Radiographic predictors for MRONJ in oncologic patients undergoing tooth extraction

Key insights into antiresorptive drug use and osteonecrosis in osteoporotic patients undergoing tooth extractions: A clinical and CBCT assessment

This study investigates the effects of antiresorptive drugs and risk factors for medication-related osteonecrosis of the jaws in osteoporotic patients undergoing tooth extraction. Among the findings, antiresorptive-treated patients had thicker lamina dura and longer healing times. Additionally, corticosteroid intake and multi-rooted teeth carried a higher osteonecrosis risk. Bone sequestrum indicated osteonecrosis.

PURPOSE

To describe the effects of antiresorptive drugs (ARD) in the maxilla and mandible and risk factors for medication-related osteonecrosis of the jaws (MRONJ) in osteoporotic patients undergoing tooth extractions using clinical data and cone beam computed tomography (CBCT).

METHODS

This retrospective cohort study collected clinical and CBCT data from 176 patients. The study group (n = 78; 224 extractions) received ARD treatment, underwent tooth extraction, and had a pre-operative CBCT. Additionally, age-, sex-, and tooth-matched controls were selected (n = 98; 227 extractions). Radiographic examinations were performed independently by three calibrated examiners. Statistical analysis included Chi-square, Fisher's exact, Mann-Whitney U, and t-tests to contrast clinical and radiographic data between study and control, MRONJ + and MRONJ - , and bisphosphonate and denosumab patients/sites. Significance was set at p ≤ 0.05.

RESULTS

From the study group, 4 patients (5%) and 5 sites (2%) developed MRONJ after tooth extraction. ARD-treated patients exhibited significantly more thickening of the lamina dura and a longer average mucosal healing time (4.4 weeks) than controls (2.6 weeks). In the study group, MRONJ risk significantly increased with corticosteroid intake and in multi-rooted teeth. No significant differences between bisphosphonates and denosumab use were seen in the tomographic features (p > 0.05). Lastly, bone sequestrum was exclusively observed in osteoporotic patients, who exhibited post-operative exposed bone or histological evidence of osteonecrosis.

CONCLUSION

Osteoporotic patients under ARD may exhibit thickening of the lamina dura and prolonged post-operative healing. Among these patients, multi-rooted teeth are at higher risk for MRONJ than single-rooted teeth. Sequester formation is a radiographic indicator of osteonecrosis.

Precursor Radiographic Findings in Patients With Medication-Related Osteonecrosis of the Jaw

BACKGROUND

Oral surgical treatment, such as tooth extraction, has been identified as a risk factor for the onset of medication-related osteonecrosis of the jaw (MRONJ). However, MRONJ may already be latent, and its manifestation may be triggered by extraction.

PURPOSE

The purpose of this study was to examine the association between pre-extraction imaging and MRONJ.

STUDY DESIGN, SETTING, SAMPLE

We performed a multicenter case-control analysis of patients receiving antiresorptive agents (ARAs) who underwent extraction between 2012 and 2016. We enrolled patients who had undergone tooth extraction in the setting of ARA exposure.

PREDICTOR VARIABLES

The predictor variables comprised preoperative radiographic findings associated with MRONJ stage 0. These findings included alveolar bone loss, thickening or obscuring of the periodontal ligament, and osteosclerosis involving the alveolar bone. They were coded as present or absent before tooth extraction.

MAIN OUTCOME VARIABLE

The primary outcome variable was MRONJ status coded as present or absent.

COVARIATES

Sex, age, underlying diseases necessitating the administration of ARA, the type of ARA used, corticosteroid use, extraction region, and wound closure were analyzed.

ANALYSES

Mann-Whitney U test, χ2 test, Fisher's exact test for univariate analysis, and multiple logistic regression analysis were performed. P values < .05 were significant.

RESULTS

The subjects consisted of 26 patients and 110 controls (male: 8/36, female: 18/74). The mean ages of the MRONJ group and the control group were 77.0 ± 11.9 and 63.0 ± 15.8, respectively (P value = .001). The prevalence of osteosclerosis was significantly higher in the MRONJ group than in the control group (14/72, 53.9%/29.3%, P < .01). Multivariate analysis identified osteosclerosis (odds ratio: 8.4, 95% confidence interval: 2.133.9, P < .01) as a significant independent predictor associated with the development of MRONJ after extraction.

CONCLUSION AND RELEVANCE

These findings suggest that a precursor to MRONJ is highly likely to be present in patients with osteosclerosis at the time of extraction. The majority of patients who developed MRONJ after extraction had imaging findings that suggested infection in the surrounding alveolar bone.

Local radiographic risk factors for MRONJ in osteoporotic patients undergoing tooth extraction

OBJECTIVE

To identify local radiographic risk factors for Medication-Related Osteonecrosis of the Jaws (MRONJ) in osteoporotic patients treated with antiresorptive drugs (ARD) and undergoing tooth extraction.

MATERIAL AND METHODS

Patients were included in this retrospective, longitudinal, case-control study, if having at least one administration of ARD, underwent tooth extraction(s), and had pre- and post-operative panoramic radiographs. Additionally, a matched control group was selected. Three calibrated, blinded, and independent observers assessed each tooth extraction site. Statistical analysis compared control against study group, and within the latter, sites MRONJ+ and MRONJ-.

RESULTS

In total, 120 patients (99 females/21 males) with 354 tooth extractions were included, from which nine patients (7.5%) and eleven tooth extraction sites (3.1%) developed MRONJ. When comparing control with study group, the latter showed significantly more thickened lamina dura, persistence of the alveolar socket, heterogeneous bone patterns, and sequestrum formation. In the study group, MRONJ developed significantly more in males (19%, p = 0.049), smokers (25%, p = 0.008), in the mandible (82%, p = 0.027), when identifying a radiolucent or sclerotic trabecular pattern (p = 0.004) or when extracting teeth with furcation involvement (p < 0.001), root remnants (p = 0.017), or unrestored caries lesions (p = 0.005).

CONCLUSIONS

Tooth extraction sites showing radiographic signs of chronic dental infection are prone to MRONJ.

Etiopathogenesis of medication-related osteonecrosis of the jaws: a review

This study compiles the main hypotheses involved in the etiopathogenesis of medication-related osteonecrosis of the jaw (MRONJ). A narrative review of the literature was performed. The etiopathogenesis of MRONJ is multifactorial and not fully understood. The main hypothesis considers the disturbance of bone turnover caused by anti-resorptive drugs. Bisphosphonates and denosumab inhibit osteoclast activity through different action mechanisms, accumulating bone microfracture. Other hypotheses also consider oral infection and inflammation, the antiangiogenic effect and soft tissue toxicity of bisphosphonates, and the inhibition of lymphangiogenesis. Knowledge of the current theories for MRONJ is necessary to define future studies and protocols to minimize the incidence of this severe condition.

Antiresorptive agent-related osteonecrosis of the jaw risk in cancer patients before bone-modifying agent therapy: A retrospective study of 511 patients

INTRODUCTION

Antiresorptive agent-related osteonecrosis of the jaw (ARONJ) is a serious adverse event associated with therapies for advanced cancer involving bone-modifying agents (BMAs). Although many studies have investigated the risk factors for ARONJ, none have provided sufficient clarifications. We aimed to determine whether there is a correlation between tooth extraction before BMA therapy and the development of ARONJ.

PATIENTS AND METHODS

We included 511 patients who were admitted to our department before BMA therapy. The incidence of ARONJ and its risk factors was retrospectively evaluated, focusing on tooth extraction before BMA therapy and radiological findings of the extracted tooth.

RESULTS

Of the 511 patients, 135 underwent tooth extraction before undergoing BMA therapy. ARONJ was observed in 17.7 % and 7.2 % of patients in the extraction and non-extraction groups, respectively (p = 0.0002). Regarding the findings of panoramic radiographs before tooth extraction, the incidence of periapical disease was significantly higher in the ARONJ group than that in the non-ARONJ group (50 % and 27 %, respectively, p = 0.034), and the proportion of bone sclerotic changes in the surrounding teeth was significantly higher in the ARONJ group (58.3 %) than in the non-ARONJ group (24.4 %) (p = 0.0004).

CONCLUSION

The presence of a hopeless tooth that requires extraction prior to BMA therapy is a risk factor for MRONJ. However, extraction of such teeth should be considered, as this is known to decrease the risk of MRONJ development after BMA therapy initiation. Moreover, the radiological findings of periapical disease and bone sclerotic changes in the extracted teeth identified in this study can be used as novel predictive factors for ARONJ.

Three-dimensional clinical assessment for MRONJ risk in oncologic patients following tooth extractions

OBJECTIVES

To identify clinical and local radiographic predictors for medication-related osteonecrosis of the jaws (MRONJ) by the assessment of pre-operative CBCT images of oncologic patients treated with anti-resorptive drugs (ARDs) undergoing tooth extractions.

METHODS

This retrospective, longitudinal, case-control study included clinical and imaging data of 97 patients, divided into study and control group. Patients in the study group (n = 47; 87 tooth extractions) had received at least one dose of ARD, undergone tooth extraction(s), and had a pre-operative CBCT. An age-, gender-, and tooth extraction-matched control group (n = 50; 106 tooth extractions) was selected. Three calibrated, blinded, and independent examiners evaluated each tooth extraction site. Statistical analysis used χ2/Fisher's exact/Mann-Whitney U test to contrast control and study group, ARD type used, and sites with or without MRONJ development. p-value ≤ 0.05 was considered significant.

RESULTS

From the study group, 15 patients (32%) and 33 sites (38%) developed MRONJ after tooth extraction. When controls were compared to study sites, the latter showed significantly more thickening of the lamina dura, widened periodontal ligament space, osteosclerosis, osteolysis, and sequestrum formation. In the study group, MRONJ risk significantly increased in patients who had multiple tooth extractions, were smokers, and had shorter drug holidays. Periosteal reaction and sequestrum formation may indicate latent MRONJ lesions. Additionally, patients given bisphosphonates showed considerably more osteosclerosis than those given denosumab.

CONCLUSIONS

Periosteal reaction and sequestrum formation are suspected to be pre-clinical MRONJ lesions. Furthermore, ARD induced bony changes and radiographic variations between ARD types were seen.

How does the clinical and tomographic appearance of MRONJ influences its treatment prognosis?

OBJECTIVES

To identify clinical and tomographic prognostic factors for conservative and surgical treatment of medication-related osteonecrosis of the jaws (MRONJ).

METHODS

A retrospective search identified patients treated with antiresorptive drugs (ARDs), diagnosed with Stage 1, 2 or 3 MRONJ, and having CBCT scans previous to conservative or surgical treatment. Following data collection, imaging assessment of the following parameters on each MRONJ site was performed: involvement of teeth and/or implants, presence of osteosclerosis, osteolysis, sequestrum formation, periosteal reaction, and pathological fractures. For statistical analysis, patients and lesions were divided into conservative and surgical treatment. Comparisons were made between successful and unsuccessful outcomes. Significance was set at p ≤ 0.05.

RESULTS

115 ARD-treated patients who developed 143 osteonecrosis lesions were selected. 40 patients and 58 lesions received conservative treatment, of which 14 patients (35%) and 25 lesions (43%) healed. Additionally, 75 patients and 85 lesions underwent surgery, with 48 patients (64%) and 55 lesions (65%) that healed. Clinical and tomographic risk factors for conservative treatment were MRONJ staging, tooth involvement, extensive osteosclerosis, and deep sequestrum formation (p < 0.05). Complementarily, poor prognostic indicators for surgical therapy were a short bisphosphonate (BP) holiday, MRONJ staging, absence of sequestrum formation, and presence of periosteal reaction (p < 0.05).

CONCLUSIONS

Lesions at Stage 3 MRONJ, with tooth involvement, or sequestrum formation showed poor outcomes when conservative treatment is chosen. Alternatively, surgical treatment is most effective when BPs are discontinued, in Stage 1 lesions, in the presence of sequestrum formation, and absence of periosteal reaction.