Osteonecrosis: pathogenesis and practicalities

Bone Complications of Corticosteroids

Background:

Systemic corticosteroids, a mainstay of treatment for severe dermatosis, are associated with systemic complications. Adverse effects of corticosteroids to bone represent a significant adverse effect that, is poorly understood and poorly managed.

Objectives:

The purpose of this article is to educate dermatologists to the current understanding of the pathogenesis, diagnosis, and treatment options available for bone complications of corticosteroids.

Results:

Virtually all patients chronically exposed to high-dose corticosteroid therapy lose bone mass and are at risk for osteoporotic fractures. In addition, osteonecrosis is an unpredictable complication of corticosteroid therapy that may occur with even low-dose corticosteroids.

Conclusion:

Optimal risk management of corticosteroid therapy includes understanding the risk factors associated with bone complications and improving communication with patients.

Ischemic osteonecrosis under fixed partial denture pontics: radiographicand microscopic features in 38 patients with chronic pain

STATEMENT OF PROBLEM

Previous studies have identified focal areas of alveolar tenderness, elevated mucosal temperature, radiographic abnormality, and increased radioisotope uptake or "hot spots" within the quadrant of pain in most patients with chronic, idiopathic facial pain (phantom pain, atypical facial neuralgia, and atypical facial pain).

PURPOSE

This retrospective investigation radiographically and microscopically evaluated intramedullary bone in a certain subset of patients with histories of endodontics, extraction, and fixed partial denture placement in an area of "idiopathic" pain.

MATERIAL AND METHODS

Patients from 12 of the United States were identified through tissue samples, histories, and radiographs submitted to a national biopsy service. Imaging tests, coagulation tests, and microscopic features were reviewed. Of 38 consecutive idiopathic facial pain patients, 32 were women.

RESULTS

Approximately 90% of subpontic bone demonstrated either ischemic osteonecrosis (68%), chronic osteomyelitis (21%), or a combination (11%). More than 84% of the patients had abnormal radiographic changes in subpontic bone, and 5 of 9 (56%) patients who underwent radioisotope bone scan revealed hot spots in the region. Of the 14 patients who had laboratory testing for coagulation disorders, 71% were positive for thrombophilia, hypofibrinolysis, or both (normal: 2% to 7%). Ten pain-free patients with abnormal subpontic bone on radiographs were also reviewed.

CONCLUSIONS

Intraosseous ischemia and chronic inflammation were suggested as a pathoetiologic mechanism for at least some patients with atypical facial pain. These conditions were also offered as an explanation for poor healing of extraction sockets and positive radioisotope scans.

The use of perioperative corticosteroids in craniomaxillofacial surgery

A literature search could not identify a study on the prevalence of the use of perioperative corticosteroids by surgeons performing craniomaxillofacial surgery. To gather this information, we conducted a survey of North American members of the American Society of Maxillofacial Surgeons classified as "active" in the society's roster. The first 90 members in forward and reverse alphabetical order who were capable of receiving a fax transmission were faxed our survey. Sixty surgeons responded, for a response rate of 66.7 percent. Twenty-eight (46.7 percent) reported using short-term, high-dose, perioperative corticosteroids to control postsurgical inflammation. Surgeons performing facial aesthetic surgery alone or in addition to craniomaxillofacial surgery were more likely to be using steroids (Fisher's exact test, p = 0.038). A variety of steroid drugs and regimens were cited by steroid users. The most common reason for using steroids was to decrease edema. Thirty-two (53.3 percent) responders reported that they were not using steroids. The most common reason for not using them was a lack of literature to support their effectiveness. All responders were asked to report any complications encountered with the use of steroids. The majority (78.3 percent) reported no complications. The most common complication encountered was euphoria (13.3 percent). No one reported the occurrence of avascular necrosis of the hip or humerus with the use of steroids. Based on a literature review, an analysis of the steroid regimens and complications reported revealed that steroid use was generally safe. Nevertheless, in addition to the traditional steroid contraindications, consideration should be given to withholding steroids in patients with any of the known risk factors for avascular necrosis, in patients who are or recently have been on nonsteroidal anti-inflammatory drugs, and in aspirin-sensitive asthmatics. These patients may be at increased risk for serious adverse effects with the use of steroids. More research is required to objectively measure the effect of steroids on edema and, if beneficial, to determine the optimal drug regimen.

The risks of systemic corticosteroid use

Because of their potent antiinflammatory and immunosuppressive properties, systemic corticosteroids are used to modify a vast array of diseases. This class of drugs, however, has the potential to produce multiple adverse effects presenting the dermatologist with difficult decisions in the management of patients with potentially steroid responsive disorders. This article reviews the side effects of systemic corticosteroids, comments on strategies to minimize these side effects, as well as, outlining suggested mechanisms by which physicians may minimize the risks of medical legal consequences owing to adverse reactions to these drugs.