Oral-Health-Related Quality of Life After Surgical Treatment of Osteonecrosis of the Jaws

Potential role of comprehensive dental care in preventing medication related osteonecrosis of the jaw (MRONJ): a single centre study

OBJECTIVE

Medication-related osteonecrosis of the jaw bones (MRONJ) is a well-known complication of antiresorptive and antiangiogenic drugs. Since the first report, more occurrences of MRONJ have been described worldwide. Dental extraction has been described by many studies as one of the risk factors for MRONJ. Comprehensive dental care (CDC) is a preventive dental method provided to patients prior to drug commencement. This study aims to determine the association between CDC and MRONJ.

PATIENTS AND METHODS

A retrospective analysis was performed on 75 medical records of patients on antiresorptive and/or antiangiogenic drugs between February 2018 and May 2021. Demographics and clinical and radiographic data were collected. Univariate and multivariate analyses were performed to determine the factors associated with MRONJ.

RESULTS

Of the 75 patients who met the inclusion criteria, 11 (14.7%) developed MRONJ. Three out of 11 patients (27.2%) developed MRONJ spontaneously, while eight patients (72.8%) developed it after trauma from dentures or dental extractions. Following a binary logistic regression analysis, the lack of CDC was identified as a significant predictor of MRONJ. Patients who did not receive CDC had an odds ratio of 8.64 (95% confidence interval (CI): 1.27-58.62, p = 0.03). However, dental extraction did not show a statistically significant association with MRONJ in both the univariate and multivariate analyses.

CONCLUSION

CDC before treatment with antiresorptive and antiangiogenic drugs is a potentially effective preventive method for reducing MRONJ. Dental extraction was not a significant factor in relation to MRONJ.

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.

Comparing the Influence of Surgical and Conservative Therapy on Quality of Life in Patients with Early-Stage Medication-Related Osteonecrosis of the Jaw-A Prospective Longitudinal Study

Background and Objectives: The purpose of this study was to evaluate the impact of surgical and conservative, non-surgical treatment on general health-related (QoL) and oral health-related quality of life (OHRQoL) in patients suffering from AAOMS stage I MRONJ. Materials and Methods: In the course of this prospective clinical study, QoL and OHRQoL using QLQ-C30 and QHIP G14 questionnaire were longitudinally assessed in N = 174 prospectively enrolled patients with indication of treatment of MRONJ stage I over a period of 12 months. Patients received conservative or surgical treatment. The measurement time points were preoperatively (T0), 12 weeks (T1), 6 months (T2) and 1 year after operation (T3). Results: For OHRQoL, no significant (p > 0.05) differences were found between both treatment groups for all timepoints (T0-T3). In the surgical treatment group, OHIP scores of T1, T2 and T3 were significantly lower than baseline measures (T0) (T0-T1 (2.99, p = 0.024), T0-T2 (5.20, p < 0.001), T0-T3 (7.44, p < 0.001)). For conservative treatment group OHIP, scores of T2 and T3 were significantly lower than baseline measures (T0) (T0-T2 (9.09, p = 0.013), T0-T3 (12.79, p < 0.001)). There was no statistically significant effect of time on QLQ-C30 scores in both groups (surgical treatment: F(3, 174) = 1.542, p < 0.205, partial η² = 0.026; conservative treatment: F(3, 30) = 0.528, p = 0.667, partial η² = 0.050). QLQ-C30 scores turned out to be significantly lower in the non-surgical group at T1 (p = 0.036) and T3 (p = 0.047) compared to the surgical treatment group. Conclusions: Surgical and conservative treatment of MRONJ stage I significantly improves patients' OHRQoL. Surgical treatment is superior to conservative treatment of MRONJ stage I regarding general QoL. Therefore, surgical treatment of MRONJ stage I should not be omitted for QoL reasons.

Oral-Health-Related Quality of Life in Patients with Medication-Related Osteonecrosis of the Jaw: A Prospective Clinical Study

Medication-related osteonecrosis of the jaw (MRONJ) represents an adverse side effect of antiresorptive and antiangiogenic medications. It is associated with impaired quality of life, oral health, and oral function and can be classified into various stages. The purpose of this prospective clinical study is to evaluate the impact of stages I and II MRONJ on oral-health-related quality of life (OHRQoL) and related parameters. Patients' OHRQoL, satisfaction with life, oral discomfort, and oral health were assessed using the German version of the Oral Health Impact Profile (OHIP-G49), visual analog scales (VAS), and Satisfaction with Life Scale (SWLS) at baseline (T0), 10 days (T1), and 3 months after treatment (T2) in 36 patients. Data were analyzed using Kolmogorov-Smirnov test, two-way mixed ANOVAs, and follow-up Mann-Whitney U tests. The impact of treatment effects on the original seven OHIP domain structures and the recently introduced four-dimensional OHIP structure were evaluated using linear regression analysis. Thirty-six patients received surgical MRONJ treatment. Before treatment, patients' perceived OHRQoL, oral discomfort, oral health, and satisfaction with life were negatively affected by MRONJ. Surgical treatment significantly improved OHRQoL and related parameters (all p ≤ 0.012). This improvement was greater in patients with higher impairment at T0. OHRQoL and oral restrictions were still impaired after treatment in patients who needed prosthetic treatment. The four-dimensional structure revealed valuable information beyond the standard seven OHIP domains. Increased awareness of MRONJ risks and an interdisciplinary treatment approach for MRONJ patients are needed.

Quality of life after segmental mandibulectomy and free flap for mandibular osteonecrosis: Systematic review

OBJECTIVE

Review QOL outcomes among patients undergoing segmental mandibulectomy and bony free flap reconstruction for ONJ.

DATA SOURCES

PubMed was searched for MeSH terms "Quality of life," "Osteonecrosis," "Osteoradionecrosis," "Bisphosphonate-associated osteonecrosis of the jaw," "Free tissue flaps," and "Mandibular reconstruction."

REVIEW METHODS

English language studies with QOL outcomes data for patients undergoing free flap reconstruction for advanced ONJ were included. 197 records were initially screened; 18 full texts assessed; 10 full texts included. PRISMA guidelines were followed.

RESULTS

Ten studies were included in this systematic review: six retrospective, three retrospective with comparison groups, and one prospective. In studies with comparison groups, ONJ patients have worse self-reported QOL than the general population as well as head and neck cancer patients without ONJ. Nearly all patients with QOL measurements (220/235 patients) had ONJ from prior radiation. Segmental mandibulectomy and bony free flap improved overall QOL in over half of patients, as well as pain associated with ONJ in 70-75 % of patients. Surgery did not improve long-term effects of radiation such as chewing, swallowing, and salivary production. Donor site morbidity rarely affects QOL.

CONCLUSIONS

Osteonecrosis of the jaw (ONJ) worsens quality-of-life, and advanced disease often requires segmental mandibulectomy and bony free flap reconstruction. Patients and surgeons may expect improvement in some, but not all, domains of patient-reported QOL by the use of segmental mandibulectomy and reconstruction for advanced ONJ.

The preventive care of medication-related osteonecrosis of the jaw (MRONJ): a position paper by Italian experts for dental hygienists

PURPOSE

The prevention and early diagnosis of medication-related osteonecrosis of the jaw (MRONJ) is fundamental to reducing the incidence and progression of MRONJ. Many in the field believe that dental hygienists should play an integral role in primary and secondary MRONJ prevention. However, to date, very few publications in the literature have proposed standardised MRONJ protocols, which are dedicated to dental hygienists. The aim of this study was to provide guidance to the health care providers managing MRONJ.

METHODS

The expert opinion in this study was developed by dental hygienists from the main Italian technical-scientific associations (Italian Dental Hygienists Association, AIDI and National Union of Dental Hygienists, UNID) and authors of the latest Italian recommendations regarding MRONJ from the field of dentistry and maxillofacial surgery.

RESULTS

The oral care protocol outlined in this position paper is focused on the role of dental hygienist in patients at risk or affected by MRONJ, and it regards 3 main issues: primary prevention, secondary prevention and supporting the treatment of MRONJ. Each issue contains easy-to-apply indications and procedures, as described by the authors, regarding the role of the dental hygienist.

CONCLUSION

Referring to the main issues under consideration (primary prevention, secondary prevention and the treatment of MRONJ), a clinical examination of periodontal tissue is critical in preventing MRONJ. It is the opinion of the authors of this study that the application of a periodontal screening score is fundamental in defining personalised strategies for patients at risk of MRONJ. By means of these basic procedures, a protocol for assisting the health care provider and the presentation of a practical approach for patients at risk or affected by MRONJ are described in this study.

Development and evaluation of the clinimetric properties of the Medication-Related Osteonecrosis of the Jaw Quality of Life Questionnaire (MRONJ-QoL)

The purpose of this study was to develop a self-administered questionnaire (MRONJ-QoL) to assess the quality of life (QoL) of patients with medication-related osteonecrosis of the jaw (MRONJ). A prospective study was performed to develop and evaluate the questionnaire. The MRONJ-QoL was formulated through a review of the literature and interviews of experts and patients. Following development, it was administered to 60 patients with a diagnosis of MRONJ. The sensibility of the questionnaire was assessed by evaluating feasibility (via interviews of patients), face validity (via interviews of patients and experts), and content validity (via evaluation of internal consistency, floor/ceiling effects, and factor analysis). Reliability was evaluated by measuring intra-rater reliability. Construct validity of the questionnaire was evaluated by both cross-sectional and longitudinal comparisons, including comparing scores of the MRONJ-QoL to disease resolution at 6 months. The final MRONJ-QoL questionnaire consisted of 14 questions, demonstrating high internal consistency (Cronbach's alpha of 0.85) and good reliability (weighted kappa score of 0.65). At the 6-month follow-up, disease resolution was found to be significantly associated with improved MRONJ-QoL scores, suggesting validity of the questionnaire (P < 0.01). Therefore, this is a sensible, reliable, and valid questionnaire for evaluating the QoL of patients with MRONJ.

Influence of Preventive Tooth Extractions on Quality of Life in Patients with Antiresorptive Intake-A Prospective Longitudinal Study

Background: To find out whether preventive tooth extractions in patients on antiresorptive therapy have a direct impact on the patients’ overall quality of life (QoL); Methods: QoL using the five-level version of the EuroQol Group’s EQ-5D instrument (EQ-5D-5L) was longitudinally assessed in N = 114 prospectively enrolled patients with indication of preventive tooth extraction over a period of 12 months. Patients were stratified as high-risk (malignant disease with bone metastasis or multiple myeloma, with monthly high-dose antiresorptive therapy delivered intravenously [bisphosphonate] or subcutaneously [denosumab]) and low-risk/osteoporosis patients (weekly low-dose antiresorptive therapy administered orally [bisphosphonate] or half-yearly subcutaneously [denosumab]). The measurement time points were 4 weeks preoperatively (T0), 2 months (T1) and 1 year postoperatively (T2), respectively. Results: EQ-5D-5L index scores fell in a range from −0.21 to 1.00 in the low-risk group to 0.15 to 1.00 in the high-risk group. The t-test comparing the baseline index scores of both groups showed EQ-5D-5L index score in the low-risk group (0.708 ± 0.292) to be significantly smaller (p = 0.037) than in the high-risk group (0.807 ± 0.19). ANCOVA showed no significant differences in EQ-5D-5L index scores between the groups at T1 and T2. Conclusions: Preventive tooth extractions in patients undergoing antiresorptive treatment have no negative effect on QoL. Therefore, if indicated, preventive tooth extraction should not be omitted. Patient-oriented outcome measures are important to obtain a good risk–benefit balance for patient-specific treatment.

CD34 and CD105 Microvessels in Resected Bone Specimen May Implicate Wound Healing in MRONJ

Clinical treatment outcome of MRONJ (medication-related osteonecrosis of the jaw) surgery despite radical osseous removal and primary closure healing still shows differences in terms of outcome and disease recurrence. The study aims to assess the rate of angiogenesis of MRONJ lesions in order to understand the impact of angiogenesis and neoangiogenesis status on MRONJ surgical treatment outcome. This is the first study correlating microvessel density with prognosis in MRONJ surgically-treated patients. The immunohistochemical expression of CD34 and CD105 in MRONJ specimens obtained from surgically-treated patients was evaluated. The most vascularized areas detected by CD34 and CD105 were selected and the microvessel density value of the samples was registered. Samples were retrospectively divided according to the clinical outcome of MRONJ surgical treatment, dividing patients into two groups, “healed” and “not healed”. Statistical analysis was performed to assess if neovessels could influence treatment outcome in patients undergoing radical surgery. In the examined cohort, this value was highly predictive of better treatment outcome after radical surgery of MRONJ. Understanding of angiogenesis-dependent factors deserves further attention as a future target for MRONJ prevention and therapies.

Treatment of Refractory Medicine Related Osteonecrosis of Jaw With Piezosurgical Debridement and Autologous Platelet Rich Fibrin: Feasibility Study

ABSTRACT

Medicine related osteonecrosis of jaw (MRONJ) is incidental in patients receiving certain bone modifying agents in oncology. These lesions may not respond to conservative management and aggravate. Autologous platelet derivatives contain bone growth factors, which help in bone regeneration. The aim of this pilot study is to develop protocol for treatment of refractory MRONJ with pizosurgical debridement and advanced platelet rich fibrin.In this feasibility study, refractory MRONJ lesions were treated by piezosurgical debridement and insertion of autologous advanced platelet rich fibrin in 15 patients. One patient had 2 lesion sites, so in all 16 MRONJ sites were treated. These patients were evaluated at the end of 1 month and 4 months for healing of MRONJ lesion. Statistical analysis was done by using Fisher test for response assessment in relation to variable. Eight lesions (50%) showed complete healing at the end of 1 month. At the end of 4 months 13 lesions (81.50%) were completely healed, 2 lesions (12.5%) were downgrades, and 1 lesion (6.25%) did not respond to treatment. Number of doses of bone modifying agent was only factor found associated with nonhealing of MRONJ when treated with this protocol.In this pilot study, feasibility of use of piezosurgical debridement and platelet rich fibrin was evaluated. The results of the study suggest complete healing can be achieved with this treatment protocol. Further research with increased sample size is warranted to determine optimum use of autologous platelet concentrates in treatment of MRONJ.

Gene expression analysis of fresh extraction wounds prior to onset of bisphosphonate-related osteonecrosis of the jaw-like lesions in mice: A preliminary animal study

PURPOSE

The aim of the present study was to investigate the effects of chemotherapeutic/bisphosphonate combination therapy with tooth extraction on gene expression patterns of fresh extraction wounds during initial stages prior to their diagnosis as bisphosphonate-related osteonecrosis of the jaw (BRONJ)-like lesions in mice.

METHODS

Female C57BL/6J mice were used. To create a high-prevalence BRONJ mouse model, combination therapy with the chemotherapy drug cyclophosphamide (CY) and zoledronic acid (ZA) was performed (CY/ZA). Both maxillary first molars were extracted 3 weeks after drug therapy. Saline was used as the control (VC). Soft tissues near the fresh extraction wounds were dissected at 72 h postextraction to investigate the gene expression patterns. Maxillae and long bones at 2 and 4 weeks postextraction were also analyzed.

RESULTS

CY/ZA significantly increased the relative expression levels of IL-6 and decreased those of IL-10 and IGF-1 when compared with those in VC. Moreover, CY/ZA significantly reduced the relative expression levels of CCR-7, cxcl12, cxcr4, and CD105 when compared with those in VC, whereas the level of F4/80 was significantly increased by CY/ZA. Furthermore, CY/ZA significantly decreased the relative expression levels of VEGFA, VEGFB, and VEGFC at 72 h postextraction compared with those in VC.

CONCLUSIONS

Considering that the present study lacked adequate in vitro models, CY/ZA markedly changed the gene expression patterns associated with wound healing from the initial stages prior to onset of BRONJ-like lesions, which may help us to understand the pathophysiology of BRONJ in humans.

Quality of life in patients affected by medication-related osteonecrosis of the jaws: A systematic review

OBJECTIVE

The aim of this systematic review was to describe the quality of life and oral health-related quality of life of patients affected by medication-related osteonecrosis of the jaw.

STUDY DESIGN

The review was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A combination of keywords and MeSH terms was used in PubMed, Scopus, Cochrane Library, Web of Science, and EBSCO up to December 13, 2020.

RESULTS

A total of 1066 results were obtained after duplicate exclusion and 11 articles were included in the final qualitative analysis. Most of the articles described the quality of life in patients with osteonecrosis of the jaw secondary to cancer treatment. The main drugs associated with the disease were bisphosphonates. Surgical treatment of the osteonecrosis improves the quality of life of these patients.

CONCLUSIONS

The present systematic review suggested the negative influence of osteonecrosis of the jaw on the quality of life and oral health-related quality of life among oncologic and osteoporotic patients. The use of quality of life questionnaires in daily practice could be an important tool to better diagnose and manage patients affected by osteonecrosis of the jaws who have received or are receiving drugs associated with this complication.

Surgical Management of Medication-Related Osteonecrosis of the Jaw Patients Related to Dental Implants

OBJECTIVES

The aim of the present study is to report a case series of patients with peri-implant medication-related osteonecrosis of the jaw (MRONJ), in particular describing the onset of the condition and surgical treatment outcome.

MATERIAL AND METHODS

Fifteen consecutive patients with clinical diagnosis of peri-implant MRONJ were retrospectively included in the study. The sample was stratified on the base of oral, pharmacological, and general health variables. The number of affected implants was recorded in all patients, and MRONJ staging applied. Surgical treatment was performed with a standardized operative protocol, involving implant removal, sequestrectomy, debridement of soft tissue, and bone curettage. Follow-up evaluating surgical outcome was performed at twelve months after surgery.

RESULTS

in our study sample, patients were almost equally distributed in terms of underlying diseases in osteoporotic and oncologic patients. All MRONJ lesions were symptomatic, and in 6 patients bone exposure was detected. 40 implants in total were evaluated, with MRONJ being present around 29 implants. 12 patients were diagnosed with Stage III MRONJ, and 3 patients with Stage II MRONJ. Surgical treatment leads to complete healing in 86.7% of cases, with 100% success for maxillary MRONJ.

CONCLUSIONS

Surgical treatment seems to have a positive impact on MRONJ treatment also in cases of peri-implant involvement. However, monitoring and prevention are fundamental in patients under pharmacological treatment with anti-resorptive/antiangiogenic drugs, as peri-implant MRONJ can develop also in absence of specific traumatic events.

The impact of medication-related osteonecrosis of the jaws on the quality of life in cancer patients

Background

To evaluate the impact of oral health on the quality of life (QOL) of individuals undergoing cancer treatment at the time of diagnosis of medication-related osteonecrosis of the jaw (MRONJ).

Material and Methods

The present cross-sectional study analyzed patients with MRONJ from 2013 to 2019. The collected data included demographic data, base disease, medications associated with MRONJ, route of administration and time of use, signs, symptoms, and tomographic features of acute MRONJ, staging according to American Association of Oral and maxillofacial Surgeons position paper 2014 (AAOMS), type of dental treatment performed, outcome, and the responses to the Oral Health Impact Profile questionnaire (OHIP-14). Statistical analysis was performed using the Tukey test to study the association between oral condition and the QOL. A p-value of less than 0.05 was considered statistically significant.

Results

The sample consisted of 16 medical records of patients with MRONJ. Psychological discomfort showed alarmingly significant results (p< 0.001) with strong negative impact on the QOL of the patients. Functional limitation was the least affected dimension (p = 0.747). The other dimensions did not show statistically significant results.

Conclusions

MRONJ compromises oral health and negatively impacts the QOL, especially with respect to the psychological discomfort (worry and stress). The OHIP-14 questionnaire proved to be an effective tool in the assessment of this impact. Key words:Medication-related osteonecrosis of the jaw, quality of life, oral health, OHIP-14.

Can Surgical Management Improve Resolution of Medication-Related Osteonecrosis of the Jaw at Early Stages? A Prospective Cohort Study

PURPOSE

There is no clarity on which protocol is proper to use in the management of medication-related osteonecrosis of the jaw (MRONJ) at early stages (ie, stages 1 and 2) to halt disease progression. The aim of this study was to evaluate the success of surgical treatment in terms of time to mucosal integrity and downstaging in patients with MRONJ at early stages.

MATERIALS AND METHODS

The study was implemented as a prospective, single-center cohort study. The sample included patients who presented at Magna Graecia University of Catanzaro with a clinical diagnosis of MRONJ and underwent surgical treatment. The primary predictor variables were gender, age, medical history, drug administration, MRONJ localization, trigger factors, and stage. The outcome variables were 1) time to mucosal integrity after surgery with time-to-event analysis and 2) time to downstaging of MRONJ lesions. Descriptive, bivariate, and regression statistics were performed.

RESULTS

The study sample included 129 MRONJ patients (90 women and 39 men; mean age, 71.2 ± 12.7 years), of whom 57 had stage 1 and 72 had stage 2. The mean time to achieve mucosal integrity was 71.6 ± 67.7 days, considering the survival probability always to be 93% or greater. The mean time to achieve downstaging of the lesion was 43.6 ± 38.4 days. Patients older than 70 years, those affected by osteometabolic disorders, and those treated with oral antiresorptive therapy showed a significantly shorter time to mucosal healing and downstaging (P < .05). In patients with stage 2 MRONJ, we recorded a significantly longer time to mucosal integrity (56.4 ± 54.5 days) but shorter time to lesion downstaging (33.6 ± 9.9 days) than in patients with stage 1 MRONJ (P < .05).

CONCLUSIONS

Surgical treatment of patients in the early stages of MRONJ guarantees benefits in outcomes such as mucosal integrity and lesion downstaging, improvement in quality of life, and faster reuptake of medication therapy, especially for oncologic patients.

A Retrospective Observational Study of Risk Factors for Denosumab-Related Osteonecrosis of the Jaw in Patients with Bone Metastases from Solid Cancers

This single-center retrospective observational study aimed to identify risk factors for developing denosumab-related osteonecrosis of the jaw (DRONJ) in stage IV solid cancer patients with bone metastases. In total, 123 consecutive patients who had received 120 mg of denosumab every 4 weeks at least twice between July 2014 and October 2018 were included. We surveyed their demographics, medical history, blood test, underlying disease, and intraoral findings. Fourteen patients (11.4%) developed DRONJ within a mean denosumab administration period of 4 months (range: 2-52 months). Univariate analyses showed a statistically significant correlation between DRONJ and hormone therapy, chemotherapy/molecular target drug, apical periodontitis, periodontal disease, sex and body mass index. Multivariate analysis showed a statistically significant correlation between DRONJ and hormone therapy (odds ratio [OR], 22.07; 95% confidence interval [CI], 2.86-170.24), chemotherapy and/or molecular targeted therapy (OR, 18.61; 95% CI, 2.54-136.27), and apical periodontitis (OR, 22.75; 95% CI, 3.20-161.73). These findings imply that collaborative oral examinations by oral specialists may reduce the risk of development of DRONJ in patients treated with denosumab for bone metastases from solid cancers.