosumab therapy following healing of ONJ lesions is recommended, and there have not been reports of subsequent local recurrence.
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Affiliation(s)
- Aliya A Khan
- Department of Medicine, Divisions of Endocrinology and Metabolism and Geriatrics, McMaster University, Hamilton, ON, Canada.
| | - Archie Morrison
- Division of Oral and Maxillofacial Surgery, Dalhousie University, Halifax, NS, Canada
| | - David L Kendler
- Department of Medicine, Division of Endocrinology, University of British Columbia, Vancouver, BC, Canada
| | - Rene Rizzoli
- Division of Bone Diseases, Geneva University Hospitals, Geneva, Switzerland
| | - David A Hanley
- Departments of Medicine, Community Health Sciences and Oncology, University of Calgary, Calgary, AB, Canada
| | - Dieter Felsenberg
- Centre of Muscle & Bone Research, Charité-University Medicine Berlin, Campus Benjamin Franklin, Free University & Humboldt University Berlin, Berlin, Germany
| | - Laurie K McCauley
- Department of Periodontics and Oral Medicine, University of Michigan School of Dentistry, Ann Arbor, MI, USA
| | - Felice O'Ryan
- Division of Maxillofacial Surgery, Kaiser Permanente Oakland Medical Center, Oakland, CA, USA
| | - Ian R Reid
- Department of Medicine, University of Auckland, Auckland, New Zealand
| | - Salvatore L Ruggiero
- Division of Oral and Maxillofacial Surgery, Hofstra North Shore-LIJ School of Medicine, Hempstead, NY, USA; Stony Brook School of Dental Medicine, Stony Brook, NY, USA; New York Center for Orthognathic and Maxillofacial Surgery, New York, NY, USA
| | - Akira Taguchi
- Department of Oral and Maxillofacial Radiology, School of Dentistry, Matsumoto Dental University, Shojiri, Japan
| | - Sotirios Tetradis
- Division of Diagnostic and Surgical Sciences, UCLA School of Dentistry, Los Angeles, CA, USA
| | - Nelson B Watts
- Mercy Health Osteoporosis and Bone Health Services, Cincinnati, OH, USA
| | - Maria Luisa Brandi
- Department of Surgery and Translational Medicine, University of Florence, Florence, Italy
| | - Edmund Peters
- Department of Dentistry, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Teresa Guise
- Department of Medicine, Division of Endocrinology at Indiana University, Indianapolis, IN, USA
| | - Richard Eastell
- Department of Human Metabolism, University of Sheffield, Sheffield, UK
| | - Angela M Cheung
- Department of Medicine, University of Toronto, Toronto, ON, Canada; Centre of Excellence in Skeletal Health Assessment, Joint Department of Medical Imaging, University Health Network (UHN), Toronto, ON, Canada; Mount Sinai Hospital, University of Toronto, Toronto, ON, Canada
| | - Suzanne N Morin
- Department of Medicine, McGill University, Montreal, QC, Canada
| | - Basel Masri
- Jordan Osteoporosis Center, Jordan Hospital & Medical Center, Amman, Jordan
| | - Cyrus Cooper
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton, UK; NIHR Nutrition Biomedical Research Centre, University of Southampton, Southampton, UK; NIHR Musculoskeletal Biomedical Research Unit, University of Oxford, Oxford, UK
| | - Sarah L Morgan
- Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham Osteoporosis Prevention and Treatment Clinic, Birmingham, AL, USA
| | - Barbara Obermayer-Pietsch
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Medical University Graz, Graz, Austria
| | - Bente L Langdahl
- Department of Endocrinology and Internal Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Rana Al Dabagh
- Faculty of Dentistry, University of Toronto, Toronto, Canada
| | - K Shawn Davison
- Department of Education, University of Victoria,Victoria, BC, Canada
| | - George K Sándor
- Department of Oral and Maxillofacial Surgery, Oulu University Hospital, University of Oulu, Oulu, Finland
| | - Robert G Josse
- Division of Endocrinology and Metabolism, University of Toronto, Toronto, ON, Canada
| | - Mohit Bhandari
- Division of Orthopaedic Surgery, Department of Surgery, Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON, Canada
| | | | | | - Riad Sulimani
- College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Deborah P Saunders
- Department of Dental Oncology, Northeast Cancer Centre/Health Science North, Sudbury, ON, Canada
| | - Jacques P Brown
- Rheumatology Division, CHU de Québec Research Centre, Laval University, Quebec City, QC, Canada
| | - Juliet Compston
- Department of Medicine, Cambridge Biomedical Campus, Cambridge, UK
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Shin SH, Kim KH, Choi NR, Kim IR, Park BS, Kim YD, Kim UK, Kim CH. Effect of low-level laser therapy on bisphosphonate-treated osteoblasts. Maxillofac Plast Reconstr Surg 2016; 38:48. [PMID: 27995121 PMCID: PMC5122599 DOI: 10.1186/s40902-016-0095-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2016] [Accepted: 10/31/2016] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND This study investigates the effect of alendronate-treated osteoblasts, as well as the effect of low-level laser therapy (LLLT) on the alendronate-treated osteoblasts. Bisphosphonate decreases the osteoblastic activity. Various treatment modalities are used to enhance the bisphosphonate-treated osteoblasts; however, there were no cell culture studies conducted using a low-level laser. METHODS Human fetal osteoblastic (hFOB 1.19) cells were treated with 50 μM alendronate. Then, they were irradiated with a 1.2 J/cm2 low-level Ga-Al-As laser (λ = 808 ± 3 nm, 80 mW, and 80 mA; spot size, 1 cm2; NDLux, Seoul, Korea). The cell survivability was measured with the MTT assay. The three cytokines of osteoblasts, receptor activator of nuclear factor κB ligand (RANKL), osteoprotegerin (OPG), and macrophage colony-stimulating factor (M-CSF) were analyzed. RESULTS In the cells treated with alendronate at concentrations of 50 μM and higher, cell survivability significantly decreased after 48 h (p < 0.05). After the applications of low-level laser on alendronate-treated cells, cell survivability significantly increased at 72 h (p < 0.05). The expressions of OPG, RANKL, and M-CSF have decreased via the alendronate. The RANKL and M-CSF expressions have increased, but the OPG was not significantly affected by the LLLT. CONCLUSIONS The LLLT does not affect the OPG expression in the hFOB cell line, but it may increase the RANKL and M-CSF expressions, thereby resulting in positive effects on osteoclastogenesis and bone remodeling.
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Affiliation(s)
- Sang-Hun Shin
- Department of Oral and Maxillofacial Surgery, School of Dentistry, Pusan National University, Beomeo, Mulgeum, Yangsan, 626-770 Republic of Korea
| | - Ki-Hyun Kim
- Department of Oral and Maxillofacial Surgery, School of Dentistry, Pusan National University, Beomeo, Mulgeum, Yangsan, 626-770 Republic of Korea
| | - Na-Rae Choi
- Department of Oral and Maxillofacial Surgery, School of Dentistry, Pusan National University, Beomeo, Mulgeum, Yangsan, 626-770 Republic of Korea
| | - In-Ryoung Kim
- Department of Oral Anatomy and Cell Biology, School of Dentistry, Pusan National University, Beomeo, Mulgeum, Yangsan, 626-770 Republic of Korea
| | - Bong-Soo Park
- Department of Oral Anatomy and Cell Biology, School of Dentistry, Pusan National University, Beomeo, Mulgeum, Yangsan, 626-770 Republic of Korea
| | - Yong-Deok Kim
- Department of Oral and Maxillofacial Surgery, School of Dentistry, Pusan National University, Beomeo, Mulgeum, Yangsan, 626-770 Republic of Korea
| | - Uk-Kyu Kim
- Department of Oral and Maxillofacial Surgery, School of Dentistry, Pusan National University, Beomeo, Mulgeum, Yangsan, 626-770 Republic of Korea
| | - Cheol-Hun Kim
- Department of Oral and Maxillofacial Surgery, Dentistry, Dong-A Medical Center, 602-715 Pusan, Republic of Korea
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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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Khan A, Morrison A, Cheung A, Hashem W, Compston J. Osteonecrosis of the jaw (ONJ): diagnosis and management in 2015. Osteoporos Int 2016; 27:853-859. [PMID: 26493811 DOI: 10.1007/s00198-015-3335-3] [Citation(s) in RCA: 70] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2015] [Accepted: 09/21/2015] [Indexed: 12/11/2022]
Abstract
Osteonecrosis of the jaw (ONJ) has been associated with the use of aminobisphosphonates and denosumab. The vast majority (>90%) of cases occur in the oncology patient population receiving high doses of intravenous bisphosphonates or subcutaneous denosumab. The incidence of ONJ in the osteoporosis patient population is very low and is estimated at 1-90 per 100,000 patient-years of exposure. In the oncology patient population the incidence appears to be related to dose and duration of exposure, and prevalence has been estimated to be as high as 18.6%. A number of risk factors in addition to antiresorptive therapy have been identified. These include the presence of periodontal disease, oral surgical procedures with extractions or implants, radiation therapy, chemotherapy, diabetes, glucocorticoid use, and smoking. Antiangiogenic agents appear to contribute to the risk of ONJ, however, data at this time are limited and further evidence is required prior to confirming a causal relationship. ONJ may be prevented with optimization of oral hygiene, the use of oral antimicrobial mouth rinses, as well as systemic antibiotic therapy. Individuals not responding to conservative management or in the advanced stages of ONJ may be considered for surgery, as data over the past several years have demonstrated surgical success in this patient population. Case reports have indicated that teriparatide may enhance healing. A number of experimental therapies are being evaluated and include the use of bone marrow stem cell intralesional transplantation, local application of platelet-derived growth factor, hyperbaric oxygen, tissue grafting, and low-level laser therapy. This paper summarizes the current research as well as the international consensus on the diagnosis and management of ONJ.
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Affiliation(s)
- A Khan
- McMaster University, Hamilton, Canada.
| | | | - A Cheung
- University of Toronto, Toronto, Canada
| | - W Hashem
- McMaster University, Hamilton, Canada
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Kim JW, Landayan MEA, Lee JY, Tatad JCI, Kim SJ, Kim MR, Cha IH. Role of microcracks in the pathogenesis of bisphosphonate-related osteonecrosis of the jaw. Clin Oral Investig 2016; 20:2251-2258. [PMID: 26795624 DOI: 10.1007/s00784-016-1718-2] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2015] [Accepted: 01/10/2016] [Indexed: 12/12/2022]
Abstract
OBJECTIVES The aim of this study was to investigate the potential role of microcrack accumulation in the pathogenesis of bisphosphonate-related osteonecrosis of the jaw (ONJ) through an animal model. MATERIALS AND METHODS Twenty-four ovariectomized rats were randomly divided into a bisphosphonate group (n = 19) and control group (n = 5) and weekly injected with zoledronic acid and normal saline, respectively. After 6 weeks, surgical intervention was performed, and the injections were continued for eight additional weeks. Then, the animals were sacrificed, and ONJ lesions were inspected for the presence of microcracks using scanning electron microscopy. Measurements included bone dimension, number of cracks, crack length, and normalized indices; crack density (Cr.Dn) and crack surface density (Cr.S.Dn) were used for group comparison. RESULTS Both number of cracks and crack length in the bisphosphonate group were greater than those in the control group (P < 0.05). Of the 19 rats injected with bisphosphonates, 13 rats (68.4 %) were classified into the ONJ group. Cr.Dn and Cr.S.Dn were significantly greater in the ONJ group than in the non-ONJ group, indicating accumulation of unrepaired microcracks (P < 0.05). Seventy-two percent of microcracks in the ONJ group conformed to the defined length that was considered significant according to a previous literature (30-80 μm); whereas 12 % of microcracks in the non-ONJ group were considered significant (P < 0.05). CONCLUSION Accumulation of unrepaired microcracks was significantly associated with the development of bisphosphonate-related ONJ. Further research is required to determine the role of microcracks in the pathogenesis of bisphosphonate-related ONJ. CLINICAL RELEVANCE Long-term bisphosphonates use may deteriorate the biomechanical and physiological bone integrity, contributing to the pathogenesis of bisphosphonate-related ONJ.
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Affiliation(s)
- Jin-Woo Kim
- Graduate School of Clinical Implant Dentistry, Ewha Womans University, Seoul, South Korea.,Research Institute for Intractable Osteonecrosis of the Jaw, School of Medicine, Ewha Womans University, Seoul, South Korea.,Department of Oral & Maxillofacial Surgery, Ewha Womans University Medical Center, Anyangcheon-ro 1071, Yangcheon-gu, Seoul, 158-710, South Korea
| | - Maria Erika A Landayan
- Graduate School of Clinical Implant Dentistry, Ewha Womans University, Seoul, South Korea.,Research Institute for Intractable Osteonecrosis of the Jaw, School of Medicine, Ewha Womans University, Seoul, South Korea
| | - Ju-Young Lee
- Graduate School of Clinical Implant Dentistry, Ewha Womans University, Seoul, South Korea.,Research Institute for Intractable Osteonecrosis of the Jaw, School of Medicine, Ewha Womans University, Seoul, South Korea.,Department of Oral & Maxillofacial Surgery, Ewha Womans University Medical Center, Anyangcheon-ro 1071, Yangcheon-gu, Seoul, 158-710, South Korea
| | - Jacquiline Czar I Tatad
- Graduate School of Clinical Implant Dentistry, Ewha Womans University, Seoul, South Korea.,Research Institute for Intractable Osteonecrosis of the Jaw, School of Medicine, Ewha Womans University, Seoul, South Korea
| | - Sun-Jong Kim
- Graduate School of Clinical Implant Dentistry, Ewha Womans University, Seoul, South Korea. .,Research Institute for Intractable Osteonecrosis of the Jaw, School of Medicine, Ewha Womans University, Seoul, South Korea. .,Department of Oral & Maxillofacial Surgery, Ewha Womans University Medical Center, Anyangcheon-ro 1071, Yangcheon-gu, Seoul, 158-710, South Korea.
| | - Myung-Rae Kim
- Graduate School of Clinical Implant Dentistry, Ewha Womans University, Seoul, South Korea.,Research Institute for Intractable Osteonecrosis of the Jaw, School of Medicine, Ewha Womans University, Seoul, South Korea
| | - In-Ho Cha
- Department of Oral and Maxillofacial Surgery, Yonsei University, Seoul, South Korea
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Kim JW, Tatad JCI, Landayan MEA, Kim SJ, Kim MR. Animal model for medication-related osteonecrosis of the jaw with precedent metabolic bone disease. Bone 2015; 81:442-448. [PMID: 26297440 DOI: 10.1016/j.bone.2015.08.012] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2015] [Accepted: 08/14/2015] [Indexed: 10/23/2022]
Abstract
Despite the fact that the medications used to treat abnormal bone conditions often induce osteonecrosis of the jaw (ONJ), previous attempts to establish an animal model for ONJ have shown insufficient consideration for this important prerequisite for the development of the disease. The purpose of this study was to establish an animal model with the most common metabolic bone disease, osteoporosis. Ninty-six rats were randomly divided into ovariectomy (Ov) group (n=48) and sham-operated group (n=48). Six weeks after Ov or sham surgery, rats in each group were subdivided into bisphosphonate group (n=36 each) and control group (n=12 each) and injected with zoledronic acid and normal saline, respectively, once a week. After additional 6weeks, surgical intervention was performed, and the injections were continued for 8 more weeks. The animals were then sacrificed for further macroscopic, histological, histomorphometric, radiological, and bone biomarker investigations. As histologically determined, the Ov group (77.8%) showed higher ONJ prevalence compared to the sham group (47.2%; P<0.05). Micro-structural and histomorphometric assessments revealed that rats with ONJ (ONJ group) presented with deteriorated bone architectures with higher necrotic bone fraction and lower number of osteoclasts (P<0.05). Compared to the sham-operated ONJ group, the Ov ONJ group showed significantly lower values of Tb.N, Tb.Sp, Conn.D, N.Oc/T.Ar, and TRACP 5b and CTX/TRACP (P<0.05). The ovariectomized rat model in this study successfully mimicked human ONJ lesions with an underlying bone disease and showed different bone characteristics than that of the previous ONJ model. Based on the differences, further researches for investigating pathophysiology of ONJ, including various pharmacological responses for deteriorated bone environment, are required.
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Affiliation(s)
- Jin-Woo Kim
- Graduate School of Clinical Implant Dentistry, Ewha Womans University, Seoul, Republic of Korea; Research Institute for Intractable Osteonecrosis of the Jaw, School of Medicine, Ewha Womans University, Seoul, Republic of Korea; Department of Oral and Maxillofacial Surgery, School of Medicine, Ewha Womans University, Seoul, Republic of Korea
| | - Jacquiline Czar I Tatad
- Graduate School of Clinical Implant Dentistry, Ewha Womans University, Seoul, Republic of Korea; Research Institute for Intractable Osteonecrosis of the Jaw, School of Medicine, Ewha Womans University, Seoul, Republic of Korea; Department of Oral and Maxillofacial Surgery, School of Medicine, Ewha Womans University, Seoul, Republic of Korea
| | - Maria Erika A Landayan
- Graduate School of Clinical Implant Dentistry, Ewha Womans University, Seoul, Republic of Korea; Research Institute for Intractable Osteonecrosis of the Jaw, School of Medicine, Ewha Womans University, Seoul, Republic of Korea; Department of Oral and Maxillofacial Surgery, School of Medicine, Ewha Womans University, Seoul, Republic of Korea
| | - Sun-Jong Kim
- Graduate School of Clinical Implant Dentistry, Ewha Womans University, Seoul, Republic of Korea; Research Institute for Intractable Osteonecrosis of the Jaw, School of Medicine, Ewha Womans University, Seoul, Republic of Korea; Department of Oral and Maxillofacial Surgery, School of Medicine, Ewha Womans University, Seoul, Republic of Korea.
| | - Myung-Rae Kim
- Graduate School of Clinical Implant Dentistry, Ewha Womans University, Seoul, Republic of Korea; Research Institute for Intractable Osteonecrosis of the Jaw, School of Medicine, Ewha Womans University, Seoul, Republic of Korea; Department of Oral and Maxillofacial Surgery, School of Medicine, Ewha Womans University, Seoul, Republic of Korea
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Kim JW, Kim SJ, Kim MR. Simultaneous Application of Bone Morphogenetic Protein-2 and Platelet-Rich Fibrin for the Treatment of Bisphosphonate-Related Osteonecrosis of Jaw. J ORAL IMPLANTOL 2015; 42:205-8. [PMID: 26103458 DOI: 10.1563/aaid-joi-d-14-00309] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Affiliation(s)
- Jin-Woo Kim
- Department of Oral and Maxillofacial Surgery, Ewha Womans University, Seoul, Korea
| | - Sun-Jong Kim
- Department of Oral and Maxillofacial Surgery, Ewha Womans University, Seoul, Korea
| | - Myung-Rae Kim
- Department of Oral and Maxillofacial Surgery, Ewha Womans University, Seoul, Korea
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Kim JW, Cha IH, Kim SJ, Kim MR. Biomarkers for Bisphosphonate-Related Osteonecrosis of the Jaw. Clin Implant Dent Relat Res 2015; 18:281-91. [PMID: 25726720 DOI: 10.1111/cid.12297] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
PURPOSE The aim of this study was to investigate a possible biomarker for bisphosphonate-related osteonecrosis of the jaw (BRONJ) in an animal model. MATERIALS AND METHODS Forty-eight Sprague-Dawley rats were randomly divided into the bisphosphonate group (n = 36), who were injected once a week with zoledronic acid, and the control group (n = 12), who were injected once a week with saline. After 6 weeks, surgical intervention was performed, and injections were continued up to 8 weeks. Rats in the bisphosphonate group were then further classified to the ONJ group, and the non-ONJ group, and biomarkers, including CTx, Glu-OC, TRACP 5b, RANKL, and OPG, were assessed at baseline (T0), at surgical intervention (T1), and at sacrifice (T2). Histomorphometric analysis for quantification of osteoclasts was performed. RESULTS Repeated measures analysis of variance revealed that TRACP 5b levels and the RANKL/OPG ratio were significantly decreased over time in the ONJ group compared with the non-ONJ group (p < .05). At T2, the area under the curve was 0.807 for TRACP 5b (sensitivity: 88.9%, specificity 66.7% at cutoff) and 0.765 for the RANKL/OPG ratio (sensitivity: 77.8%, specificity 62.9% at cutoff). TRACP 5b showed a lower least significant change (29.6%) with lower intra-assay coefficient of variability (CV; 6.32%) and interassay CV (11.20%) compared with those of the RANKL/OPG ratio (39.27%) and showed a higher signal-to-noise ratio (2.76) than that of the RANKL/OPG ratio (1.62). N.Oc/T.Ar and N.Oc/B.Ar demonstrated significantly decreased number of osteoclasts in ONJ group versus non-ONJ group. CONCLUSIONS These results show that serum TRACP 5b and the RANKL/OPG ratio were possible biomarkers for BRONJ. These data may provide useful additional information for future ONJ research. Further studies are needed to validate these results in humans with ONJ.
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Affiliation(s)
- Jin-Woo Kim
- Department of Oral and Maxillofacial Surgery, Graduate School of Dentistry, Yonsei University, Seoul, Korea.,Department of Oral and Maxillofacial Surgery, School of Medicine, Research Institute for Intractable Osteonecrosis of the Jaw, Ewha Womans University Medical Center, Ewha Womans University, Seoul, Korea
| | - In-Ho Cha
- Department of Oral and Maxillofacial Surgery, Graduate School of Dentistry, Yonsei University, Seoul, Korea
| | - Sun-Jong Kim
- Department of Oral and Maxillofacial Surgery, School of Medicine, Research Institute for Intractable Osteonecrosis of the Jaw, Ewha Womans University Medical Center, Ewha Womans University, Seoul, Korea
| | - Myung-Rae Kim
- Department of Oral and Maxillofacial Surgery, School of Medicine, Research Institute for Intractable Osteonecrosis of the Jaw, Ewha Womans University Medical Center, Ewha Womans University, Seoul, Korea
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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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Abstract
Osteonecrosis of the jaw to a certain extent has been with us for many years. But recently the advent of various medications such as bisphosphonates, VEGF inhibitors, tyrosine kinase inhibitors and humanized antibodies to osteoclastic action have resulted in thousands of cases. While the bisphosphonates continue to be the most common medication associated with osteochemonecrosis antibodies such as denosumab which irreversibly act on osteoclastic action are also being reported. This narrative review will serve as an update with a focus on some of the histopathologic features discussed and reviewed. Perhaps even more uncommonly seen in past reports a discussion of features possibly observed while grossing specimens will be discussed. At the end of this report is hoped that the pathologist will have a better understanding of the historical features, clinical settings, gross examination features as well as histopathologic features associated with osteochemonecrosis.
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Affiliation(s)
- John Hellstein
- grid.214572.70000000419368294University of Iowa, Iowa City, IA USA
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Paulo S, Abrantes AM, Laranjo M, Carvalho L, Serra A, Botelho MF, Ferreira MM. Bisphosphonate-related osteonecrosis of the jaw: specificities. Oncol Rev 2014; 8:254. [PMID: 25992241 PMCID: PMC4419650 DOI: 10.4081/oncol.2014.254] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2014] [Revised: 08/01/2014] [Accepted: 08/04/2014] [Indexed: 12/31/2022] Open
Abstract
Bisphosphonate-related osteonecrosis of the jaws (BRONJ) is a severe complication that has recently emerged in patients treated with intravenous bisphosphonates for malignant diseases. This complication usually presents after a minor local trauma during a dental treatment. Several etiopathogenic mechanisms of this pathological condition have been proposed, but no model can explain all morphological changes observed at the macroscopic and microscopic level. BRONJ is likely to be related to direct toxicity in the bone and soft tissue cells, due to nitrogen-containing bisphosphonates. This review elucidates the clinical indications and mechanism of action of bisphosphonates, reports some clinical diagnostic criteria for BRONJ, describe the histopathological criteria for BRONJ diagnosis, the potential triggering pathways and the available treatment strategies.
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Affiliation(s)
- Siri Paulo
- Faculty of Medicine, Coimbra University , Portugal
| | | | | | | | - Arménio Serra
- Faculty of Science and Technology, Coimbra University , Portugal
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Barba-Recreo P, Del Castillo Pardo de Vera JL, García-Arranz M, Yébenes L, Burgueño M. Zoledronic acid – Related osteonecrosis of the jaws. Experimental model with dental extractions in rats. J Craniomaxillofac Surg 2014; 42:744-50. [DOI: 10.1016/j.jcms.2013.11.005] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2013] [Revised: 08/26/2013] [Accepted: 11/04/2013] [Indexed: 10/26/2022] Open
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Leucocyte-rich and platelet-rich fibrin for the treatment of bisphosphonate-related osteonecrosis of the jaw: a prospective feasibility study. Br J Oral Maxillofac Surg 2014; 52:854-9. [PMID: 25138613 DOI: 10.1016/j.bjoms.2014.07.256] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2014] [Accepted: 07/28/2014] [Indexed: 11/24/2022]
Abstract
Our aim was to assess the feasibility of using leucocyte-rich and platelet-rich fibrin (L-PRF) for the treatment of bisphosphonate-related osteonecrosis of the jaw (BRONJ) in a single group study. After treatment with L-PRF, the response of each patient was recorded 1 month and 4 months postoperatively. Further assessments were made of the site, stage, concentration of c-terminal crosslinked telopepide of type 1 collagen, and actinomycosis. Among the total of 34 patients, 26 (77%) showed complete resolution, 6 (18%) had delayed resolution, and 2 (6%) showed no resolution. There was a significant association between the response to treatment and the stage of BRONJ (p=0.002) but no other significant associations were detected. This study has shown that it is feasible to use L-PRF for the treatment of BRONJ, but the effectiveness cannot be judged with this study design. Randomised prospective trials are needed to confirm this.
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Pelaz A, Junquera L, Gallego L, García-Consuegra L, Junquera S, Gómez C. Alternative treatments for oral bisphosphonate-related osteonecrosis of the jaws: a pilot study comparing fibrin rich in growth factors and teriparatide. Med Oral Patol Oral Cir Bucal 2014; 19:e320-6. [PMID: 24608203 PMCID: PMC4119305 DOI: 10.4317/medoral.19458] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2013] [Accepted: 01/24/2014] [Indexed: 01/08/2023] Open
Abstract
Objectives: The aim of this study is to describe and compare the evolution of recurrent bisphosphonate-related osteonecrosis of the jaws (BRONJ) in patients treated with plasma rich in growth factors or teriparatide.
Material and Methods: Two different types of treatments were applied in patients diagnosed of recurrent BRONJ in a referral hospital for 1.100.000 inhabitants. In the group A, plasma rich in growth factors was applied during the surgery. In the group B, the treatment consisted in the subcutaneous administration of teriparatide. All the cases of BRONJ should meet the following conditions: recurrent BRONJ, impossibility of surgery in stage 3 Ruggiero classification and absence of diagnosed neoplastic disease. Clinical and radiographic evolution of the patients from both groups was observed.
Results: Nine patients were included, 5 in group A and 4 in group B. All the patients were women on oral bis-phosphonate therapy for primary osteoporosis (5 patients) or osteoporosis-related to the use of corticosteroids (4 patients). Alendronate was the most common oral bisphosphonate associated with BRONJ in our study (four patients in group A and two in group B). The mean age was 72,8 years in the group A and 73,5 years in the group B. All the patients from group A showed a complete resolution of their BRONJ. Only one patient in the group B showed the same evolution.
Conclusions: In our series, the plasma rich in growth factors showed better results than the teriparatide in the treatment of recurrent BRONJ.
Key words:Osteonecrosis, oral bisphosphonate, treatment, teriparatide, plasma rich in growth factors.
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Affiliation(s)
- Alejandro Pelaz
- Universidad de Oviedo, Facultad de Ciencias de la Salud, Catedrático José Serrano s/n, 33009, Oviedo, Spain,
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Vercruysse H, Backer TD, Mommaerts MY. Outcomes of osseous free flap reconstruction in stage III bisphosphonate-related osteonecrosis of the jaw: systematic review and a new case series. J Craniomaxillofac Surg 2014; 42:377-86. [PMID: 24642091 DOI: 10.1016/j.jcms.2014.01.005] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2013] [Revised: 09/19/2013] [Accepted: 01/03/2014] [Indexed: 12/22/2022] Open
Abstract
INTRODUCTION There is currently no gold standard for the treatment of Stage III bisphosphonate-related osteonecrosis of the jaw (BRONJ). The question remains whether osseous reconstruction can offer an additional gain in outcome given the theoretical risk of non-union at the resection margins and recurrence in the osseous free flap. The objective was to conduct a systematic review of articles describing outcomes of osseous microsurgical reconstruction in cases of BRONJ with a minimum follow-up of 12 months, and to present the long-term outcomes of a new case series of three patients. MATERIAL AND METHODS A multi-database QUORUM-based single-reviewer systematic review identified eight papers that fulfilled the selection criteria. There are only case series and case reports available (Level 4 of the Oxford Evidence-based medicine scale). A total of 31 patients were analysed including the cases described in this article. CONCLUSION The limited overall rate of non-union at the resection margins and the 6.5% recurrence rate of BRONJ in the transplant counters the theoretical objections and advocates for considering osseous free flap reconstruction in the treatment of refractory BRONJ Stage III lesions. However, additional data derived from larger case series or case-control studies are imperative to support this hypothesis.
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Affiliation(s)
- Herman Vercruysse
- Dienst Mond-, Kaak- en Aangezichtschirurgie (Head: Maurice Y. Mommaerts), European Face Center, Universitair Ziekenhuis Brussel, Laarbeeklaan 101, 1090 Brussels, Belgium.
| | - Tom de Backer
- Dienst Mond-, Kaak- en Aangezichtschirurgie (Head: Herman Van den Eynde), OLV Ziekenhuis, Aalst, Belgium
| | - Maurice Y Mommaerts
- Dienst Mond-, Kaak- en Aangezichtschirurgie (Head: Maurice Y. Mommaerts), European Face Center, Universitair Ziekenhuis Brussel, Laarbeeklaan 101, 1090 Brussels, Belgium
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Neuprez A, Coste S, Rompen E, Crielaard JM, Reginster JY. Osteonecrosis of the jaw in a male osteoporotic patient treated with denosumab. Osteoporos Int 2014; 25:393-5. [PMID: 23835864 PMCID: PMC3889627 DOI: 10.1007/s00198-013-2437-z] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2013] [Accepted: 06/21/2013] [Indexed: 01/22/2023]
Abstract
Osteonecrosis of the jaw (ONJ) is a clinical condition associated with long-term exposure to inhibitors of bone resorption, mainly bisphosphonates. Denosumab (DMab) is a human monoclonal antibody of the receptor activator of nuclear factor kappa-B ligand. It prevents osteoclast-mediated bone resorption and is widely prescribed for the management of postmenopausal osteoporosis. Whereas ONJ has already been reported in women treated with DMab, we report for the first time the development of ONJ, following tooth extraction, in a male patient treated for idiopathic osteoporosis with DMab. Due to the constant increase in DMab prescription, for the management of osteoporosis, in both genders, physicians should be made aware of this potential risk.
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Affiliation(s)
- A. Neuprez
- Public Health, Epidemiology and Health Economics Department, University of Liège, Belgium, Liège, Belgium
- Bone and Cartilage Metabolism Unit, CHU, Liège, Belgium
- Motricity Sciences Department, CHU, Liège, Belgium
| | - S. Coste
- Gynecology Department, CHC St. Joseph, Liège, Belgium
| | - E. Rompen
- Stomatology Department, CHU, Liège, Belgium
| | | | - J. Y. Reginster
- Public Health, Epidemiology and Health Economics Department, University of Liège, Belgium, Liège, Belgium
- Bone and Cartilage Metabolism Unit, CHU, Liège, Belgium
- Motricity Sciences Department, CHU, Liège, Belgium
- Department of Public Health, Epidemiology and Health Economics, CHU Sart Tilman, Boulevard de l’Hôpital, 3 4000 Liège, Belgium
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Kim JW, Kong KA, Kim SJ, Choi SK, Cha IH, Kim MR. Prospective biomarker evaluation in patients with osteonecrosis of the jaw who received bisphosphonates. Bone 2013; 57:201-5. [PMID: 23954759 DOI: 10.1016/j.bone.2013.08.005] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2013] [Revised: 07/06/2013] [Accepted: 08/05/2013] [Indexed: 10/26/2022]
Abstract
Bone biomarkers have been suggested for the risk assessment for osteonecrosis of the jaw, a serious complication associated with bisphosphonate (BP) use; however, no consensus has been reached. This study investigated the possible associations between bone biomarkers and the development of bisphosphonates-related osteonecrosis of the jaw (BRONJ). This is a case-control study of 37 patients with BRONJ (age, 73.6±11.2years) who had at least 1 sample available at diagnosis, out of which, 35 were taking BPs for osteoporosis and 2 patients for bone metastasis. Age- and gender-matched 37 patients who had been exposed to BPs for >24months and had no evidence of BRONJ after dentoalveolar surgery served as control group. The association between biomarkers (osteocalcin [OC], deoxypyridinoline [DPD], C-terminal telopeptide of collagen I [CTX], N-terminal telopeptides [NTX], bone-specific alkaline phosphatase [BAP], and parathyroid hormone [PTH]) and BRONJ development, the effects of BP discontinuation on biomarkers, and the performance of biomarkers for risk assessment were investigated. In our study, the PTH levels were found to be significantly higher in BRONJ patients compared to controls (P<0.05). But the OC, DPD, CTX, NTX, and BAP levels were not significantly different between the 2 groups (P>0.05). The CTX level in reference to a 150pg/mL cutoff was also not significant for BRONJ development (P>0.05). Among BRONJ patients who discontinued BP, in a linear mixed model, only CTX showed a significant increase over time (β=0.002, P=0.007). The cutoff PTH level was >41.52pg/mL (AUC=0.719, P=0.009), and that of CTX was ≤0.094ng/mL (AUC=0.619, P=0.069). In conclusion, there is insufficient evidence for the risk prediction for BRONJ of current bone biomarkers; additional research is necessary.
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Affiliation(s)
- Jin-Woo Kim
- Department of Oral and Maxillofacial Surgery, Ewha Womans University, Seoul, Republic of Korea
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Ersan N, van Ruijven LJ, Bronckers ALJJ, Olgaç V, Ilgüy D, Everts V. Teriparatide and the treatment of bisphosphonate-related osteonecrosis of the jaw: a rat model. Dentomaxillofac Radiol 2013; 43:20130144. [PMID: 24170800 DOI: 10.1259/dmfr.20130144] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVES The objectives of this study were to establish a bisphosphonate-related osteonecrosis of the jaw (BRONJ) rat model and to analyse the effects of teriparatide (TP) on this model. METHODS Sprague-Dawley rats were divided into three groups: I-zoledronic acid (ZA, n = 10); II-ZA and teriparatide (ZA + TP, n = 10); III-control (n = 10). Osteonecrosis was induced by administering zoledronic acid to groups ZA and ZA + TP. A week after the injections, rats underwent extraction of the first left mandibular molar. Following a four week period, TP was administered to the ZA + TP group for 28 days. Upon killing, extraction sockets were examined clinically, radiologically and histopathologically. RESULTS Clinical examination revealed necrotic bone exposure in none of the animals. MicroCT (µCT) examination showed that bone mineral density of the newly formed bone in the extraction socket was lower in the ZA group than in the ZA + TP group (p < 0.05). Histopathological examination revealed that only the ZA and ZA + TP groups developed osteonecrosis, and the osteonecrotic bone area in the ZA group was larger than that in the ZA + TP group (p < 0.05). Tartrate-resistant acid phosphatase (TRAcP) enzyme histochemistry revealed that the number of detached and large osteoclasts were higher in the ZA group than in other groups, whereas the number of apoptotic osteoclasts in both ZA and ZA + TP groups were higher than in the control group (p < 0.05). CONCLUSIONS Our data indicate that bisphosphonate-related osteonecrosis of the jaw model used in the present study is an attractive model to investigate treatment modalities and that TP might be an effective treatment in BRONJ.
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Affiliation(s)
- N Ersan
- Department of Dentomaxillofacial Radiology, Faculty of Dentistry, Yeditepe University, Istanbul, Turkey
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Janovska Z, Mottl R, Slezak R. Experience with the treatment of bisphosphonate-related osteonecrosis of the jaw. Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub 2013; 159:313-7. [PMID: 24108250 DOI: 10.5507/bp.2013.069] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2013] [Accepted: 09/13/2013] [Indexed: 11/23/2022] Open
Abstract
AIM This article covers the authors' experience with the treatment of bisphosphonate-related osteonecrosis of the jaw in 11 individuals. METHODS A retrospective study of patients diagnosed and treated for bisphosphonate-related osteonecrosis of the jaw at the Department of Dentistry, University Hospital Hradec Králové during the period January 2006 to October 2012. The treatment protocol consisted of antimicrobial mouth rinses and systemic antibiotic administration according to the stage of the disease. Additional surgical debridement and sequestrectomy in combination with antimicrobial therapy was performed in two cases. RESULTS Complete healing was achieved in six patients. In two cases, satisfactory healing was noted. Stage of the disease was lowered and only a small area of asymptomatic necrotic bone of up to five mm in diameter persisted. Two patients developed a stable disease without progression. In one patient, the disease progressed to the third stage with osteonecrosis involving all quadrants of both jaws. CONCLUSION From these data it was concluded that conservative approach in the treatment of bisphosphonate-related osteonecrosis of the jaw led to symptom regression but was not curative. Surgical intervention, however, bears the risk of further progression of the osteonecrosis and must be carefully planned with respect to the patient's general health status and life expectancy. The treatment of bisphosphonate-related osteonecrosis of the jaw is generally difficult. For this reason, prevention plays a predominant role in the management of the disease.
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Affiliation(s)
- Zuzana Janovska
- Department of Dentistry, Charles University in Prague, Faculty of Medicine and University Hospital Hradec Kralove, Czech Republic
| | - Radovan Mottl
- Department of Dentistry, Charles University in Prague, Faculty of Medicine and University Hospital Hradec Kralove, Czech Republic
| | - Radovan Slezak
- Department of Dentistry, Charles University in Prague, Faculty of Medicine and University Hospital Hradec Kralove, Czech Republic
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Kuchuk I, Mazzarello S, Butterfield K, Appleton A, Addison CL, Clemons M. Oral care and the use of bone-targeted agents in patients with metastatic cancers: A practical guide for dental surgeons and oncologists. J Bone Oncol 2013; 2:38-46. [PMID: 26909271 PMCID: PMC4723342 DOI: 10.1016/j.jbo.2012.12.001] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2012] [Revised: 11/26/2012] [Accepted: 12/11/2012] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Bone-targeted agents such as bisphosphonates and the RANKL antibody have revolutionised the care of patients with bone metastases. There has, however been increasing concern about the oral health of these patients and in particular osteonecrosis of the jaw (ONJ), especially with the increasing use of these agents at higher potencies for greater periods of time. METHODS A review of the published data in PubMed and meeting abstracts was performed to examine incidence, risk factors, pathogenesis, clinical course and management of osteonecrosis of the jaw with focus on cancer patients treated with bone-targeted agents (BTA) for bone metastases. This manuscript takes the most frequent and pertinent questions raised by oncologists, dentists and oral and maxillofacial surgeons and tries to give a pragmatic overview of the literature. RESULTS The incidence of ONJ varies depending on types of bone-targeted agents, duration of treatment and additional risk factors. The causes and pathogenesis of ONJ is not fully elucidated, however bone-targeted therapy induced impaired bone remodelling, microtrauma secondary to jaw activity, and oral bacterial infection seem to be important factors. Since the treatment options for ONJ are limited and not well established, preventive strategies have to be included in patients management. CONCLUSIONS Many unanswered questions remain about the optimal oral care of patients receiving bone-targeted agents. Prospective data collection will remedy this and help to provide practical guidelines for the management and treatment of those patients that require dental intervention.
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Affiliation(s)
- Iryna Kuchuk
- Division of Medical Oncology, Ottawa Regional Cancer Centre and University of Ottawa, Canada
| | - Sasha Mazzarello
- Division of Medical Oncology, Ottawa Regional Cancer Centre and University of Ottawa, Canada
| | - Kevin Butterfield
- Ottawa Hospital Division of Dentistry/Oral & Maxillofacial Surgery and University of Ottawa, Canada
| | | | | | - Mark Clemons
- Division of Medical Oncology, Ottawa Regional Cancer Centre and University of Ottawa, Canada
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Subramanian G, Quek SYP. Comment on Narváez et al.: lack of response to teriparatide therapy for bisphosphonate-associated osteonecrosis of the jaw. Osteoporos Int 2013; 24:735-6. [PMID: 22581290 DOI: 10.1007/s00198-012-1995-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2012] [Accepted: 03/27/2012] [Indexed: 10/28/2022]
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Narváez J, Narváez JA, Gómez-Vaquero C, Nolla JM. Lack of response to teriparatide therapy for bisphosphonate-associated osteonecrosis of the jaw. Osteoporos Int 2013; 24:731-3. [PMID: 22398853 DOI: 10.1007/s00198-012-1918-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2011] [Accepted: 01/23/2012] [Indexed: 10/28/2022]
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Subramanian G, Fritton JC, Quek SYP. Osteonecrosis and atypical fractures-common origins? Osteoporos Int 2013; 24:745-6. [PMID: 22407260 DOI: 10.1007/s00198-012-1953-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2011] [Accepted: 01/20/2012] [Indexed: 10/28/2022]
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Ohbayashi Y, Miyake M, Sawai F, Minami Y, Iwasaki A, Matsui Y. Adjunct teriparatide therapy with monitoring of bone turnover markers and bone scintigraphy for bisphosphonate-related osteonecrosis of the jaw. Oral Surg Oral Med Oral Pathol Oral Radiol 2012; 115:e31-7. [PMID: 23246226 DOI: 10.1016/j.oooo.2012.09.006] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2012] [Revised: 09/05/2012] [Accepted: 09/09/2012] [Indexed: 01/24/2023]
Abstract
The management of bisphosphonate-related osteonecrosis of the jaw (BRONJ) is still difficult in many cases that do not respond to conservative treatments. We report a case of BRONJ treated by adjunctive teriparatide therapy for 6 months with monitoring of bone turnover markers (at baseline, at 1, 3, and 6 months of treatment, and after 9 months off therapy) and bone scintigraphy (at baseline, 3 and 6 months, and after 9 months off therapy). The patient was a 78-year-old woman with osteoporosis and BRONJ. She had not responded to previous conventional treatment. Teriparatide was added for resolution of BRONJ. The pain disappeared after 1 month, and remarkable bone regeneration was obtained after 6 months, with significantly increasing bone formation and resorption markers. Bone scintigraphy showed regression of the uptake area. This case suggests the usefulness of monitoring bone turnover markers and using bone scintigraphy to increase the effectiveness of teriparatide therapy.
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Affiliation(s)
- Yumiko Ohbayashi
- Department of Oral and Maxillofacial Surgery, Faculty of Medicine, Kagawa University, Kagawa, Japan.
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Subramanian G, Fritton JC, Iyer S, Quek SY. Atypical dental implant failure with long-term bisphosphonate treatment—akin to atypical fractures? Oral Surg Oral Med Oral Pathol Oral Radiol 2012; 114:e30-5. [DOI: 10.1016/j.oooo.2012.03.026] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2011] [Revised: 03/21/2012] [Accepted: 03/26/2012] [Indexed: 11/27/2022]
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Subramanian G, Quek SYP. Teriparatide's role in the management of bisphosphonate-associated osteonecrosis of the jaw. Osteoporos Int 2012; 23:2727-8; author reply 2729-30. [PMID: 22407259 DOI: 10.1007/s00198-012-1951-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2012] [Accepted: 02/01/2012] [Indexed: 11/28/2022]
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Subramanian G, Quek SY. Osteonecrosis of the jaw (ONJ) nomenclature—missing the forest for the trees? Oral Surg Oral Med Oral Pathol Oral Radiol 2012; 114:666-7; author reply 667. [DOI: 10.1016/j.oooo.2012.05.046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2012] [Accepted: 05/17/2012] [Indexed: 10/27/2022]
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Current World Literature. Curr Opin Support Palliat Care 2012; 6:402-16. [DOI: 10.1097/spc.0b013e3283573126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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ARONJ—A SPECTRUM DISORDER? J Am Dent Assoc 2012; 143:739-40; author reply 740-1. [DOI: 10.14219/jada.archive.2012.0252] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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