What Affects Healing Rates in Patients Treated for Medication-Related Osteonecrosis of the Jaw? The Role of Operative Therapy and Other Clinical Factors

BACKGROUND

In the therapy of medication-related osteonecrosis of the jaw (MRONJ), the healing rate, effectiveness of operative therapy, and factors associated with healing remain unclear.

PURPOSE

This study aimed to estimate MRONJ therapy healing rates and identify associated prognostic factors.

STUDY DESIGN, SETTING, SAMPLE

A 25-center prospective cohort study was conducted on 291 patients with MRONJ treated with a common therapeutic protocol during 2013-2016. Patients unable to continue examinations or treatment were excluded.

PREDICTOR VARIABLE

The primary predictor variable was MRONJ therapy grouped into two categories: operative and nonoperative. Secondarily, the prognostic factors categorized as demographic, medical, clinical, and perioperative were evaluated.

MAIN OUTCOME VARIABLES

The primary outcome variable was treatment duration, defined as the time (in months) between the initiation of therapy and when the site was healed or the date of the final visit or loss to follow-up.

COVARIATES

Not applicable.

ANALYSES

Descriptive statistics and 3-year cumulative healing rates were calculated. The association between clinical factors and time to healing was analyzed using bivariate and multivariate analyses and propensity score analysis. P < .05 was considered significant.

RESULTS

We analyzed data from 291 subjects with 76 (26.1%) and 215 (73.9%) subjects in the operative and nonoperative therapy groups, respectively. The healing rates for operative and nonoperative therapies were 95.8 and 70.7%, respectively (hazard ratio [HR] = 1.6, 95% confidence interval [CI] = 1.1-2.2, P value [P] < .01). The healing rates in patients for whom anti-resorptive agent (ARA) treatment was discontinued and continued were 87.2 and 37.4%, respectively (HR = 1.8, 95% CI = 1.1-3.0, P = .02). In a multiple regression analysis using ARA indication, the therapy method showed a significant association in the MRONJ malignancy group (HR = 2.75, 95% CI = 1.46-5.17, P < .01).

CONCLUSION AND RELEVANCE

Operative therapy and ARA discontinuation were associated with better healing rates in MRONJ therapy. However, the choice of therapy for MRONJ should be based on a comprehensive consideration of the patient's condition. ARA discontinuation should be considered an adjunctive measure because of the possibility of adverse events such as fragility fractures and skeletal related events.

Italian position paper (SIPMO-SICMF) on medication-related osteonecrosis of the jaw (MRONJ)

OBJECTIVE

This paper aims to describe the 2023 update position paper on MRONJ developed by the Italian Societies of Oral Pathology and Medicine (SIPMO) and of Maxillofacial Surgery (SICMF).

METHODS

This is the second update following the 2013 and 2020 Italian position papers by the Expert panel, which is a representation of the two scientific societies (SIPMO and SICMF). The paper is based on an extensive analysis of the available literature from January 2003 to February 2020, and the subsequent review of literature conducted between March 2020 and December 2022 to include all new relevant published papers to confirm or modify the previous set of recommendations.

RESULTS

This position paper highlights the main issues of MRONJ on risk estimates, disease definition, diagnostic pathway, individual risk assessment, and the fundamental role of imaging in the diagnosis, classification, and management of MRONJ.

CONCLUSION

The Expert Panel confirmed the MRONJ definition, the diagnostic work-up, the clinical-radiological staging system and the prophylactic drug holiday, as recognized by SIPMO-SICMF; while, it presented novel indications regarding the categories at risk of MRONJ, the prevention strategies, and the treatment strategies associated with the therapeutic drug holiday.

A Systematic Review of Laser Photobiomodulation Dosimetry and Treatment Protocols in the Management of Medications-Related Osteonecrosis of the Jaws: A Rationalised Consensus for Future Randomised Controlled Clinical Trials

Medication-related osteonecrosis of the jaw (MRONJ) is a debilitating adverse effect of bisphosphates, antiresorptive therapy or antiangiogenic agents that can potentially increase oxidative stress, leading to progressive osteonecrosis of the jaws. Despite the large number of published systematic reviews, there is a lack of potential MRONJ treatment protocols utilising photobiomodulation (PBM) as a single or adjunct therapy for preventive or therapeutic oncology or non-oncology cohort. Hence, this systematic review aimed to evaluate PBM laser efficacy and its dosimetry as a monotherapy or combined with the standard treatments for preventive or therapeutic approach in MRONJ management. The objectives of the review were as follows: (1) to establish PBM dosimetry and treatment protocols for preventive, therapeutic or combined approaches in MRONJ management; (2) to highlight and bridge the literature gaps in MRONJ diagnostics and management; and (3) to suggest rationalised consensus recommendations for future randomised controlled trials (RCTs) through the available evidence-based literature. This review was conducted according to the PRISMA guidelines, and the protocol was registered at PROSPERO under the ID CRD42021238175. A multi-database search was performed to identify articles of clinical studies published from their earliest records until 15 December 2023. The data were extracted from the relevant papers and analysed according to the outcomes selected in this review. In total, 12 out of 126 studies met the eligibility criteria. The striking inconsistent conclusions made by the various authors of the included studies were due to the heterogeneity in the methodology, diagnostic criteria and assessment tools, as well as in the reported outcomes, made it impossible to conduct a meta-analysis. PBM as a single or adjunct treatment modality is effective for MRONJ preventive or therapeutic management, but it was inconclusive to establish a standardised and replicable protocol due to the high risk of bias in a majority of the studies, but it was possible to extrapolate the PBM dosimetry of two studies that were close to the WALT recommended parameters. In conclusion, the authors established suggested rationalised consensus recommendations for future well-designed robust RCTs, utilising PBM as a monotherapy or an adjunct in preventive or therapeutic approach of MRONJ in an oncology and non-oncology cohort. This would pave the path for standardised PBM dosimetry and treatment protocols in MRONJ management.

Preoperative Assessment of Medication-Related Osteonecrosis of the Jaw Using [18F]fluoride Positron Emission Tomography (PET)/CT and [18F]fluorodeoxyglucose PET/MRI in Correlation with Histomorphometry and Micro-CT-A Prospective Comparative Study

OBJECTIVES

The purpose of this study was to investigate the imaging characteristics of medication-related osteonecrosis of the jaw (MRONJ) using [18F]fluoride positron emission tomography/computed tomography (PET/CT) and [18F]fluorodeoxyglucose (FDG) PET/magnetic resonance imaging (MRI) for preoperative assessment and to correlate them with microarchitectural and histomorphometric data with respect to clinical findings.

METHODS

Twelve patients (five female; mean age 75 ± 7.6 yr) with symptomatic MRONJ underwent both scans on the same day, and imaging findings were used to plan surgical interventions for seven patients. Bone tracer uptake was classified as high, medium, or low, and surgical samples were evaluated using Micro-CT and histomorphometric analysis.

RESULTS

CT showed medullary sclerosis in all patients, and MRI revealed gadolinium enhancement in four patients. PET imaging revealed remarkably elevated [18F]fluoride uptake and moderately increased [18F]FDG uptake in MRONJ compared to healthy jawbones, with both differences being statistically significant. [18F]fluoride uptake was associated with necrosis, bacteria, and inflammatory tissue. Micro-CT data did not show significant differences, but histomorphometric analysis revealed higher osteocyte and lacunae densities in the high [18F]fluoride uptake group, and more necrotic bone in the medium [18F]fluoride uptake group. Bacteria were observed in all areas.

CONCLUSIONS

In summary, [18F]fluoride PET accurately identified MRONJ extent, revealing functional changes in jawbone remodeling not visible on CT. [18F]FDG PET showed differences in bone and soft tissue, though less pronounced. This method aids in evaluating disease activity and guiding treatment planning, requiring further research for optimal surgical approaches based on tracer uptake.

Treatment outcomes and time to healing of medication-related osteonecrosis of the jaw based on image findings

OBJECTIVES

This study aimed to evaluate the prognostic treatment outcome of non-operative management of medication-related osteonecrosis of the jaw (MRONJ), particularly regarding the relationship between image findings and treatment outcomes.

METHODS

This single-center, retrospective observational study included patients with MRONJ who were conservatively treated between 2010 and 2020. All patients were evaluated in terms of MRONJ treatment outcomes, time to healing, and prognostic factors, including sex, age, underlying disease, antiresorptive drug type, discontinuation of antiresorptive treatment, chemotherapy, corticosteroid treatment, diabetes mellitus, location of MRONJ, clinical stage of MRONJ, and computed tomography image findings.

RESULTS

The complete healing rate among the patients was 68.5%. Cox proportional hazards regression analysis revealed that "Sequestrum formation" on the internal texture (hazard ratio = 3.66; 95% confidence interval, 1.30-10.29; P =.014) and chemotherapy (hazard ratio = 0.41; 95% confidence interval, 0.18-0.95; P =.037) were significantly associated with treatment outcome. The median time to healing in patients with "Sequestrum formation" on the internal texture (4.4 months) was significantly shorter than the median time to healing in those marked with "Sclerosis" or "Normal" (35.5 months; P <.001) and "Lytic changes with sclerosis" (14.5 months; P =.015).

CONCLUSIONS

The image findings on the internal texture of the lesions at the initial examination and chemotherapy were associated with the treatment outcomes of nonoperative management of MRONJ. The image findings of "Sequestrum formation" were associated with lesions taking a short time to heal and better outcomes, whereas "Sclerosis" and "Normal" were associated with lesions with longer healing times.

Systematic review of medication related osteonecrosis of the jaw (MRONJ) in patients undergoing only antiangiogenic drug therapy: surgery or conservative therapy?

Osteonecrosis of the jaw is a severe adverse condition affecting patients exposed to specific types of medications. Previous studies have highlighted that osteonecrosis of the jaw is triggered by invasive dental procedures and can be very challenging to manage, especially in patients with cancer. The primary aim of this review was to analyse all available evidence on the management (surgical and/or conservative) of medication related osteonecrosis of the jaws (MRONJ) in patients with a history of antiangiogenic drugs therapy and who had not been previously exposed to any antiresorptive drug treatments. A multi-database search (PubMed, MEDLINE, EMBASE and CINAHL) was performed to identify related multi-language papers published from January 2003 until November 2020. Data were extracted from relevant papers and analysed according to the outcomes selected in this review. The search generated 28 studies eligible for the analysis. The total number of patients included in the analysis was 36. Sixteen patients were treated with anti-vascular endothelial growth factor drugs (anti-VEGF) while the remaining patients were administered a combination of antiangiogenic drugs. The most common MRONJ site was the mandible in 29 patients. MRONJ recurrence after treatment was only reported in six patients, the majority of which were treated conservatively. The data reviewed confirmed that an invasive procedure was the most common trigger of MRONJ with relatively high frequency of postoperative recurrence following treatment. However, due to the low quality of available research in the literature, it is difficult to draw a definitive conclusion on the validity of the presented treatment to manage patients affected by MRONJ associated with angiogenic therapy.

Non-antiresorptive drugs associated with the development of medication-related osteonecrosis of the jaw: a systematic review and meta-analysis

OBJECTIVE

The aim of this systematic review was to provide evidence related to the association between non-antiresorptive medications and MRONJ.

MATERIALS AND METHODS

The following three electronic databases were screened: PubMed, EMBASE, and Web of Science from December 2020 until April 2021. Two reviewers independently performed the study selection, data extraction, and quality assessment of the included studies. The Newcastle-Ottawa Scale (NOS) was used for assessing the risk of bias. A meta-analysis was performed for assessing the relationship between MRONJ and non-antiresorptive medications.

RESULTS

The search strategy retrieved 996 articles. Following removal of duplicates, title, and abstract screening and full-text reading, 58 publications were eligible to be included in the review. A total of 867 cases of MRONJ were included (33% female, 55% male, 12% no gender reported). The mean age of the patients when MRONJ was diagnosed was 61 years (range 19-100 years) and the average time of diagnosis was 10 months following non-antiresorptive drug therapy. Patients with a history of corticosteroids (0.61, 95% CI 0.39, 0.82, p =  < 0.001) and chemotherapy (0.59, 95% CI 0.51, 0.67, p =  < 0.001) showed the highest significant effect size (ED) compared to the control group for MRONJ occurrence.

CONCLUSION

A significant association existed between MRONJ and non-antiresorptive drugs. However, considering limited evidence, findings should be interpreted with caution.

CLINICAL RELEVANCE

The non-antiresorptive drugs might allow the dentist to apply the principle of "drug holiday" following concurrence from the drug prescribing clinician.

PROSPERO REGISTRATION NUMBER

CRD42020173891.

An unusual case of bone regeneration of a necrotic mandible with pathologic fracture in an elderly hemodialysis patient with medication-related osteonecrosis of the jaw: a case report and review of the literature

Background

Bisphosphonates are frequently used for osteoporosis. Medication-related osteonecrosis of the jaw, a complication of bone-modifying agents, including bisphosphonates or angiogenic inhibitors, can be challenging to treat in elderly patients with numerous preexisting conditions. Achieving good treatment outcomes is especially difficult in patients with pathological fractures accompanied with extraoral fistulae.

Case presentation

We report an unusual case of prominent bone regeneration following palliative surgical treatment in a 72-year-old Japanese female patient undergoing hemodialysis. She previously had severe osteoporosis due to renal osteodystrophy and was receiving antiresorptive intravenous bisphosphonate. Computed tomography revealed a discontinuous left lower mandibular margin with a pathologic fracture and extensive, morphologically irregular sequestrum formation (80 × 35 × 20 mm). The patient was diagnosed with stage III medication-related osteonecrosis of the jaw and pathologic mandibular fracture. Immediately before the surgery, the anticoagulant used for dialysis was changed from heparin to nafamostat mesylate to reduce the risk of intraoperative bleeding. Sequestrectomy was performed under general anesthesia. Postoperative infection was not observed, the intraoral and submandibular fistula disappeared, and, surprisingly, prominent spontaneous bone regeneration was observed postoperatively at 6 months. Despite the severe systemic condition of the patient, the conservative surgical approach with sequestrectomy has yielded desirable results for more than 6 years since the surgery.

Conclusions

This rare report of spontaneous bone regeneration in a patient of advanced age and poor general condition is the oldest case of mandibular regeneration ever reported.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13256-021-03206-5.

Medication-Related Osteonecrosis of the Jaw: A Critical Narrative Review

Background: Nearly two decades have passed since a paradoxical reaction in the orofacial region to some bone modifying agents and other drugs was recognized, namely medication-related osteonecrosis of the jaw (MRONJ). Purpose: The aim of this manuscript was to critically review published data on MRONJ to provide an update on key terminology, concepts, and current trends in terms of prevention and diagnosis. In addition, our objective was to examine and evaluate the therapeutic options available for MRONJ. Methods: The authors perused the most relevant literature relating to MRONJ through a search in textbooks and published articles included in several databases for the years 2003–2021. Results and conclusions: A comprehensive update of the current understanding of these matters was elaborated, addressing these topics and identifying relevant gaps of knowledge. This review describes our updated view of the previous thematic blocks, highlights our current clinical directions, and emphasizes controversial aspects and barriers that may lead to extending the accumulating body of evidence related to this severe treatment sequela.

18F-Fluoride PET/CT Imaging of Medication-Related Osteonecrosis of the Jaw in Conservative Treatment-A Case Report

Medication-related osteonecrosis of the jaw (MRONJ) is a serious side effect in antiresorptive treatment. Treatment of MRONJ is considered primarily conservative with oral mouth rinses and antibiotics but may demand surgery, depending on the complaints and general condition of the patient, the extent of the necrosis, and the overall prognosis with respect to the underlying disease. A 77 year old female patient with invasive ductal breast cancer and bone metastases was treated with intravenous bisphosphonate (BP) zoledronic acid. During therapy, she developed MRONJ in the mandible with severe pain. Clinical examination revealed confluent exposed bone of the lower left jaw and a fistula at the right molar region. The panoramic radiograph revealed a mandibular osseous involvement with diffuse radiopaque areas between radiolucent areas. For preoperative planning, ¹⁸F-fluoride positron emission tomography/computed tomography (PET/CT) of the jaw was performed, showing substantially increased ¹⁸F-fluoride uptake in regions 38 to 47 of the mandible with a focal gap in region 36 (area of clinically exposed bone). CT revealed medullary sclerosis and cortical thickening with confluent periosteal reaction and focal cortical erosion in the regions 37 to 42, whereas the regions 43 to 47 were only subtly sclerotic without cortical thickening. After systemic antibiotic therapy with sultamicillin following significant symptom and pain relief, ¹⁸F-fluoride PET/CT imaging was performed again after 5 months. No changes in either CT and PET were observed in regions 38 to 42, whereas the bony sclerosis was slightly increased in regions 43 to 47 with a slight reduction of ¹⁸F-fluoride uptake. ¹⁸F-fluoride PET/CT showed no significant changes assessing the extent of MRONJ prior and after systemic antibiotic therapy, providing no evidence that conservative treatment reduced the extent of the MRONJ-affected jawbone. The additional information of ¹⁸F-fluoride PET enables to identify the true extent of MRONJ which may be underestimated by CT imaging alone. Patients with MRONJ undergoing conservative treatment could benefit because additional imaging may be avoided as the pre-therapeutic ¹⁸F-fluoride PET/CT delivers all information needed for further treatment. Our findings support the recommendation of a surgical approach as long-term antibiotics cannot downsize the extent of MRONJ.

Clinical considerations for medication-related osteonecrosis of the jaw: a comprehensive literature review

Background

Medication-related osteonecrosis of the jaw (MRONJ), which was first reported as bisphosphonate-related osteonecrosis of the jaw (BRONJ) in bisphosphonate users, is a rare but severe soft and hard tissue disease induced by several types of medications. There has been a deluge of information about MRONJ, such as epidemiology, risk factors, clinical recommendations for dental treatment to prevent it, and treatment strategies in medication-prescribed users. The aim of this study was to comprehensively review recent articles and provide the current scientific information about MRONJ, especially clinical considerations or recommendations for dental treatment to prevent its occurrence.

Materials and methods

The current literature review was mainly based on 14 systematic reviews with or without meta-analysis, 4 position papers, 1 consensus statement, 1 clinical guideline, and 2 clinical reviews regarding MRONJ after a PubMed database and manual searches according to inclusion and exclusion criteria. Moreover, 53 articles were selected by manual search in regard to all references from selected articles and other articles identified on the PubMed search, irrespective of publication date, and inclusion and exclusion criteria.

Results

The incidence and prevalence of MRONJ are relatively low, although they are clearly higher in cancer patients receiving high-dose antiresorptive agents or angiogenesis inhibitors rather than osteoporosis patients receiving oral bisphosphonates or denosumab. There are many types of local, systemic, and other risk factors for the development of MRONJ. Clinical recommendations are provided for each clinical situation of patients to prevent MRONJ. There are also treatment strategies for MRONJ in each stage.

Conclusions

General dentists should perform appropriate dental treatment to prevent MRONJ in the patients prior to or when receiving medications that could induce MRONJ. Moreover, there are treatment strategies for MRONJ in each stage that oral surgeons could follow. Adequate and updated clinical information regarding MRONJ based on scientific data is required whenever possible.

Bisphosphonate-Related Osteonecrosis of the Jaw

OBJECTIVES

Antiresorptive agents for bone pain were widely used to treat patients with advanced osteoporosis, multiple myeloma, and bone metastatic cancer. In recent years, however, bisphosphonate-related osteonecrosis of the jaw (BRONJ) has been a rare but major complication of this therapy. Most patients with BRONJ undergo dental procedures during treatment with antiresorptive agents. However, BRONJ may also occur spontaneously. This study reports 13 BRONJ patient cases at Kaohsiung Veterans General Hospital, Taiwan, and their related treatments. We also compare patients with cancer with patients with osteoporosis in treatment outcomes.

METHODS

Thirteen symptomatic patients with BRONJ were reviewed between 1985 and 2018 at Kaohsiung Veterans General Hospital. We included patients at advanced stage who were hospitalized for infection control of osteonecrosis of the jaw and excluded asymptomatic patients at stage 0 and stage 1. Four multiple myeloma, 3 patients with bone metastatic breast cancer and 6 patients with advanced osteoporosis (average ages, 63.57 ± 14.54 years in cancer patients and 79.5 ± 9.31 years in osteoporosis patients; average drug durations, 25.86 ± 27.23 months in cancer patients and 58.33 ± 23.87 months in osteoporosis patients; average follow-up times, 22.71 ± 14.46 months in cancer patients and 28.08 ± 36.35 months in osteoporosis patients) were included.

RESULTS

Seven patients were defined as having stage 3 (53.8%) and 6 as having stage 2 (46.2%) medication-related osteonecrosis of the jaw, according to the American Association of Oral and Maxillofacial Surgeons classification. The complete response rate with totally healed mucosa was 61.5%. Four cancer patients received free fibular flap (FFF) reconstruction with a high complete response rate (100%). All of them had a relatively better performance status, and the average age was also younger than osteoporosis patients.

CONCLUSION

Free fibular flap with a high complete response rate may improve pain relief and infection control for patients with BRONJ. Younger age is seemed to be a great indicator for FFF, but poor self-care ability (Eastern Cooperative Oncology Group status >3) is not suitable for these surgical treatments.

Evaluation of segmental mandibular resection without microvascular reconstruction in patients affected by medication-related osteonecrosis of the jaw: a systematic review

Medication-related osteonecrosis of the jaw (MRONJ) is a severe condition that affects the jaw in patients exposed to specific drugs. More often it has been described in association with bisphosphonates (BP), but nowadays it has been observed with the use of other medications, such as denosumab (a RANK ligand inhibitor and monoclonal antibody agent) and antiangiogenic drugs. Managing the condition has unfortunately proven difficult and still remains a major challenge for clinicians and surgeons. The aim of this systematic review was to identify and analyse the evidence on mandibular segmental resection in patients with advanced MRONJ. A multi-database (PubMed, MEDLINE, EMBASE, CINAHL, and Cochrane Central Register of Controlled Trials) systematic search was performed. Any type of study on human patients treated with antiresorptive and antiangiogenic drugs was considered. The primary aim was to understand the success of mandibular segmental resection in the short, medium, and long term, and to understand its effects before, during, and after the operation. The search yielded 11 studies that were eligible for analysis with a total of 67 patients. Of the 11 studies, seven reported no complications, and overall, postoperative complications were seen in 16 cases. Recurrence of osteonecrosis was reported in one study. The most common postoperative complication was removal of hardware (n = 11). The mean (SD) follow-up time for eight studies was 35.57 (17.73) months. According to the limited data available in the literature, mandibular segmental resection is a viable treatment that has been used successfully in patients with various stages of MRONJ. The data show a relatively high percentage of recurrence. Additional data based on a larger cohort of patients or case-control studies are necessary to justify routine use of this type of intervention in patients affected by the condition.

Preventing, identifying, and managing medication-related osteonecrosis of the jaw: a practical guide for nurses and other allied healthcare professionals

BACKGROUND

Medication-related osteonecrosis of the jaw (MRONJ) is an infrequent, but potentially serious, adverse event that can occur after exposure to bone-modifying agents (BMAs; e.g., bisphosphonates, denosumab, and antiangiogenic therapies). BMAs are typically used at higher doses to prevent skeletal-related events in cancer patients and at lower doses for osteoporosis/bone loss. MRONJ can cause significant pain, reduce quality of life, and can be difficult to treat, requiring a multiprofessional approach to care.

METHODS

We reviewed the literature and guidelines to summarize a practical guide on MRONJ for nurses and other allied healthcare professionals.

RESULTS

While there is a risk of MRONJ with BMAs, this should be considered in relation to the benefits of treatment. Nurses and other allied healthcare professionals can play a key role alongside physicians and dentists in assessing MRONJ risk, identifying MRONJ, counseling the patient on the benefit-risk of BMA treatment, preventing MRONJ, and managing the care pathway of these patients. Assessing patients for MRONJ risk factors before starting BMA treatment can guide preventative measures to reduce the risk of MRONJ. Nurses can play a pivotal role in facilitating multiprofessional management of MRONJ by communicating with patients to ensure compliance with preventative measures, and with patients' physicians and dentists to ensure early detection and referral for prompt treatment of MRONJ.

CONCLUSIONS

This review summarizes current evidence on MRONJ and provides practical guidance for nurses, from before BMA treatment is started through to approaches that can be taken to prevent and manage MRONJ in patients receiving BMAs.

Medication-Related Osteonecrosis of the Jaw: MASCC/ISOO/ASCO Clinical Practice Guideline

PURPOSE

To provide guidance regarding best practices in the prevention and management of medication-related osteonecrosis of the jaw (MRONJ) in patients with cancer.

METHODS

Multinational Association of Supportive Care in Cancer/International Society of Oral Oncology (MASCC/ISOO) and ASCO convened a multidisciplinary Expert Panel to evaluate the evidence and formulate recommendations. Guideline development involved a systematic review of the literature and a formal consensus process. PubMed and EMBASE were searched for studies of the prevention and management of MRONJ related to bone-modifying agents (BMAs) for oncologic indications published between January 2009 and December 2017. Results from an earlier systematic review (2003 to 2008) were also included.

RESULTS

The systematic review identified 132 publications, only 10 of which were randomized controlled trials. Recommendations underwent two rounds of consensus voting.

RECOMMENDATIONS

Currently, MRONJ is defined by (1) current or previous treatment with a BMA or angiogenic inhibitor, (2) exposed bone or bone that can be probed through an intraoral or extraoral fistula in the maxillofacial region and that has persisted for longer than 8 weeks, and (3) no history of radiation therapy to the jaws or metastatic disease to the jaws. In patients who initiate a BMA, preventive care includes comprehensive dental assessments, discussion of modifiable risk factors, and avoidance of elective dentoalveolar surgery (ie, surgery that involves the teeth or contiguous alveolar bone) during BMA treatment. It remains uncertain whether BMAs should be discontinued before dentoalveolar surgery. Staging of MRONJ should be performed by a clinician with experience in the management of MRONJ. Conservative measures comprise the initial approach to MRONJ treatment. Ongoing collaboration among the dentist, dental specialist, and oncologist is essential to optimal patient care.

Novel insight into the management of bisphosphonate-related osteonecrosis of the jaw (BRONJ)

Bisphosphonate-related osteonecrosis of the jaw (BRONJ), characterized by refractory bone exposure, has recently emerged as a serious side effect of bisphosphonate (BPs) treatment. We discuss novel insights that may help to improve the efficacy of BRONJ treatment and prevention. Our report highlights the following: (1) The presence of exposed bone in patients taking BPs does not necessarily reflect BRONJ, and diagnoses of oral ulceration with bone sequestration and malignancy must be excluded. (2) Osteonecrosis type of BRONJ is difficult to avoid using preventive dental measures alone. However, as with osteomyelitis type of BRONJ, preventive dental measures are indispensable for reducing the risk of secondary infection and disease progression. (3) The importance of tooth extraction as a risk factor for BRONJ among patients taking BPs has been overstated, particularly when they are administered at low doses. Delaying tooth extraction may increase the risk for the onset and progression of osteomyelitic BRONJ. (4) In patients taking low doses of BPs, dental implant surgery is not necessarily contraindicated if there are no other risk factors, such as combined use of corticosteroids or concomitant diabetes. However, the risk of BRONJ due to peri-implantitis must be explained when obtaining patient consent.

Surgical Management of Medication-Related Osteonecrosis of the Jaw Is Associated With Improved Disease Resolution: A Retrospective Cohort Study

PURPOSE

Optimal management approaches for medication-related osteonecrosis of the jaw (MRONJ) using either surgical or nonsurgical approaches remain inconclusive. Our objective was to compare the effects of surgical versus nonsurgical therapy on the resolution of MRONJ.

METHODS

We conducted a retrospective review of eligible patients with a diagnosis of MRONJ at Mount Sinai Hospital, Toronto, Ontario, Canada, who either were seen in the outpatient clinic from January 2014 to December 2016 or received major surgical intervention from January 2011 to December 2016. A multivariate logistic regression was conducted to evaluate the effects of surgical therapy on disease resolution.

RESULTS

A total of 78 patients were included in this study. Of these, 56 (72%) received surgical therapy. Antiresorptive agents were being taken for the treatment of osteoporosis by 46 patients (82%) in the surgical group compared with 20 nonsurgical patients (91%) (P = .28). The median follow-up period was 15.5 months (interquartile range, 8.0 to 34.3 months) in the surgical group compared with 11.0 months (interquartile range, 8.0 to 20.5 months) in the nonsurgical group (P = .75). Disease resolution occurred in 39 surgical patients (70%) compared with 8 nonsurgical patients (36%). Surgical therapy was associated with disease resolution compared with nonsurgical therapy alone, after adjustment for age, duration of antiresorptive or antiangiogenic therapy, whether the antiresorptive or antiangiogenic agents were used for oncologic purposes, and the stage of MRONJ at initial presentation (adjusted odds ratio, 4.33; 95% confidence interval, 1.28 to 14.60).

CONCLUSIONS

Surgical therapy compared with nonsurgical therapy was associated with disease resolution in patients with MRONJ. High-quality evidence of the superiority of any specific surgical approach in the treatment of MRONJ is needed.

☆Symposium: Imaging modalities for drug-related osteonecrosis of the jaw (5), utility of bone scintigraphy and 18F-FDG PET/CT in early detection and risk assessment of medication-related osteonecrosis of the jaw (secondary publication)

Medication-related osteonecrosis of the jaw (MRONJ) is a significant side effect of antiresorptive and antiangiogenic drugs. Since MRONJ is intractable, early detection is the best way to limit progression. Bone scintigraphy and ¹⁸F- fluorodeoxyglucose positron-emission tomography can detect minimal and subclinical changes in bones earlier than conventional radiological modalities. A differential diagnosis including MRONJ is recommended when abnormally high uptakes are incidentally detected in the jaws of patients who have bone metastases. Quantitative analysis of uptakes, such as bone scan index of the jaw using neural network analysis and maximum standardized uptake value, could differentiate MRONJ from common dental diseases and be useful for the early detection and risk assessment of MRONJ.

Is the conservative non-surgical management of medication-related osteonecrosis of the jaw an appropriate treatment option for early stages? A long-term single-center cohort study

PURPOSE

No consensus has been reached regarding the best treatment option for early-stage lesions in medication-related osteonecrosis of the jaw (MRONJ). The purpose of the present study was to evaluate the long-time outcomes of conservative non-surgical management in stage I patients with underlying malignant disease.

MATERIALS AND METHODS

We designed and implemented a retrospective cohort study and enrolled, between 2008 and 2018, a sample of patients with the indication for non-surgical conservative treatment stage I lesions. The primary outcome variable was treatment success defined as mucosal integrity without signs of infection. Secondary outcomes were: (i) worsening stage, (ii) necessity for surgical intervention over time, and (iii) discontinuation of antiresorptive therapy.

RESULTS

The sample included 75 patients with 92 lesions. Eight lesions showed full mucosal coverage, whereas 84 continued with exposed jaw bone (91.3%). Of the treatment-resistent 84 lesions, 67 presented a worsening stage shift over time. Indication for surgical intervention was set in 57 lesions. Of all lesions, 28 developed highly advanced necrotic bone destruction. Antiresorptive medication was paused in all evaluated patients after the first diagnosis of MRONJ.

CONCLUSION

Conservative non-surgical therapy in MRONJ stage I leads to a healing in rare cases. Conservative management might be a good option to preserve symptoms in patients either unwilling to undergo surgery or in those whose reduced general condition does not allow surgery. Early and consequent surgical advances should be performed throughout all stages of the disease to prevent the possibility of silent disease progression with the risk of large-scale bone loss.

Treatment outcomes and prognostic factors of medication-related osteonecrosis of the jaw: a case- and literature-based review

OBJECTIVES

The purpose of this study was to investigate the treatment outcomes and prognostic factors of medication-related osteonecrosis of the jaw (MRONJ) in Japanese patients.

PATIENTS AND METHODS

Among 409 cases, treatment outcomes and prognostic factors were investigated in 275 patients. In statistical analyses, the 1-year cumulative curative rate was calculated with the Kaplan-Meier method, and significance was examined with the Wilcoxon test. Cox's proportional hazards regression analysis was used for the multivariate analysis.

RESULTS

Resolution of the disease was achieved in 137 out of 275 MRONJ patients (49.8%). One-year cumulative curative rates were 39.8% in stage 1 patients, 26.3% in stage 2, and 19.0% in stage 3. The 1-year cumulative curative rates of treatment interventions were 17.2% for conservative treatment, 34.5% for sequestrectomy, and 40.7% for extended surgery including bone resection and segmental resection. As the prognostic factors of treatment outcomes, the type of medication, stage of MRONJ, and type of surgical intervention were identified as independent factors in a multivariate analysis.

CONCLUSION

These results suggest that surgical interventions may lead to a good prognosis in MRONJ patients.

CLINICAL RELEVANCE

This study indicated that surgical intervention for MRONJ might lead to improvement of prognosis and quality of life in MRONJ patients.

Prevalence, initiating factor, and treatment outcome of medication-related osteonecrosis of the jaw-a 4-year prospective study

OBJECTIVES

Medication-related osteonecrosis of the jaw (MRONJ) has a wide range of prevalence, and a standard therapy has not yet been established. The aim of this study was to analyze the prevalence and initiating factors of MRONJ and the outcomes of surgical therapy.

STUDY DESIGN

In a prospective cohort study, all patients diagnosed with MRONJ in the Region of Skåne, in Sweden, were included. Predictor variables (comorbidity, site, stage, gender) and initiating factors (tooth extraction, periodontitis) were recorded. Surgical treatment was sequestrectomy or block resection, and the outcome variable was healing after 2 months. To estimate the prevalence, data on the use of bisphosphonate and denosumab were used.

RESULTS

Fifty-five patients with MRONJ were identified. The prevalence of MRONJ was 0.043% among patients treated with oral bisphosphonates, 1.03% among those on intravenous bisphosphonates and 3.64% in those on high-dose denosumab. Periodontal disease preceded development of MRONJ in 41 patients. Fifty patients were treated surgically and followed up for at least 2 months. Remission or healing occurred in 80% of patients treated with sequestrectomy and in 92.5% of patients treated with block resection.

CONCLUSIONS

The prevalence of MRONJ in Sweden is low. Periodontitis is the most common initiating factor. The outcome of treatment of MRONJ is healing in most patients treated surgically.

Can platelet-rich fibrin improve healing after surgical treatment of medication-related osteonecrosis of the jaw? A pilot study

OBJECTIVE

The aim of this study was to evaluate the efficacy of platelet-rich fibrin (PRF) after bone surgery compared to surgery alone in the treatment of medication-related osteonecrosis of the jaw (MRONJ).

STUDY DESIGN

A total of 47 patients with diagnosis of stage II or III of MRONJ were recruited at the Academic Hospital of Magna Graecia University of Catanzaro and allocated to 2 groups: In the first, patients were treated with PRF in addition to surgery (PRF group), in the other, only bone surgery was performed (non-PRF group). Fisher's exact and Student t tests were used to evaluate differences between the 2 surgical protocols in terms of mucosal integrity, absence of infection, and pain evaluation at scheduled follow-ups of 1 month (T1), 6 months (T2), and 1 year (T3).

RESULTS

Analysis of mucosal integrity, absence of infection, and pain evaluation showed a significant difference between the 2 groups in favor of PRF only at T1 (P < .05), whereas no differences were determined at T2 and T3 (P > .05).

CONCLUSIONS

Our results suggested that local application of PRF after bone surgery may improve the quality of life limited to the short-term follow-up and reduce pain and postoperative infections.

Medication-related osteonecrosis of the jaw: Prevention, diagnosis and management in patients with cancer and bone metastases

Medication-related osteonecrosis of the jaw (MRONJ) is primarily an adverse side effect of denosumab or bisphosphonates (particularly when used at high doses to prevent skeletal-related events [SREs] in patients with cancer and bone metastases) or possibly anti-angiogenic cancer treatment. While the implementation of preventive measures over recent years has reduced the risk of MRONJ in patients with bone metastases due to cancer, it is imperative to balance the risk of MRONJ against the beneficial effects of treatment with denosumab or bisphosphonates on the skeletal health of patients. Despite growing awareness of MRONJ within the medical community, there is a lack of large-scale, prospective clinical studies in this rapidly evolving field. Discussing preventive measures with patients and implementing them, both before and during treatment with bisphosphonates or denosumab, is the best option to reduce the risk of MRONJ. In particular, avoiding bone trauma and preventing and treating dental infections before and during denosumab or bisphosphonate therapy is crucial to minimize the risk of MRONJ. If MRONJ develops, conservative (non-surgical) treatment can provide symptom relief, but achieving mucosal closure remains challenging. When management of symptoms and mucosal healing are the ultimate goals of therapy, or after failure of conservative treatment, a surgical approach may be beneficial. This critical review, based on a best-evidence review of currently available literature, provides clear practical guidelines to help to prevent, manage and treat MRONJ. Overall, a multidisciplinary, pragmatic approach to MRONJ should be adopted, prioritizing patient's quality of life and management of their skeletal malignant disease.

Microsurgical Reconstruction of the Jaws Using Vascularised Free Flap Technique in Patients with Medication-Related Osteonecrosis: A Systematic Review

Background

Osteonecrosis of the jaw (ONJ) has been reported to be associated with patients receiving primarily bisphosphonate (BP) therapies. However, lately it has been documented that other medications, such as RANK ligand inhibitor (denosumab) and antiangiogenic drug, can cause ONJ. Micro-osseous-vascular reconstruction of the jaws in patients affected by medication-related osteonecrosis of the jaw represents a viable option of treatment for patients affected by stage III of the disease. However, there are still considerable doubts about the success of this procedure in the short, medium, and long term.

Material and Methods

A multidatabase (PubMed/MEDLINE, EMBASE, and CENTRAL) systematic search was performed. Any type of studies considering human patients treated with antiresorptive and antiangiogenic drugs was considered. The aim of the research is to primarily understand the success rate of micro-osseous-vascular reconstruction in the short, medium, and long period of time. This review has also the goal of better understanding any perioperative and postoperative complications resulting from the use of the reconstruction techniques.

Results

Eighteen studies resulted eligible for the study. Fibula free flap is the most commonly utilised vascularised free flap reconstruction technique (80.76%). Ten out of eighteen studies reported no complications. Recurrence of osteonecrosis was registered in five cases (6.41%) after free flap reconstruction. The overall free flap success rate was 96.16%.

Conclusions

Based on the limited data available in literature (Level 4 of the Oxford Evidence-based medicine scale), micro-osseous-vascular reconstruction of the jaws represents a valid treatment in patients with bisphosphonate-related osteonecrosis at stage III of the disease. However, additional data based on a larger cohort of patients are necessary to justify this type of intervention in patient affected by MRONJ.

Osteonecrosis of the Jaw Associated with Antiangiogenics in Antiresorptive-Naïve Patient: A Comprehensive Review of the Literature

Objectives

To review the available literature on medication-related osteonecrosis of the jaw (MRONJ) associated with antiangiogenics in antiresorptive-naïve individuals.

Methods

A literature search was performed using MEDLINE via PubMed, EMBASE, and Web of Science in December 2017.

Results

We identified reports describing a total of 35 antiresorptive drugs-naïve patients who developed antiangiogenic-related MRONJ. The mean age of these patients was 59.06 years and the F : M ratio was 4 : 5. The most common underlying disease was metastatic renal cell cancer. Pain to the mandible was the most common complaint (34.29%) and the majority of patients presented with bone exposure. The mean duration of intravenous and oral antiangiogenics before MRONJ development was 6.5 and 16.72 months, respectively. The most common additional risk factor was dental extraction (37.14%). Almost half of the MRONJ patients (48.57%) received surgical treatment. 18 patients (62.06%) were reported to have disease resolution within an average time of 6.75 months.

Conclusion

MRONJ associated with antiangiogenic therapy in antiresorptive-naïve patients is a rare but potentially serious adverse effect. Available data suggests that there might be notable differences between MRONJ associated with antiangiogenics and antiresorptives; however, further prospective well-designed studies are required.

Stage-specific therapeutic strategies of medication-related osteonecrosis of the jaws: a systematic review and meta-analysis of the drug suspension protocol

OBJECTIVE

The most debated topic about medication-related osteonecrosis of the jaws (MRONJ) is its therapy, as there are no definitive guidelines. The aims of this systematic review were (a) to outline the best therapeutic approach according to the stage at diagnosis and (b) to perform a meta-analysis to assess whether the drug-holiday protocol may be or not an effective method in the management of MRONJ patients.

MATERIALS AND METHODS

The systematic review was performed following the PRISMA principles. Results were screened according to inclusion and exclusion criteria regarding staging before/after treatment, follow-up, and information provided by the authors. For statistical analysis, linear variables are reported as means and standard deviations, medians, and inter-quartile range (IQR); normality of data, according to the distribution of complete healing (primary outcome variable), was assessed with the Kolmogorov-Smirnov test. A p value < 0.05 was considered statistically significant for all tests.

RESULTS

Thirteen studies were selected out of 1480. None of them was case-controlled or randomized. Conservative approach showed good results at early stages, but heterogeneous result at advanced stages (100% stage 0, stage I range 81-97%, stage II range 63.6-100%, stage III 73%). Surgical approach showed heterogeneous results at all stages (stage I range 0-100%, stage II range 52-100%, stage III range 50-100%). Statistical analysis showed a significantly higher prevalence of completely healed sites in patients who followed the drug-holiday protocol.

CONCLUSIONS

The results suggest that the current stage-specific approach for MRONJ therapy is based on a sound clinical rationale. Conservative treatment appears to yield better outcomes at early stages, while further investigations are needed to elucidate the best protocols for the management of advanced stages. The drug-holiday protocol statistically promotes complete healing after oral surgery procedures but the application should be dictated by the condition of each patient.

CLINICAL RELEVANCE

At present, early MRONJ stages should be primarily treated by means of a conservative approach while more advanced stages must be carefully evaluated. Individual decisions should be made for every single case even with respect to the drug-holiday protocol.

Can Autofluorescence Guide Surgeons in the Treatment of Medication-Related Osteonecrosis of the Jaw? A Prospective Feasibility Study

PURPOSE

The main limitation of surgical treatment of medication-related osteonecrosis of the jaw (MRONJ) is difficulty in defining resection margins. The aim of this study was to compare the efficacy of the surgeon's experience and autofluorescence-guided bone surgery to delimit resection margins for necrotic bone.

MATERIALS AND METHODS

MRONJ requiring surgical treatment was classified according to American Association of Oral and Maxillofacial Surgeons staging. To detect vital bone and resection margins, patients of each stage were randomly assigned to 1 of 2 surgical groups: an autofluorescence-guided surgery (AF) group and a conventional surgery (non-AF) group based on the surgeon's experience. Bone samples from the 2 groups were analyzed histopathologically. The main outcomes were defined as the absence of bone exposure or infection at the time of evaluation. Infection was defined as the presence of swelling, pain, or numbness in the area. Measurements were collected preoperatively and 1 week, 1 month, 6 months, and 1 year after surgery. Statistical analysis included descriptive statistics and the Fisher exact test to evaluate eventual differences between the 2 surgical protocols.

RESULTS

The 36 patients (21 women and 15 men) included in this study were equally divided into 2 groups according to the surgical protocol: 18 patients in the non-AF group and 18 in the AF group. Thirty-nine lesions were included in this analysis: 20 lesions in the non-AF group and 19 in the AF group. Histopathologic examination confirmed the necrotic nature of all bone samples. Statistical analysis showed no differences in necrotic bone exposure or signs of infections between the 2 surgical protocols at different times (P > .05).

CONCLUSIONS

Although the VELscope appears to be useful in guiding bone resection margins in patients with MRONJ, autofluorescence does not appear to be superior to conventional surgical techniques in mucosal healing and quality of life.

Nasolabial Flap Improves Healing in Medication-Related Osteonecrosis of the Jaw

PURPOSE

Medication-related osteonecrosis of the jaw (MRONJ) is an adverse side effect of antiresorptive and antiangiogenic therapeutic agents that is difficult to treat owing to its high relapse rate. The aim of the present study was to determine whether patients with MRONJ treated using decortication and a nasolabial flap compared with those who underwent decortication with mucoperiosteal flaps have better outcomes regarding stable wound closure.

MATERIALS AND METHODS

Two groups of patients with MRONJ and intraoral exposed bone were evaluated in a cohort clinical study retrospectively. The primary predictor variable was the treatment group. The experimental group used the nasolabial flap for wound closure, and the control group used the mucoperiosteal flap for closure. The outcome variable was successful wound closure defined as a symptomless and closed wound after at least 12 months. Other study variables included factors such as perioperative drug holiday, duration of postoperative oral antibiotic administration, and postoperative use of nasogastric feeding tubes. Cox proportional hazard regression analysis and Kaplan-Meier curves were used to determine the factors independently associated with the dependent variable. The Mann-Whitney U test and χ² test were used for analyses regarding group-related data.

RESULTS

Both groups showed similar demographics. The 16 study patients receiving nasolabial flaps had a mean age of 69.9 years, and the 16 control patients receiving mucoperiosteal flaps had a mean age of 71.8 years. Both groups included 10 women and 6 men. Of the 16 patients in each group, 15 had received a bisphosphonate and 1, monoclonal antibody therapy. All evaluated patients underwent combined treatment, including decortication and intravenous antibiotics. Of the 16 patients receiving nasolabial flaps, symptomless intact wound closure was achieved in 68.8%. Of the 16 patients with mucoperiosteal closure, 18.7% achieved wound closure, with 81.2% developing a relapse of MRONJ, a statistically significant difference (P < .001). No statistically significant differences were found between the 2 groups in the demographic variables. The mean interval to relapse for the experimental and control groups was 13.6 ± 7.8 and 8.2 ± 7.9 months, respectively (P = .017).

CONCLUSIONS

MRONJ is a complication of antiosteoclastic treatment of mostly oncologic, palliative patients, which requires a very methodical approach to surgical treatment. A variety of different methods have been reported. The use of nasolabial flaps can be considered as a highly reliable option for coverage the bone wound with less morbidity than microvascular free flaps and better long-term results compared with mucoperiosteal flaps.

Osteonecrosis of the jaw and survival of patients with cancer: a nationwide cohort study in Denmark

Osteonecrosis of the jaw (ONJ) is an adverse effect of bone‐targeted therapies, which are used to prevent symptomatic skeletal events following bone malignancy. We examined the association between ONJ and survival among cancer patients treated with bone‐targeted agents. Using nationwide registries and databases in Denmark, we identified 184 cancer patients with incident ONJ between 2010 and 2015, and a comparison cohort of 1067 cancer patients without ONJ and with a history of hospital‐administered treatment with bisphosphonates or denosumab initiating from cancer diagnosis. At the date of confirmed ONJ diagnosis, the comparison cohort was matched to the ONJ patients on age, cancer site, year of cancer diagnosis, and stage at diagnosis. The patients were followed up for survival until emigration or 15 June 2016. We computed overall survival and estimated mortality rate ratios adjusted for sex, and for the presence of distant metastases and other comorbidity at start of follow‐up. A match was found for 149 of the 184 ONJ patients. The 1‐ and 3‐year survival among all 184 cancer patients with ONJ was 70% (95% confidence interval [CI]: 63%–76%) and 42% (95% CI: 34%–51%), respectively. Among the matched patients, ONJ was associated with an adjusted mortality rate ratio of 1.31 (95% CI: 1.01–1.71). ONJ was associated with reduced survival among cancer patients treated with bone‐targeted agents. ONJ may be a marker of advanced disease or of survival‐related lifestyle characteristics.

Use of Leukocyte- and Platelet-Rich Fibrin in the Treatment of Medication-Related Osteonecrosis of the Jaws

Lesions associated with medication-related osteonecrosis of the jaws (MRONJ) are refractory to different treatment approaches. Hence, auxiliary approaches capable of improving patient outcomes should be explored. Leukocyte- and platelet-rich fibrin (LPRF) is a second-generation platelet concentrate (natural autologous fibrin matrix). It shows anti-infectious activity through immune regulation and accelerates the angiogenesis and multiplication of fibroblasts and osteoblasts; in consequence, it stimulates soft tissue healing and prevents exposure of the alveolar bone in the oral cavity. This report describes 2 cases involving women with breast cancer who were being treated with zoledronic acid and exhibited advanced MRONJ. In case 1, MRONJ developed in the maxilla after dental extraction; in case 2, it was assumed that MRONJ arose spontaneously in the mandible because no other risk factors could be detected. These cases were managed with surgical resection of the necrotic bone followed by placement of an LPRF membrane. Complete wound healing and intact mucosal cover were achieved. At clinical and tomographic follow-up after 2 years, there were no oral lesions or complaints. Therefore, this could be a noninvasive, quick, and alternative approach to manage bone exposure. The LPRF membrane contributes to a successful outcome and acts as a physical barrier against micro-organisms, thus preventing secondary infections.

Effectiveness of treatments for medication-related osteonecrosis of the jaw: A systematic review and meta-analysis

BACKGROUND

The effectiveness of management strategies used for the treatment of medication-related osteonecrosis of the jaw (MRONJ) remains poorly understood. The authors evaluated systematically the effectiveness of the various treatment modalities used for MRONJ.

TYPES OF STUDIES REVIEWED

The authors conducted a comprehensive search of MEDLINE, Embase, the Cochrane Library, and Scopus to identify randomized controlled trials, nonrandomized controlled trials, and prospective cohort studies to evaluate comparatively the effectiveness of management strategies for the treatment of MRONJ. The authors conducted the identification of eligible studies in duplicate and synthesized the extracted data by means of a meta-analysis, when feasible.

RESULTS

The authors found 13 studies with a medium-to-high risk of bias that met the inclusion criteria of this review. The authors found that, compared with medical treatment of local antimicrobials with or without systemic antimicrobials, the study investigators associated surgical treatment with higher odds of complete resolution of the condition (2 studies; 76 participants; unadjusted odds ratio, 3.55; 95% confidence interval, 1.12 to 11.19). The effectiveness of other therapies, such as bisphosphonate drug holidays, teriparatide, and hyperbaric oxygen, was uncertain.

CONCLUSIONS AND PRACTICAL IMPLICATIONS

On the basis of the results of an unadjusted analysis, the results of the studies that were deemed to be medium to low quality and to have medium-to-low statistical power suggested that there are higher odds of resolving MRONJ with surgical treatment compared with medical treatment. High-quality research is required for conclusive statements to be made regarding treatment strategies for management of MRONJ.

[Research progress on bisphosphonate-related osteonecrosis of the jaws]

Bisphosphonates (BPs), as potent drugs inhibiting bone resorption, have been widely used for treatment of several diseases. In recent years, dentists and oral and maxillofacial surgeons reported continuously increasing cases of bisphosphonate-related osteonecrosis of the jaws (BRONJ). This disease is clinically characterized by exposed bones, formation of sequestrum, pain, and halitosis. Provided that pathogenesis of BRONJ is unclear, effective treatments for this disease are currently unavailable. Thus, prevention plays an important role in the management of BRONJ. This review summarizes research progress on pathogenesis, risk factors, clinical characteristics, treatment, and prevention of this condition.

Skeletal Site-specific Effects of Zoledronate on in vivo Bone Remodeling and in vitro BMSCs Osteogenic Activity

Bisphosphonate-related osteonecrosis of the jaw (BRONJ) has been associated with long-term oral or intravenous administration of nitrogen-containing bisphosphonates (BPs). However, the pathogenesis of BRONJ remains unknown, and definitively effective treatment has not yet been established. Bisphosphonate-related osteonecrosis (BRON) tends to occur in maxillofacial bones. Why this occurs is still unclear. Here we show that zoledronate (Zol) treatment suppresses alveolar bone remodeling after tooth typical clinical and radiographic hallmarks of the human BRONJ, whereas enhances peripheral bone quantity in bone remodeling following injury in the same individuals, shown as increased cortical bone thickness, increased trabecular bone formation and accelerated bone defect repair. We find that the RANKL/OPG ratio and Wnt-3a expression are suppressed at the extracted alveolar sites in Zol-treated rats compared with those at the injured sites of peripheral bones. We also show that Zol-treated bone marrow stromal cell (BMSCs) derived from jaw and peripheral bones exhibit differences in cell proliferation, alkaline phosphatase (ALP) activity, expression of osteogenic and chondrogenic related marker genes, and in vivo bone formation capacity. Hopefully, this study will help us better understand the pathogenesis of BRONJ, and deepen the theoretical research.

Medication-related osteonecrosis of the jaw: a preliminary retrospective study of 130 patients with multiple myeloma

Background

Multiple myeloma (MM) is characterized by a neoplastic proliferation of plasma cells primarily in the bone marrow. Bisphosphonates (BP) are used as supportive therapy in the management of MM. This study aimed to analyze the incidence, risk factors, and clinical outcomes of medication-related necrosis of the jaw (MRONJ) in MM patients.

Methods

One hundred thirty MM patients who had previous dental evaluations were retrospectively reviewed. Based on several findings, we applied the staging and treatment strategies on MRONJ. We analyzed gender, age, type of BP, incidence, and local etiological factors and assessed the relationship between these factors and the clinical findings at the first oral examination.

Results

MRONJ was found in nine male patients (6.9%). The mean patient age was 62.2 years. The median BP administration time was 19 months. Seven patients were treated with a combination of IV zoledronate and pamidronate, and two patients received single-agent therapy. The lesions were predominantly located in the mandible (n = 8), and the most common predisposing dental factor was a history of prior extraction (n = 6). Half of the MRONJ were related to diseases found on the initial dental screen. Patients with MRONJ were treated with infection control and antibiotic therapy. When comparing between the MRONJ stage and each factor (sign, location, etiologic factor, BP type, treatment, and outcome), there were no significant differences between stages, except for between the stage and sign (with or without purulence).

Conclusions

For prevention of MRONJ, we recommend routine dental examinations and treatment prior to starting BP therapy.

Analysis of different therapeutic protocols for osteonecrosis of the jaw associated with oral and intravenous bisphosphonates

Introduction

Chemotherapy-associated osteonecrosis of the jaw caused by bisphosphonates is an exposure of necrotic bone with more than eight weeks of evolution that is attributable to bisphosphonates and no prior radiation therapy. Its etiopathogenesis remains unknown, although there are two hypotheses that may explain it: the drug’s mechanism of action, and the risk factors that can lead to osteonecrosis. There is a wide range of treatment options for managing chemotherapy-associated osteonecrosis of the jaw, from conservative treatments to surgical procedures of varying levels of invasiveness, which are sometimes supplemented with adjuvant therapies.

Objectives

The objective of this article is to group the therapeutic options for osteonecrosis of the jaw (ONJ) into seven different protocols and to evaluate their effectiveness in relation to stage of ONJ.

Material and Methods

A literature review was carried out in PubMed following the PRISMA criteria. A total of 47 were collected after compiling a series of variables that define ONJ, applied treatments, and the clinical results obtained.

Results and Discussion

The 47 articles selected have a low to average estimated risk of bias and are of moderate to good quality. According to the data obtained, Protocol 3 (conservative treatment, clinical and radiological follow-up, minimally invasive surgical treatment, and adjuvant therapies) is the most favorable approach for ONJ lesions caused by oral bisphosphonates. For lesions caused by intravenous bisphosphonates, Protocol 2 (conservative treatment, clinical and radiological follow-up, minimally invasive surgical treatment, and no adjuvant therapies) is the best approach. When comparing the different stages of ONJ, Protocol 1 (conservative treatment, clinical and radiological follow-up) promotes better healing of Stage 1 ONJ lesions caused by orally administered bisphosphonates, and Protocol 3 is recommended for Stage II. For ONJ lesions attributable to intravenous bisphosphonates, Protocol 7 (conservative treatment, clinical and radiological follow-up, and adjuvant therapies) provides the best results in Stage 0; in Stages I, II, and III, Protocol 1 gives better results.

Key words:Bisphosphonates, bronj, therapeutic protocol, clinical result.

Prophylaxis and antibiotic therapy in management protocols of patients treated with oral and intravenous bisphosphonates

INTRODUCTION

Osteonecrosis of the jaw (MRONJ) linked to bisphosphonate treatment has specific characteristics that render its therapeutic management challenging for clinicians. Poor response to standard treatment makes it essential to take special precautions when treating this type of disease; therefore, antibiotic prophylaxis and/or antibiotic therapy have been proposed as effective and helpful tools in these situations.

OBJECTIVES

This article seeks to assess published evidence in order to evaluate the different protocols used for antibiotic prophylaxis and/or antibiotic therapy in the general context of patients treated with bisphosphonates.

MATERIAL AND METHODS

A literature review of the last 10 years was carried out in PubMed using the following keywords: "antibiotic prophylaxis and osteonecrosis," "bisphosphonates AND osteonecrosis AND dental management," "bisphosphonate AND osteonecrosis AND antibiotic prophylaxis AND oral surgery." A total of 188 articles were obtained, of which 18 were ultimately selected.

RESULTS AND DISCUSSION

In patients treated with oral and intravenous bisphosphonates without chemotherapy-associated osteonecrosis of the jaw, antibiotic prophylaxis prior to oral surgery is an important tool to avoid osteonecrosis and promote healing of the affected area. If the patient previously exhibited chemotherapy-associated osteonecrosis after tooth extraction, antibiotic prophylaxis is indicated to prevent recurrent osteonecrosis and promote healing of the extraction site. If chemotherapy-associated osteonecrosis is already present, antibiotic therapy is a vital part of conservative management to reduce the symptomatology of MRONJ and keep it from worsening. Finally, a lack of clinical data and randomized controlled trials makes it difficult to choose the most appropriate protocol for the various clinical situations studied. Key words:Bisphosphonates, antibiotic prophylaxis, maxillary osteonecrosis, antibiotic treatment.

Treatment of osteonecrosis of the jaw related to bisphosphonates and other antiresorptive agents

Background

The clinical management of medication-related osteonecrosis of the jaw (MRONJ) in patients treated with bisphosphonates and other antiresorptive agents is subject to controversy. The American Association of Oral and Maxillofacial Surgeons (AAOMS) has developed guidelines for the correct management of the disorder which are revised and updated by a panel of experts.

Material and Methods

The present systematic review analyzes the different treatments currently used to treat this clinical condition, based on the PRISMA® (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement published in 2009. An electronic Medline search was made of the PubMed database, covering the period 2006-2014. The last search date was 31 December 2014.

Results

A total of 29 articles were selected from the initial search according to the different drugs implicated in the appearance of osteonecrosis; the treatment modality used according to the stage of the disease; and the recorded success rate.

Conclusions

It is currently still recommended that the management of MRONJ should be decided according to the stage of the disease – conservative treatment being preferred in early stages without symptoms, while surgical management is preferred in the case of bone exposure with symptoms.

Key words:Osteonecrosis, medication, bisphosphonates, treatments, review

Evaluation of surgical outcome and influencing risk factors in patients with medication-related osteonecrosis of the jaws

PURPOSE

Surgical treatment of the medication-related osteonecrosis of the jaw (MRONJ) is still challenging. We examined the outcome of the resection of osteonecrotic lesions and the influence of potential risk factors on the operative success.

METHODS

Seventy six surgical interventions on 40 patients were evaluated in a prospective design with a mean follow-up of 55 weeks. Primary endpoints were: (i) maintenance of the mucosal closure and (ii) decrease of MRONJ stage. Influential variables included preoperative duration, location and diameter of MRONJ, duration and change of antiresorptive therapy, presence of actinomyces species.

RESULTS

Only in 27.6% of cases long-term maintenance of the mucosal closure was achieved. However, stage II patients decreased to stage I in 81% after surgery (p < 0.01) and stage III patients improved in 83% of cases (OR = 8.08; p = 0.07). Stage I patients profited only in 38% by surgical intervention. MRONJ recurrence after surgery was associated with extended preoperative MRONJ duration (p = 0.015). There was no significance of further influential variables, but MRONJ of the upper jaw seems prognostically more favorable.

CONCLUSION

Advanced stages of MRONJ benefit from surgical treatment, whereas stage I diseases may also be treated conservatively. An early intervention reduces the risk of recurrence.

Sinusitis and oroantral fistula in patients with bisphosphonate-associated necrosis of the maxilla

Background

The management of bisphosphonate related necrosis of the jaw has become clinical routine. While approximately two thirds of the lesions are in the mandible, one third is located in the maxilla. In 40–50 % of maxillary necrosis the maxillary sinus is involved, leading to maxillary sinusitis and oro-antral communications.

Methods

This retrospective single center study includes all patients with diagnosis of BP-ONJ of the maxilla and concomitant maxillary sinusitis. The information collected includes age, gender, primary disease, bisphosphonate intake, involving type of bisphosphonate, route of administration and duration of BP treatment previous to surgical treatment and treatment outcome.

Results

A total of 12 patients fulfill the criteria of the diagnosis of maxillary sinusitis associated to maxillary necrosis, of which 6 Patients showed purulent sinusitis. All patients underwent surgical treatment with complete resection of the affected bone and a multilayer wound closure. A recurrence appeared in one patient with open bone and no sign of sinusitis and was treated conservatively.

Conclusions

Purulent maxillary Sinusitis is a common complication of bisphosphonate-related necrosis of the maxilla. The surgical technique described can be suggested for the treatment of these patients.

Surgical management of bisphosphonate-related osteonecrosis of the jaws: literature review

PURPOSE

Surgical management of bisphosphonate-related osteonecrosis of the jaws (BRONJ) has been performed in an attempt to increase healing rates of the affected cases. This literature review aimed to identify clinical studies of surgical management of bisphosphonate-related osteonecrosis of the jaws (BRONJ) in order to assess their surgical treatment modalities, outcome and the follow-up.

METHODS

A search in the PubMed (Medline) database using specific terms and/or phrases as "bisphosphonate-related osteonecrosis" or "jaw osteonecrosis", and "surgical treatment" or "surgical management" was conducted in order to identify clinical trials and cases of surgical treatment of BRONJ. The review search covered the time period from 2004 to 2014. All studies identified in the search were selected according to the inclusion criteria. Relevant information was recorded according to the following items: author, year, number of patients, BRONJ clinical stage, surgical treatment modality, clinical success, and follow-up.

RESULTS

The initial database search yielded 345 titles. After filtering, 67 abstracts were selected culminating in 67 full text articles. A variety of surgical approach was found in this review: debridement, sequestrectomy bone resection, and bone reconstruction. Adjunctive therapies included hyperbaric oxygen, laser therapy, growth factors, and ozone.

CONCLUSION

Although there are many indexed studies about BRONJ, well-documented reports concerning surgical therapeutically techniques are scarce, resulting from a lack of well-established protocols. Considerable differences were found regarding sample size, surgical treatment modalities and outcomes. Clinical studies with larger number of patients and longer follow-up are required to provide best information for each surgical treatment modality and its outcomes.

Medication Related Osteonecrosis of the Jaw: 2015 Position Statement of the Korean Society for Bone and Mineral Research and the Korean Association of Oral and Maxillofacial Surgeons

Bisphosphonates are the most widely prescribed drugs for the treatment of osteoporosis, and are also used in malignant bone metastases, multiple myeloma, and Paget's disease, and provide therapeutic efficacy on those diseases. However, it was reported that occurrence of osteonecrosis of the jaw (ONJ) could be related with bisphosphonate exposures, and there have been many cases regarding this issue. Therefore, a clearer definition and treatment guidelines were needed for this disease. The American Society for Bone and Mineral Research (ASBMR) and American Association of Oral and Maxillofacial Surgeons (AAOMS) reported statements on bisphosphonate-related ONJ (BRONJ), and a revised version was recently presented. In the revised edition, the diagnosis BRONJ was changed to medication-related ONJ (MRONJ), which reflects a consideration of the fact that ONJ also occurs for denosumab, a bone resorption inhibitor of the receptor activator of nuclear factor-kappa B ligand (RANKL) antibody family, and bevacizumab, an anti-angiogenesis inhibitor. In 2009, a statement on ONJ was also reported locally by a relevant organization, which has served as basis for clinical treatment in Korea. In addition to the new official stance of the AAOMS and ASBMR, with an increasing pool of ONJ clinical experience, a revised version of the 2009 local statement is needed. As such, the Korean Society for Bone and Mineral Research (KSBMR) and the Korean Association of Oral and Maxillofacial Surgeons (KAOMS) have collectively formed a committee for the preparation of an official statement on MRONJ, and have reviewed recent local and international data to propose guidelines customized for the local Korean situation.

Value of nonsurgical therapeutic management of stage I bisphosphonate-related osteonecrosis of the jaw

There is still controversy about the best treatment strategy for patients with bisphosphonate-related osteonecrosis of the jaw (BRONJ) stage I. Therefore, the aim of the present study was to analyse the effect of a nonsurgical treatment protocol in patients with BRONJ stage I. During the study period we included 17 patients (11 male; 6 female) who presented with a total of 24 separate areas of BRONJ, stage I. All patients were exclusively treated with a monthly intravenous regime of zoledronic acid due to an underlying malignant disease. All patients were treated using a standardized nonsurgical protocol consisting of antimicrobial mouth rinsing with chlorhexidine (CHX) (0.12%) three times a day, and daily CHX gel application. In 11 patients (45.8%) the surface area of the exposed jawbone was completely healed by nonsurgical treatment. In seven patients (29.2%), nonsurgical treatment reduced the size of the exposed bone area by a mean of 64.7% (range 20.0-96.8%). None of the patients showed an increase in size of the area of exposed jawbone, or a worsening of the BRONJ from stage I to stages II or III. However, the duration of nonsurgical treatment or the duration of intravenous bisphosphonate therapy did not significantly influence the treatment outcome (p = 0.6628, p = 0.6077, respectively). The results of the present study support the beneficial role of nonsurgical treatment in patients presenting with BRONJ stage I. Surgical therapy of BRONJ should be restricted to patients with advanced stages with clinical symptoms and local signs of infection.

Evaluation of dental implants as a risk factor for the development of bisphosphonate-related osteonecrosis of the jaw in breast cancer patients

It remains unclear whether dental implants are a risk factor for the development of bisphosphonate-related osteonecrosis of the jaw (BRONJ). We retrospectively evaluated the status of dental implants in patients given intravenous bisphosphonates (BPs) in a breast cancer cohort to elucidate the risk for BRONJ at the implant site. We established a BRONJ oral monitoring program for 247 breast cancer patients given intravenous BP in our institution. The 3-year cumulative incidence rate was determined. The systemic and local risk factors of 44 patients who completed comprehensive oral examinations were evaluated by logistic regression analysis. The 3-year cumulative incidence rate of the 247 patients was 0.074 % (8/247, 95 % CI 0.0081-0.014). In the 44 orally examined patients, 6 (13.6 %: 6/44) had dental implants. Of these 6 patients, 1 developed BRONJ at the implant site. There were no significant differences in the age, total BP treatment period, number of residual teeth, time of regular oral monitoring, oral hygiene level, or dental implant insertion. Although a case of ONJ was identified, dental implants which were inserted before intravenous BP administration were not a risk factor for the development of ONJ in breast cancer patients.

Successful treatment of bisphosphonate-related osteonecrosis of the jaw (BRONJ) patients with sitafloxacin: new strategies for the treatment of BRONJ

BRONJ has become a well-known, occasionally severe side effect of bisphosphonate therapy, as well as a clinical problem. Although treatment recommendations exist, no standard therapy has yet been established for BRONJ. Also, these recommendations identify several limitations that prevent clinicians from confidently diagnosing BRONJ. The aim of the present study was to establish a treatment approach in which all patients with exposed, infected bone or intraoral/extraoral fistulas were treated with sitafloxacin (STFX). We examined 20 BRONJ patients, fourteen with cancer and six with osteoporosis. We used the current updated definition of BRONJ (12), except that we included patients who had shown symptoms for a minimum of only one month, rather than two months. Thus half of our patients had infection with no exposed, necrotic bone in the oral cavity. We purposely excluded all patients exhibiting no signs of infection (current Stages 0 and 1). In addition, each potentially causative organism was isolated from pus collected from an intraoral or extraoral fistula in ten patients on their first visit to our department. 90% of the patients had received a course of treatment with common antibiotics. STFX was administered to all patients. We then re-evaluated the lesion every other week, to determine whether epithelialization was present. We recommended surgical treatment for cases without epithelialization within 4 weeks after the onset of administration of STFX even if bone was not exposed at the lesion. 19 of our 20 cases of Stages 2-3 BRONJ responded to 2-10 weeks of STFX treatment by entering either a remission or healed phase. While surgery was done on thirteen cases, seven others reached such phases without surgery. Every patient had at least one bacterial species that showed resistance to common antibiotics. All species in all patients were susceptible to STFX. Our results indicate that STFX, with or without minor surgery, gives a high probability of controlling infection in BRONJ patients with persistent infection after use of common antibiotics, leading to remission and/or complete healing in 95% of patients.