Neuropathic pain in maxillofacial osteonecrosis

Is preexisting inflamed jaw marrow a "hidden" co-morbidity affecting outcomes of COVID-19 infections? - Clinical comparative study

Introduction: Exceedingly high levels of the chemokine CCL5/RANTES have been found in fatty degenerated osteonecrotic alveolar bone cavities (FDOJ) and aseptic ischemic osteolysis of the jaw (AIOJ) from toothless regions. Because CCL5/RANTES seems to have a prominent role in creating the COVID-19 "cytokine storm", some researchers have used the monoclonal antibody Leronlimab to block the CCR5 on inflammatory cells.Objective: Is preexisting FDOJ/AIOJ jaw marrow pathology a "hidden" co-morbidity affecting some COVID-19 infections? To what extent does the chronic CCL5/RANTES expression from preexisting FDOJ/AIOJ areas contribute to the progression of the acute cytokine storm in COVID-19 patients?Methods: Authors report on reducing the COVID-19 "cytokine storm" by treating infected patients through targeting the chemokine receptor 5 (CCR5) with Leronlimab and interrupting the activation of CCR5 by high CCL5/RANTES signaling, thus dysregulating the inflammatory phase of the viremia. Surgical removal of FDOJ/AIOJ lesions with high CCL5/RANTES from patients with inflammatory diseases may be classified as a co-morbid disease.Results: Both multiplex analysis of 249 FDOJ/AIOJ bone tissue samples as well as serum levels of CCL5/RANTES displayed exceedingly high levels in both specimens.Discussion: By the results the authors hypothesize that chronic CCL5/RANTES induction from FDOJ/AIOJ areas may sensitize CCR5 throughout the immune system, thus, enabling it to amplify its response when confronted with the virus. As conventional intraoral radiography does little to assess the quality of the alveolar bone, ultrasonography units are available to help dentists locate the FDOJ/AIOJ lesions in an office setting.Conclusion: The authors propose a new approach to containment of the COVID-19 cytokine storm by a prophylactic focus for future viral-related pandemics, which may be early surgical clean-up of CCL5/RANTES expression sources in the FDOJ/AIOJ areas, thus diminishing a possible pre-sensitization of CCR5. A more complete dental examination includes trans-alveolar ultrasono-graphy (TAU) for hidden FDOJ/AIOJ lesions.

Expression of JCAD and EGFR in Perineurial Cell-Cell Junctions of Human Inferior Alveolar Nerve

Although perineurium has an important role in maintenance of the blood-nerve barrier, understanding of perineurial cell-cell junctions is insufficient. The aim of this study was to analyze the expression of junctional cadherin 5 associated (JCAD) and epidermal growth factor receptor (EGFR) in the perineurium of the human inferior alveolar nerve (IAN) and investigate their roles in perineurial cell-cell junctions using cultured human perineurial cells (HPNCs). In human IAN, JCAD was strongly expressed in endoneurial microvessels. JCAD and EGFR were expressed at various intensities in the perineurium. In HPNCs, JCAD was clearly expressed at cell-cell junctions. EGFR inhibitor AG1478 treatment changed cell morphology and the ratio of JCAD-positive cell-cell contacts of HPNCs. Therefore, JCAD and EGFR may have a role in the regulation of perineurial cell-cell junctions.

The persistently sensitive or painful osseointegrated implant

OBJECTIVE

To determine why some implants can appear to be well osseointegrated with no signs of infection and yet can remain sensitive to percussion and painful and unable to tolerate the weight of a restoration.

STUDY DESIGN

Five patients were identified who between them had 7 implants that met the criteria of being persistently painful and sensitive to percussion while appearing to be well integrated and otherwise disease free. High-definition cone beam computed tomography scans were obtained for all patients. All patients had failed medical treatment.

RESULTS

The cone beam computed tomography scans showed radiolucent channels running from the nearest nerve trunk to the vicinity of the sensitive implants. These may represent neurovascular channels that originally supplied the teeth that were present at the site of the implants, and they may have terminal neuromas that neuromas may be irritated by the implant. In all cases removal of the offending implant caused either substantial or complete relief of discomfort.

CONCLUSION

The presence of terminal neuromas within the jaws may be responsible for persistent pain and sensitivity in an otherwise well-integrated and disease-free implant. Removal of the offending implant appears to be the only treatment.

Osteonecrosis of the Jaws in Patients with Hereditary Thrombophilia/Hypofibrinolysis-From Pathophysiology to Therapeutic Implications

Osteonecrosis of the jaws (ONJ) usually has a clear etiology. Local infection or trauma, radiotherapy and drugs that disrupt the vascular supply or bone turnover in the jaws are its major contributors. The thrombotic occlusion of the bone’s venous outflow that occurs in individuals with hereditary thrombophilia and/or hypofibrinolysis has a less known impact on jaw health and healing capability. Our research provides the most comprehensive, up-to-date and systematized information on the prevalence and significance of hereditary thrombophilia and/or hypofibrinolysis states in ONJ. We found that hereditary prothrombotic abnormalities are common in patients with ONJ refractory to conventional medical and dental treatments. Thrombophilia traits usually coexist with hypofibrinolysis traits. We also found that frequently acquired prothrombotic abnormalities coexist with hereditary ones and enhance their negative effect on the bone. Therefore, we recommend a personalized therapeutic approach that addresses, in particular, the modifiable risk factors of ONJ. Patients will have clear benefits, as they will be relieved of persistent pain and repeated dental procedures.

Neuralgia-inducing cavitational osteonecrosis - A systematic review

OBJECTIVE

To assess the aetiologic factors, proposed diagnostic means and treatment strategies for neuralgia-inducing cavitational osteonecrosis.

METHODS

A search of the literature published up to June 2020 was conducted using Medline, the Cochrane Library, PsycINFO, CINAHL and Web of Science. The scientific quality of the evidence was rated according to NIH Quality Assessment Tools.

RESULTS

4,051 articles were found, 59 were reviewed in full text, and 29 studies were included. With the exception of hereditary coagulopathies, which were identified as potential risk factors in five studies, suggestions concerning the aetiology varied widely. No gold standard diagnostic mean could be identified. Treatment was most often performed by surgical curettage of the affected bone. Surgical treatment outcomes were equally varied: significant facial pain remission was reported in 66%-100% for periods varying between 2 months to 18 years, whereas no or little relief and recurrences were reported in up to ⅓ of cases. All studies were observational in their design. All investigations were rated as poor quality because of high risk of bias and non-transparent reporting.

CONCLUSIONS

Evidence concerning the aetiology, diagnosis and treatment of NICO is poor. Prospective diagnostic and therapeutic studies are needed before the usefulness of invasive therapeutic procedures can be evaluated.

Neuralgia-inducing cavitational osteonecrosis - Fact or myth, the debate persists

Neuralgia-inducing cavitational osteonecrosis (NICO) is a debated condition characterized by cavitary lesions in the maxillary-mandibular region, often missed on conventional radiographs, and the golden standard for diagnostic measures is bone scintigraphy. It may arise secondary to trauma, such as dental extraction and endodontic treatment, and due to a low-grade chronic infection. NICO has been documented as a frequent cause of face pain involving the trigeminal nerve divisions. It may be severe, piercing pain, of short duration or even continuous pain of moderate intensity. It affects females with a greater predilection than males. A lack of awareness of the condition among health professionals is often put into the basket of atypical facial pain. Current studies describe ischemic alveolar bone marrow coagulation disorders as the cause for NICO, which may also be the result of thrombosis with or without hypofibrinolysis, which would obstruct vascular spaces impairing blood flow in the region. Treatment is decided on a case basis, depending on the clinicians’ experience, on previous treatments, on the patient's general status, and more importantly, whether the site is edentulous or dentate. If surgical intervention is chosen, tissue should be sent for pathological examination. Over the years, with the advance of imaging diagnosis processes and the study and detection of genetic changes, one may also include as a cause of NICO the decreased bone marrow blood flow causing bone cavities. All of this was also associated with genetic mutations which would predispose patients to thrombophilia and hypofibrinolysis.

Association between pain severity and clinicohistopathologic findings in the mandibular canal and inferior alveolar nerve of patients with advanced mandibular osteoradionecrosis

OBJECTIVE

Pain is one of the most problematic symptoms in patients with osteoradionecrosis of the jaws. This study investigated the associations between pain severity and morphologic alterations of the mandibular canal and inferior alveolar nerve, in respective computerized tomography images and resected specimens of mandibular osteoradionecrosis.

STUDY DESIGN

We assessed 14 lesions in 13 patients who underwent segmental mandibulectomy for surgical debridement and simultaneous reconstruction with free fibula flap (1 patient exhibited bilateral lesions). The extent of the mandibular canal bone defect on preoperative coronal computerized tomography images and the number of inferior alveolar nerve fascicles in resected specimens were evaluated. Comparisons were made between the slight pain and extreme pain groups. In most of the patients in the extreme pain group, either mandibular canal bone defects were absent or entire circumferential defects were present; inferior alveolar nerve fascicles were either distinguishable or completely absent in the resected specimens.

RESULTS

Although there was no statistically significant association between extreme pain and computerized tomography or histopathologic findings, the histopathologically indistinguishable inferior alveolar nerve fascicles was significantly associated with slight pain.

CONCLUSIONS

The degree of degeneration of mandibular canal and inferior alveolar nerve may be associated with pain severity in patients with mandibular osteoradionecrosis.

Peripheral Neuropathic Facial/Trigeminal Pain and RANTES/CCL5 in Jawbone Cavitation

Introduction. In this study, we elucidate the possible causative role of chronic subclinical inflammation in jawbone of patients with atypical facial pain (AFP) and trigeminal neuralgia (TRN) in the local overexpression of the chemokine regulated on activation and normal T-cell expressed and secreted (RANTES/C-C motif ligand 5 CCL5). Neurons contain opioid receptors that transmit antipain reactions in the peripheral and central nervous system. Proinflammatory chemokines like RANTES/CCL5 desensitize μ-opioid receptors in the periphery sensory neurons and it has been suggested that RANTES modifies the nociceptive reaction. Materials and Methods. In 15 patients with AFP/TRN, we examined fatty degenerated jawbone (FDOJ) samples for the expression of seven cytokines by multiplex analysis and compared these results with healthy jawbones. Results. Each of these medullary jawbone samples exhibited RANTES as the only highly overexpressed cytokine. The FDOJ cohort with AFP/TRN showed a mean 30-fold overexpression of RANTES compared to healthy jawbones. Conclusions. To the best of our knowledge, no other research has identified RANTES overexpression in silent inflamed jawbones as a possible cause for AFP/TRN. Thus, we hypothesize that the surgical clearing of FDOJ might diminish RANTES signaling pathways in neurons and contribute to resolving chronic neurological pain in AFP/TRN patients.

Surgical neurolysis for the treatment of neuropathic pain in 2 postmenopausal women with mandibular necrosis resulting from oral bisphosphonates

We analyze the use of surgical neurolysis for the treatment of neuropathic pain of the inferior alveolar nerve. For that, 3 surgical neurolysis were performed on 2 postmenopausal women experiencing neuropathic pain of the inferior alveolar nerve due to mandibular necrosis resulting from treatment with oral bisphosphonates. Both patients showed sensory impairment of the inferior alveolar nerve. We obtained complete control of neuropathic pain after 6 months of the patients' evolution, preserving the function of the lingual nerve in all 3 neurolysis, without causing any impact as regards to the sensitive situation before treatment. Surgical neurolysis of the inferior alveolar nerve may be considered as the choice therapeutic technique to treat neuropathic pain of this nerve when there is a sensory impairment in patients showing mandibular necrosis resulting from bisphosphonates.

T-786C polymorphism of the endothelial nitric oxide synthase gene and neuralgia-inducing cavitational osteonecrosis of the jaws

OBJECTIVE

We hypothesized that, similar to idiopathic hip osteonecrosis, the T-786C mutation of the endothelial nitric oxide synthase (eNOS) gene affecting nitric oxide (NO) production was associated with neuralgia-inducing cavitational osteonecrosis of the jaws (NICO).

DESIGN

In 22 NICO patients, not having taken bisphosphonates, mutations affecting NO production (eNOS T-786C, stromelysin 5A6A) were measured by polymerase chain reaction. Two healthy normal control subjects were matched per case by race and gender.

RESULTS

Homozygosity for the mutant eNOS allele (TT) was present in 6 out of 22 patients (27%) with NICO compared with 0 out of 44 (0%) race and gender-matched control subjects; heterozygosity (TC) was present in 8 patients (36%) versus 15 control subjects (34%); and the wild-type normal genotype (CC) was present in 9 patients (36%) versus 29 controls (66%) (P = .0008). The mutant eNOS T-786C allele was more common in cases (20 out of 44 [45%]) than in control subjects (15 out of 88 [17%]) (P = .0005). The distribution of the stromelysin 5A6A genotype in cases did not differ from control subjects (P = .13).

CONCLUSIONS

The eNOS T-786C polymorphism affecting NO production is associated with NICO, may contribute to the pathogenesis of NICO, and may open therapeutic medical approaches to treatment of NICO through provision of L-arginine, the amino-acid precursor of NO.

Bisphosphonate-associated osteonecrosis of the jaw: a review of 35 cases and an evaluation of its frequency in multiple myeloma patients

Over a period of 28 months, we observed five cases of osteonecrosis of the jaw (ONJ) in cancer patients treated with bisphosphonates (BP) at our institution. This prompted us to undertake a retrospective, multicenter study to analyse the characteristics of patients who exhibited ONJ and to define the frequency of ONJ in multiple myeloma (MM). We identified 35 cases in Gruppo Italiano Studio Linfomi centers during the period 2002 - 05. The median time from cancer diagnosis to the clinical onset of ONJ was 70 months. In these 35 cases of ONJ, 24 appeared 20 - 60 months after starting BP treatment. The time for the onset of ONJ was significantly shorter for patients treated with zoledronic acid alone than for those treated with pamidronate followed by zoledronic acid. The frequency of ONJ in the MM group during the study period was 1.9%, although the nature of the present study may have resulted in an underestimation of ONJ cases. Our analysis strongly suggested an association between the use of BP and the occurrence of ONJ, although we were unable to identify any definite risk factors with a retrospective study. The most frequently ONJ-associated clinical characteristics were chemotherapy treatment, steroid treatment, advanced age, female sex, anemia, parodonthopaties/dental procedures and thalidomide (in the case of MM patients).

Nd:YAG laser biostimulation in the treatment of bisphosphonate-associated osteonecrosis of the jaw: clinical experience in 28 cases

OBJECTIVE

To research an efficient treatment for the management of bisphosphonate-associated osteonecrosis.

BACKGROUND DATA

Necrosis of the jawbone has recently been described in association with systemic bisphosphonate therapy with drugs including zoledronic acid, pamidronate, and alendronate. The extent and clinical characteristics of bisphosphonate-associated osteonecrosis (BON) of the jaw are extremely variable, and range from the presence of fistulae in the oral mucosa or orofacial tissues, to large exposed areas of necrotic bone within the oral cavity. Clinical signs and symptoms commonly reported include pain, swelling, the presence of pus, loose teeth, ill-fitting dentures, and paresthesias of the inferior alveolar nerve when the necrosis affects the mandible. Fractures have also been reported. The treatment of BON of the jaw is still controversial since no therapy has proven to be efficacious as shown by the literature on the subject.

MATERIALS AND METHODS

In this study we report results achieved with 28 patients affected by BON of the jaw, who received treatment with the Nd:YAG laser alone or in combination with conventional medical or surgical treatment. Clinical variables such as severity of symptoms, presence of pus, and closure of mucosal flaps before and after therapy were evaluated to establish the effectiveness of laser irradiation. The 28 patients with BON were subdivided into four groups: eight patients were treated with medical therapy only (antibiotics with or without antimycotics and/or antiseptic rinses), six patients were treated with medical and surgical therapy (necrotic bone removal and bone curettage), six patients were treated with medical therapy associated with laser biostimulation, and eight patients were treated with medical therapy associated with both surgical therapy and laser biostimulation.

RESULTS

Of the 14 patients who underwent laser biostimulation, nine reported complete clinical success (no pain, symptoms of infection, or exposed bone or draining fistulas), and three improved their symptomatology only, with a follow-up of between 4 and 7 mo.

CONCLUSIONS

While the results reported in this study are not conclusive, they indicate that laser therapy has potential to improve management of BON.

Osteonecrosis of the jaw and bisphosphonates: a comparison with white phosphorus, radium, and osteopetrosis

INTRODUCTION

Recent reports of bisphosphonate-associated jaw osteonecrosis are reminiscent of earlier incidents in which a comparable syndrome was caused by occupational exposure to white phosphorus or radium. Osteonecrosis of the jaw is also caused by an inherited disease: osteopetrosis. This review analyzes the biomedical and social aspects of these four situations associated with jaw osteonecrosis.

RESULTS

Clinical evidence is contradictory but suggests aminobisphosphonates cause rare cases of jaw necrosis. In addition to jaw problems, generalized skeletal defects characterize osteopetrosis and exposure to phosphorus or radium and there is evidence of decreased bone resorption in these conditions and with bisphosphonate therapy.

CONCLUSION

Bisphosphonate-induced jaw necrosis appears to be an on-target toxicity as the same mechanism, inhibition bone resorption, probably underlies both the therapeutic and adverse effects. Since bisphosphonates are retained for long periods by bone the theoretical potential for skeletal toxicity is increased by using higher doses of potent aminobisphosphonates administered less frequently.

Ozone Therapy in the Treatment of Avascular Bisphosphonate-Related Jaw Osteonecrosis

Avascular osteonecrosis of the jaw (ONJ) may occur as a consequence of several conditions, even including chemotherapy treatment in patients affected by tumors or osteoporosis. We report our clinical experience in treating bisphosphonate-induced ONJ with a therapeutic methodology that includes ozone therapy as a new and original approach for the clinical management of maxillary necrotic lesions. Of 58 patients with ONJ observed at our department, 33 gave their informed consent to be part of the research and were treated according to a therapeutic approach, which included noninvasive surgery associated with pre- and postsurgical cycles of ozone therapy consisting of eight sessions lasting 3 minutes each besides antibiotic and antifungal therapies. Outcomes showed how ozone therapy increases the benefits of surgical and pharmacologic treatments, increasing the complete healing of the lesions with the disappearance of symptoms and brings cases of lesion progression down to zero. In conclusion, ozone therapy is a reliable presidium in treatment of ONJ; its benefits are remarkable and improve significantly the outcomes of the surgical approach.

Bisphosphonates and osteonecrosis of the jaws: Science and rationale

Bisphosphonates as a group of drugs were introduced for the management of various conditions such as osteoporosis, Paget's disease, multiple myeloma, hypercalcemia of malignancy, breast cancer, prostate cancer, and other tumors. This group of drugs has improved the quality of life in many patients with proven efficacy in limiting pain and skeletal-related events. The controversy of osteonecrosis of the jaws and bisphosphonates is a recent and growing problem. Osteonecrosis of the jaws is recognized as a serious complication of bisphosphonate therapy, more commonly with the intravenous form of the drugs. However, there is limited scientific understanding about the association between osteonecrosis of the jaws and bisphosphonates. In the present article we discuss various mechanisms of action of bisphosphonates, the rationale for occurrence of osteonecrosis in the jaws, and treatment guidelines for the condition.

New Therapeutic Protocol in the Treatment of Avascular Necrosis of the Jaws

Osteonecrosis of the jaws is being increasingly reported in patients with bone metastasis from a variety of solid tumors and disseminated multiple myeloma receiving intravenous bisphosphonates. Agreement exists that these drugs can initiate vascular endothelial cell damage and accelerate disturbances in the microcirculation of the jaws, possibly resulting in thrombosis of nutrient-end arteries. The role of bisphosphonates in cancer patients with previously treated jaws has yet to be elucidated. The signs and symptoms that may occur before the appearance of evident osteonecrosis include changes in the health of periodontal tissues, nonhealing mucosal ulcers, loose teeth and unexplained soft tissue infection. A series of 30 periodontally involved patients showing osteonecrosis of the jaws that appeared following the intravenous use of bisphosphonates is reported. Clinical management of the avascular necrosis of the jaws in patients treated with bisphosphonates presents several problems. An analysis of the international medical literature shows that surgical treatment of the necrotic jaws in patients treated with bisphosphonates has proven to be ineffective in stopping the pathological process. The use of hyperbaric oxygen and antibiotics are not effective, either. The authors have developed a new protocol for the management of these lesions. Compared with other therapeutic choices, this protocol has introduced the use of ozone therapy as therapeutic support.

Jaw bone necrosis without previous dental extractions associated with the use of bisphosphonates (pamidronate and zoledronate): a four-case report

Jaw bone necrosis is a clinical condition associated with defects in vascularization of the maxilla or the mandibular bone, usually present following head and neck radiotherapy and/or oral surgical interventions. Bisphosphonates are synthetic analogues of pyrophosphate used in the treatment of patients with hypercalcemia as a result of malignancy, bone metastasis and for the treatment of other disorders such as metabolic bone diseases, Paget's disease and osteoporosis. Over last 10 years, cases of jaw bone necrosis have been associated with the use of bisphosphonate therapy. In particular, Ruggiero et al. (J Oral Maxillofac Surg 2004; 62: 527-534) in 2004 described a large group of patients (63) with jaw bone necrosis probably related to the use of these drugs. It should be noted that all the patients in the group described either underwent head and neck radiotherapy or had a dental extraction while taking bisphosphonates. In the present study, we reported four cases of jawbone necrosis in patients taking pamidronate (Aredia) and zoledronate (Zometa) without having undergone any kind of radiotherapy or dental surgery. All the patients were females between the ages of 56 and 71 years; three were treated with bisphosphonates for bone metastasis and one for multiple myeloma. All the patients received surgical treatment with bone curettage, with partial and/or temporary improvement of the lesions. Although a treatment for bisphosphonate-induced bone lesions has not yet been established, we suggest careful evaluation of the patients' oral health before prescribing bisphosphonate treatment.

Osteonecrosis of jaw in patient with hormone-refractory prostate cancer treated with zoledronic acid

Intravenous bisphosphonates are widely used in the management of metastatic bone disease, as well as osteoporosis. Recent published reports have documented a possible link between treatment with intravenous bisphosphonates and osteonecrosis of the jaw. We report a case of osteonecrosis of the jaw in 1 patient with prostate cancer receiving both chemotherapy and intravenous zoledronic acid (Zometa). Bisphosphonates have been demonstrated to alter the normal bone microenvironment and appear to have direct effects on tumors as well. These changes may contribute to the development of osteonecrosis of the jaw, particularly after tooth extractions or other invasive dental procedures.

Medullary and odontogenic disease in the painful jaw: clinicopathologic review of 500 consecutive lesions

Ischemic jawbone lesions were first discussed in the dental literature more than a century ago, but then seemingly forgotten. In recent years, there has been considerable resurgence in interest in this unique pathological condition. Controversy surrounds the subject. Some proclaim these lesions to be mere fabrications of the imaginations of non-traditional or alternative dental surgeons. Others attribute all human maladies to these maxillofacial lesions. Aside from these philosophical and metaphysical arguments, are there common diagnoses of jawbone pathologies that produce pain? This present investigation reviews the clinicopathologic features of 500 consecutive jawbone surgeries with pathological confirmation in patients with idiopathic facial pain. Four hundred seventy-six (476) of the 500 lesions (95.2%) were directly attributed to impaired blood flow in the jawbone, tooth, or both, according to histopathological analysis and confirming Cavitat (bone ultrasound) examination. Statistical data concerning the location, frequency, and pathological diagnoses of these bony lesions are presented, as are brief methods of diagnosis, and treatment is also discussed.