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Nowak SM, Sacco R, Mitchell FL, Patel V, Gurzawska-Comis K. The effectiveness of autologous platelet concentrates in prevention and treatment of medication-related osteonecrosis of the jaws: A systematic review. J Craniomaxillofac Surg 2024; 52:671-691. [PMID: 38644092 DOI: 10.1016/j.jcms.2024.01.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2023] [Revised: 12/21/2023] [Accepted: 01/16/2024] [Indexed: 04/23/2024] Open
Abstract
The systematic review aims to answer the PICOS question: "Are the autologous platelet concentrates (APCs) an effective strategy in prevention and/or treatment of patients at risk of/affected by medication-related osteonecrosis of the jaws (MRONJ)?". A literature search was conducted via PubMed, MEDLINE, EMBASE, and CINAHL (January 2006 - September 2023). 30 articles were included, evaluating preventive (n = 8*) and treatment strategies (n = 23*). The risk of bias and quality of studies were assessed utilising ROB-2, ROBIN-1 and GRADE criteria. Meta-analysis was undertaken for eligible studies. The application of APCs demonstrated a statistically significant effectiveness in prevention of MRONJ in 86.13% (p < 0.001) but failed to achieve the same level of certainty in treatment of established MRONJ in 83.4% (p = 0.08). High levels of bias were identified; thus, the results should be interpreted with caution. More high quality prospective randomised controlled trials are needed to further evaluate the effectiveness of APCs in management of MRONJ.
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Affiliation(s)
- Sylwia Maria Nowak
- Department of Oral Surgery, Leeds Dental Institute, Leeds University Hospitals Trust, United Kingdom
| | - Roberto Sacco
- Department of Oral Surgery, Faculty of Dentistry, Oral & Craniofacial Sciences, King's College London, United Kingdom
| | | | - Vinod Patel
- Department of Oral Surgery, Guy's and St Thomas' NHS Foundation Trust, United Kingdom
| | - Katarzyna Gurzawska-Comis
- Department of Oral Surgery, Liverpool University Dental Hospital, United Kingdom; Liverpool Head and Neck Centre, University of Liverpool, United Kingdom.
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Di Fede O, La Mantia G, Del Gaizo C, Mauceri R, Matranga D, Campisi G. Reduction of MRONJ risk after exodontia by virtue of ozone infiltration: A randomized clinical trial. Oral Dis 2024. [PMID: 38807567 DOI: 10.1111/odi.15006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2023] [Revised: 04/03/2024] [Accepted: 05/07/2024] [Indexed: 05/30/2024]
Abstract
INTRODUCTION Exodontia is commonly considered as a risk factor for the development of medication-related osteonecrosis of the jaw (MRONJ) in individuals exposed to bone modifying agents. This study was aimed at assessing the efficiency and safety of a gaseous oxygen-ozone mixture as an adjuvant to a standard exodontia to reduce the risk of MRONJ development. METHODS A randomized, open-label, phase II, single-center clinical trial involving 117 patients at risk of MRONJ was conducted. The study protocol tested injections of an oxygen-ozone mixture in the post-extraction site. Participants were randomly assigned to two groups: oxygen-ozone therapy, and standard tooth extraction protocol. Post-extraction wound healing was assessed using the Inflammatory Proliferative Remodeling (IPR) Wound Healing Scale. RESULTS The oxygen-ozone therapy group exhibited a significant improvement in wound healing post-extraction during the inflammatory and proliferative phases, as indicated by the IPR scale scores at 3-5 days (p = 0.006) and 14 days (p < 0.001) respectively. CONCLUSION Oxygen-ozone therapy shows promise in improving post-extraction healing in patients at risk of MRONJ. Future studies with larger sample sizes and multicenter collaborations are recommended to confirm the validity of these findings and explore the long-term efficacy of ozone therapy.
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Affiliation(s)
- Olga Di Fede
- Department of Precision Medicine in Medical, Surgical and Critical Care (Me.Pre.C.C.), University of Palermo, Palermo, Italy
| | - Gaetano La Mantia
- Department of Precision Medicine in Medical, Surgical and Critical Care (Me.Pre.C.C.), University of Palermo, Palermo, Italy
- Unit of Oral Medicine and Dentistry for Fragile Patients, Department of Rehabilitation, Fragility and Continuity of Care, University Hospital Palermo, Palermo, Italy
- Department of Biomedical and Dental Sciences and Morphofunctional Imaging, University of Messina, Messina, Italy
| | | | - Rodolfo Mauceri
- Department of Precision Medicine in Medical, Surgical and Critical Care (Me.Pre.C.C.), University of Palermo, Palermo, Italy
- Unit of Oral Medicine and Dentistry for Fragile Patients, Department of Rehabilitation, Fragility and Continuity of Care, University Hospital Palermo, Palermo, Italy
| | - Domenica Matranga
- Department of Health Promotion Sciences and Mother-Child Care "G. D'Alessandro", University of Palermo, Palermo, Italy
| | - Giuseppina Campisi
- Department of Precision Medicine in Medical, Surgical and Critical Care (Me.Pre.C.C.), University of Palermo, Palermo, Italy
- Unit of Oral Medicine and Dentistry for Fragile Patients, Department of Rehabilitation, Fragility and Continuity of Care, University Hospital Palermo, Palermo, Italy
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Pellicano AA, Benites BM, Paschoa AFN, Oliveira LC, Campos ACP, Martins DO, Real CC, de Paula Faria D, Fonseca FP, Martinez RRC, Pagano RL, Fregnani ER. Mitigating jaw osteonecrosis: bioactive glass and pericardial membrane combination in a rat model. Front Oncol 2024; 14:1348118. [PMID: 38800378 PMCID: PMC11116668 DOI: 10.3389/fonc.2024.1348118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Accepted: 04/17/2024] [Indexed: 05/29/2024] Open
Abstract
Objectives Bisphosphonates (BFs) show clinical effectiveness in managing osteoporosis and bone metastases but pose risks of bisphosphonate-related jaw osteonecrosis (BRONJ). With no established gold standard for BRONJ treatment, our focus is on symptom severity reduction. We aimed to assess the preventive effects of bioactive glass and/or pericardial membrane in a preclinical BRONJ model, evaluating their potential to prevent osteonecrosis and bone loss post-tooth extractions in zoledronic acid (ZA)-treated animals. Methods Rats, receiving ZA or saline biweekly for four weeks, underwent 1st and 2nd lower left molar extractions. Pericardial membrane alone or with F18 bioglass was applied post-extractions. Microarchitecture analysis and bone loss assessment utilized computerized microtomography (CT) and positron emission tomography (PET) with 18F-FDG and 18F-NaF tracers. Histological analysis evaluated bone injury. Results Exclusive alveolar bone loss occurred post-extraction in the continuous ZA group, inducing osteonecrosis, osteolysis, osteomyelitis, and abscess formation. Concurrent pericardial membrane with F18 bioglass application prevented these outcomes. Baseline PET/CT scans showed no discernible uptake differences, but post-extraction 18F-FDG tracer imaging revealed heightened glucose metabolism at the extraction site in the ZA-treated group with membrane, contrasting the control group. Conclusion These findings suggest pericardial membrane with F18 bioglass effectively prevents BRONJ in the preclinical model.
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Affiliation(s)
| | - Bernar M. Benites
- Laboratory of Neuroscience, Hospital Sírio-Libanês, São Paulo, SP, Brazil
| | | | - Laura C. Oliveira
- Department of Radiology and Oncology, Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brazil
| | | | - Daniel O. Martins
- Laboratory of Neuroscience, Hospital Sírio-Libanês, São Paulo, SP, Brazil
| | - Caroline C. Real
- Department of Radiology and Oncology, Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brazil
| | - Daniele de Paula Faria
- Department of Radiology and Oncology, Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brazil
| | - Felipe P. Fonseca
- Department of Oral Surgery and Pathology, School of Dentistry, Universidade Federal de Minas Gerais, Belo Horizonte, MG, Brazil
| | - Raquel R. C. Martinez
- Laboratory of Neuroscience, Hospital Sírio-Libanês, São Paulo, SP, Brazil
- LIM/23, Institute of Psychiatry, University of Sao Paulo School of Medicine, Sao Paulo, Brazil
| | - Rosana L. Pagano
- Laboratory of Neuroscience, Hospital Sírio-Libanês, São Paulo, SP, Brazil
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Seluki R, Seluki M, Vaitkeviciene I, Jagelaviciene E. Comparison of the Effectiveness of Conservative and Surgical Treatment of Medication-Related Osteonecrosis of the Jaw: a Systematic Review. J Oral Maxillofac Res 2023; 14:e1. [PMID: 38222882 PMCID: PMC10783881 DOI: 10.5037/jomr.2023.14401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Accepted: 12/22/2023] [Indexed: 01/16/2024]
Abstract
Objectives The objective of this systematic review is to evaluate the current knowledge on the effectiveness of conservative and surgical treatment of medication-related osteonecrosis of the jaw. Material and Methods MEDLINE (PubMed), ScienceDirect and Cochrane Library search in combination with hand-search of relevant journals was conducted including human studies published in English between January 2017 and February 2023. Studies assessing treatment strategies for medication-related osteonecrosis of the jaw (MRONJ) were included. Quality and risk-of-bias assessment were evaluated by Joanna Briggs Institute (JBI) Risk of Bias tool. Results A total of 4227 articles were screened from which 9 studies (7 cohort studies and 2 randomized controlled trials) met the inclusion criteria and were included in the final data synthesis. Two studies evaluate effectiveness of conservative approaches for treating MRONJ, 5 studies evaluate surgical approaches effectiveness, and 2 studies compare between those approaches. The follow-up period ranged from 6 months to 60 months. According to bias assessment, the mean JDI score of the included studies was > 9 ("low risk of bias"). The stage of the disease, the procedure performed on the patient and the results of the treatment were presented. Conclusions Surgical therapy seems to be superior to conservative therapy for the management of adverse stages medication-related osteonecrosis of the jaws, while conservative treatment appears to yield good outcomes at asymptomatic patients with early stages of the disease.
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Affiliation(s)
- Rial Seluki
- Clinic of Dental and Oral Pathology, Faculty of Odontology, Medical Academy, Lithuanian University of Health Sciences, KaunasLithuania.
- S-clinic Dr Seluki, Hod HasharonIsrael.
| | | | - Inga Vaitkeviciene
- Clinic of Dental and Oral Pathology, Faculty of Odontology, Medical Academy, Lithuanian University of Health Sciences, KaunasLithuania.
| | - Egle Jagelaviciene
- Clinic of Dental and Oral Pathology, Faculty of Odontology, Medical Academy, Lithuanian University of Health Sciences, KaunasLithuania.
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Bayhaqi YA, Hamidi A, Navarini AA, Cattin PC, Canbaz F, Zam A. Real-time closed-loop tissue-specific laser osteotomy using deep-learning-assisted optical coherence tomography. BIOMEDICAL OPTICS EXPRESS 2023; 14:2986-3002. [PMID: 37342720 PMCID: PMC10278623 DOI: 10.1364/boe.486660] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Revised: 05/15/2023] [Accepted: 05/18/2023] [Indexed: 06/23/2023]
Abstract
This article presents a real-time noninvasive method for detecting bone and bone marrow in laser osteotomy. This is the first optical coherence tomography (OCT) implementation as an online feedback system for laser osteotomy. A deep-learning model has been trained to identify tissue types during laser ablation with a test accuracy of 96.28 %. For the hole ablation experiments, the average maximum depth of perforation and volume loss was 0.216 mm and 0.077 mm3, respectively. The contactless nature of OCT with the reported performance shows that it is becoming more feasible to utilize it as a real-time feedback system for laser osteotomy.
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Affiliation(s)
- Yakub. A. Bayhaqi
- Biomedical Laser and Optics Group (BLOG), Department of Biomedical Engineering, University of Basel, 4123 Allschwil, Switzerland
| | - Arsham Hamidi
- Biomedical Laser and Optics Group (BLOG), Department of Biomedical Engineering, University of Basel, 4123 Allschwil, Switzerland
| | - Alexander A. Navarini
- Digital Dermatology Group, Department of Biomedical Engineering, University of Basel, 4123 Allschwil, Switzerland
| | - Philippe C. Cattin
- Center for medical Image Analysis and Navigation (CIAN), Department of Biomedical Engineering, University of Basel, 4123 Allschwil, Switzerland
| | - Ferda Canbaz
- Biomedical Laser and Optics Group (BLOG), Department of Biomedical Engineering, University of Basel, 4123 Allschwil, Switzerland
| | - Azhar Zam
- Biomedical Laser and Optics Group (BLOG), Department of Biomedical Engineering, University of Basel, 4123 Allschwil, Switzerland
- Division of Engineering, New York University Abu Dhabi, Abu Dhabi, 129188, United Arab Emirates
- Tandon School of Engineering, New York University, Brooklyn, NY, 11201, USA
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Scribante A, Ghizzoni M, Pellegrini M, Pulicari F, Spadari F. Laser Devices and Autologous Platelet Concentrates in Prevention and Treatment of Medication-Related Osteonecrosis of the Jaws: A Systematic Review. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:medicina59050972. [PMID: 37241204 DOI: 10.3390/medicina59050972] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/22/2023] [Revised: 05/14/2023] [Accepted: 05/16/2023] [Indexed: 05/28/2023]
Abstract
Background and Objectives: Medication-related osteonecrosis of the jaws (MRONJ) is a disease that affects many patients taking anti-angiogenic and antiresorptive medicines. Since the pathogenetic mechanism is still partially unknown, preventive strategies, as well as treatment alternatives, are needed. Therefore, the aim of this research is to describe the main evidence from the last 10 years of clinical trials regarding the use of auxiliary devices such as autologous platelet concentrates (APCs) and laser, other than their effects against MRONJ disease onset or therapy. Advantages in the healing process and recurrence rates were also analyzed. Materials and Methods: A systematic search of the electronic databases of PubMed and Scopus was carried out. Data from the studies were analyzed, and the risk of bias was evaluated. Results: Nineteen studies between interventional studies, observational studies, and cohort studies have been considered in this review. Conclusions: Based on the studies included, the literature analysis shows that APCs could be a beneficial alternative in preventing and treating MRONJ. Laser technology, as a surgical tool or used on the antimicrobial photodynamic or photobiomodulation side, has been becoming increasingly popular in the last few years. The latest proposal concerning the combination of both auxiliary tools suggests interesting effects, but more studies should be conducted to evaluate eventual relapses and long-term consequences.
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Affiliation(s)
- Andrea Scribante
- Section of Dentistry, Department of Clinical, Surgical, Diagnostic and Pediatric Sciences, University of Pavia, 27100 Pavia, Italy
| | - Martina Ghizzoni
- Section of Dentistry, Department of Clinical, Surgical, Diagnostic and Pediatric Sciences, University of Pavia, 27100 Pavia, Italy
| | - Matteo Pellegrini
- Maxillo-Facial Surgery and Dental Unit, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy
- Department of Biomedical, Surgical and Dental Sciences, University of Milan, Via della Commenda 10, 20122 Milan, Italy
| | - Federica Pulicari
- Maxillo-Facial Surgery and Dental Unit, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy
- Department of Biomedical, Surgical and Dental Sciences, University of Milan, Via della Commenda 10, 20122 Milan, Italy
| | - Francesco Spadari
- Maxillo-Facial Surgery and Dental Unit, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy
- Department of Biomedical, Surgical and Dental Sciences, University of Milan, Via della Commenda 10, 20122 Milan, Italy
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Vidán-Estévez J, Escalante-Barrigón F, Sánchez-Herráez S, Seco-Calvo J. Platelet-derived growth factors from a single donor by apheresis and one freeze-thaw cycle for treating medication-related osteonecrosis of the jaw. Regen Med 2022; 17:915-929. [PMID: 36169261 DOI: 10.2217/rme-2022-0126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Aim: To assess whether the use of allogeneic platelet-derived growth factors could serve as a feasible, effective and safe biological therapy for the treatment of medication-related osteonecrosis of the jaw (MRONJ). Materials & methods: Patients with multiple myeloma and MRONJ were included and treated with allogeneic platelet-rich plasma, continued for between 6 and 18 weeks (mean: 9). Results: We observed a treatment success rate of 87.5% (p < 0.05). Assessing the association between healing and treatment duration, we observed a statistically significant relationship (χ2 = 8.00; p = 0.018; Cramer's V = 1), confirming that healing was very closely related to the duration of the treatment. Conclusion: Allogeneic platelet-rich plasma could be a recommended treatment for MRONJ. Future research with a large sample to validate our findings is required.
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Affiliation(s)
- Julia Vidán-Estévez
- Transfusion, Hematology & Hemotherapy Unit, Complejo Asistencial Universitario de León (CAULE), León, 24071, Spain
| | - Fernando Escalante-Barrigón
- Transfusion, Hematology & Hemotherapy Unit, Complejo Asistencial Universitario de León (CAULE), León, 24071, Spain
| | - Sergio Sánchez-Herráez
- Department of Traumatology & Orthopedic Surgery, Complejo Asistencial Universitario de León (CAULE), León, 24071, Spain
| | - Jesús Seco-Calvo
- Department of Physical Therapy, Institute of Biomedicine (IBIOMED), University of León, León, 24071, Spain.,Visiting Professor & Researcher of Department of Physiology, University of the Basque Country, Leioa, 48940, Spain
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Di Fede O, Del Gaizo C, Panzarella V, La Mantia G, Tozzo P, Di Grigoli A, Lo Casto A, Mauceri R, Campisi G. Ozone Infiltration for Osteonecrosis of the Jaw Therapy: A Case Series. J Clin Med 2022; 11:jcm11185307. [PMID: 36142954 PMCID: PMC9502994 DOI: 10.3390/jcm11185307] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Revised: 08/31/2022] [Accepted: 09/05/2022] [Indexed: 11/29/2022] Open
Abstract
Medication-related osteonecrosis of the jaw (MRONJ) is a serious adverse reaction, mainly due to bone-modifying agents (BMA), and it is a potentially painful and debilitating condition. To date, the literature has reported a 90% rate of successful outcomes for MRONJ patients undergoing surgical treatment. Particularly for patients with advanced disease stages who are unsuitable for surgery, prolonged medical treatment is required, with a consequent risk of the overuse of antibiotics and antibiotic resistance. The aim of this study is to evaluate the efficiency and safety of ozone, via oral mucosal infiltrations, in seven cancer patients with MRONJ, who are not eligible for surgery. The protocol (OZOPROMAF) consists of intratissue injections of an oxygen ozone (O2O3) mixture, which is applied until formation of a sequestrum and clinical healing. Follow-up was scheduled to confirm the healing of MRONJ and radiological evaluations by CBCT were planned. In order to assess the level of pain, a questionnaire including the Numeric Rating Scale for Pain (NRS Pain) was administered on the first visit, one day after treatment, and one week after treatment. After an application of OZOPROMAF, all patients reported discomfort for some hours, probably due to soft tissue pressure around the infiltration site. Thereafter, the discomfort subsided within 6–8 h. Complete mucosal healing of MRONJ occurred within a number of cycles ranging from 7 to 16. Complete resolution with an improvement in bone condition was observed in all patients. The MRONJ lesions of all patients healed after 18–24 months. The authors of this study contend that these preliminary results suggest the efficiency and safety of the O2O3 mixture. However, further research is required to confirm the efficacy of the O2O3 mixtures in MRONJ treatment, at least for patients who are unsuitable for surgery.
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Affiliation(s)
- Olga Di Fede
- Department of Surgical, Oncological and Oral Sciences, University of Palermo, Via del Vespro 129, 90127 Palermo, Italy
| | - Carmine Del Gaizo
- Department of Surgical, Oncological and Oral Sciences, University of Palermo, Via del Vespro 129, 90127 Palermo, Italy
| | - Vera Panzarella
- Department of Surgical, Oncological and Oral Sciences, University of Palermo, Via del Vespro 129, 90127 Palermo, Italy
| | - Gaetano La Mantia
- Department of Surgical, Oncological and Oral Sciences, University of Palermo, Via del Vespro 129, 90127 Palermo, Italy
| | - Pietro Tozzo
- Unit of Stomatology, Azienda Ospedaliera Ospedali Riuniti “Villa Sofia-Cervello” of Palermo, Piazza Salerno, 1, 90146 Palermo, Italy
| | | | - Antonio Lo Casto
- Biomedicine, Neuroscience and Advanced Diagnostic Department, University of Palermo, Via del Vespro 129, 90127 Palermo, Italy
| | - Rodolfo Mauceri
- Department of Surgical, Oncological and Oral Sciences, University of Palermo, Via del Vespro 129, 90127 Palermo, Italy
- Correspondence:
| | - Giuseppina Campisi
- Unit of Oral Medicine and Dentistry for Fragile Patients, Department of Rehabilitation, Fragility and Continuity of Care, University Hospital Palermo, Via del Vespro 129, 90127 Palermo, Italy
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Therapeutic Effect of Benidipine on Medication-Related Osteonecrosis of the Jaw. Pharmaceuticals (Basel) 2022; 15:ph15081020. [PMID: 36015167 PMCID: PMC9412249 DOI: 10.3390/ph15081020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Revised: 08/12/2022] [Accepted: 08/15/2022] [Indexed: 11/25/2022] Open
Abstract
Medication-related osteonecrosis of the jaw (MRONJ) is an intractable disease that is typically observed in patients with osteoporosis or tumors that have been treated with either bisphosphonate (BP) or antiangiogenic medicine. The mechanism of MRONJ pathogenesis remains unclear, and no effective definitive treatment modalities have been reported to date. Previous reports have indicated that a single injection of benidipine, an antihypertensive calcium channel blocker, in the vicinity of a tooth extraction socket promotes wound healing in healthy rats. The present study was conducted to elucidate the possibility of using benidipine to promote the healing of MRONJ-like lesions. In this study, benidipine was administered near the site of MRONJ symptom onset in a model rat, which was then sacrificed two weeks after benidipine injection, and analyzed using histological sections and CT images. The analysis showed that in the benidipine groups, necrotic bone was reduced, and soft tissue continuity was recovered. Furthermore, the distance between epithelial edges, length of necrotic bone exposed in the oral cavity, necrotic bone area, and necrotic bone ratio were significantly smaller in the benidipine group. These results suggest that a single injection of benidipine in the vicinity of MRONJ-like lesions can promote osteonecrotic extraction socket healing.
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Factors Exacerbating Clinical Symptoms and CT Findings in Patients with Medication-Related Osteonecrosis of the Jaw Receiving Conservative Therapy: A Multicenter Retrospective Study of 53 Cases. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19137854. [PMID: 35805513 PMCID: PMC9265462 DOI: 10.3390/ijerph19137854] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/28/2022] [Revised: 06/22/2022] [Accepted: 06/23/2022] [Indexed: 12/04/2022]
Abstract
Recent reports have shown that better treatment outcomes are obtained with surgical therapy in patients with medication-related osteonecrosis of the jaw (MRONJ) than with conservative therapy. However, conservative treatment is selected due to factors such as old age and poor general condition. Conservative therapy aims to relieve symptoms and prevent lesion exacerbation; however, the lesion may expand rapidly in some cases. This study investigated the clinical and imaging findings of 53 MRONJ patients undergoing conservative therapy, and the changes in the clinical findings and the lesion enlargement on CT imaging were examined. Improved clinical findings and no worsening of the imaging findings were considered overall comprehensive treatment successes. Among the 53 patients, the clinical symptoms disappeared or improved in 15 patients, whereas they worsened in 6. In contrast, osteolytic lesion enlargement occurred in 17 patients. The comprehensive treatment outcome of conservative therapy was successful in 12 patients and unsuccessful in 41 patients. The periosteal reaction was significantly correlated with poor comprehensive treatment outcomes (p = 0.038). MRONJ lesions may advance, even if they appear to improve clinically while undergoing conservative treatments. Patients, especially those with periosteal reactions, must be closely followed up with CT examinations, regardless of the clinical findings.
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Current Trends in Adjuvant Therapies for Medication-Related Osteonecrosis of the Jaw. APPLIED SCIENCES-BASEL 2022. [DOI: 10.3390/app12084035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
Medication-related osteonecrosis of the jaw (MRONJ) is a refractory disease, and a standard protocol for its treatment has not yet been established. In addition, owing to the old age of MRONJ patients and various complications, treatment goals focus on relieving the symptoms and improving the quality of life. For this reason, different treatments such as conservative, surgical, and adjunctive treatments have been attempted. In particular, adjunctive treatment, which is effective for promoting healing and reducing recurrence, is gaining increasing interest, and several studies and clinical trials related to it have been published. Representative adjuvant therapies include teriparatide, recombinant human bone morphogenetic protein-2, hyperbaric oxygen, photobiomodulation and platelet concentrates. All have generally shown beneficial effects; however, no standard protocol for adjunctive treatment exists. Therefore, in this literature review, we briefly summarized the different adjuvant therapies and reviewed clinical reports to help decide whether to use adjuvant therapies in treating patients with MRONJ.
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Tröltzsch M, Tröltzsch M, Pautke C, Otto S. [Management of medication-related osteonecrosis of the jaw-a review of recent study results in comparison to established strategies]. HNO 2022; 70:499-507. [PMID: 35050392 PMCID: PMC9242957 DOI: 10.1007/s00106-021-01130-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/31/2021] [Indexed: 11/15/2022]
Abstract
Hintergrund Antiresorptiva gehören weltweit zu den am häufigsten applizierten Arzneimitteln. Ihr Haupteinsatzbereich liegt in der Osteologie und Onkologie. Trotz allgemein guter Verträglichkeit treten bei Patienten unter Therapie unerwünschte Arzneimittelwirkungen (UAW) auf. Eine spezifische UAW im Bereich der Kiefer ist die sog. medikamentenassoziierte Osteonekrose („medication-related osteonecrosis of the jaw“, MRONJ) der Kiefer. Ziel der Arbeit Diese Arbeit stellt neuesten Entwicklungen in Ätiologie, Diagnostik und Therapie der MRONJ im Vergleich zu bereits bestehenden Erkenntnissen zusammen. Methodik Es wurde eine systematische Literaturübersicht der Jahre 2016–2021 zu diesem Thema durchgeführt. Prospektive Therapiestudien, Diagnostikstudien mit Vergleichsgruppe und innovative Studien zur Pathogenese der MRONJ wurden eingeschlossen und nach den MINORS-Kriterien („methodological index for non-randomized studies“) bewertet. Ergebnisse und Diskussion Die MRONJ tritt bei ca. 2–12 % der Patienten, die aus onkologischer Indikation mit Antiresorptiva behandelt werden, auf (osteologische Indikation ca. 0,1–1 %). Die Therapie der MRONJ sollte frühzeitig und operativ erfolgen. Die Heilungsrate ist bei einem operativen Therapieansatz mit über 85 % sehr gut.
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Affiliation(s)
- Matthias Tröltzsch
- Zentrum für Zahn- Mund- und Kieferheilkunde Ansbach, Ansbach, Deutschland. .,Klinik und Poliklinik für Mund‑, Kiefer- und Gesichtschirurgie, Ludwig-Maximilians-Universität München, Lindwurmstr. 2A, 80337, München, Deutschland.
| | - Markus Tröltzsch
- Zentrum für Zahn- Mund- und Kieferheilkunde Ansbach, Ansbach, Deutschland
| | | | - Sven Otto
- Klinik und Poliklinik für Mund‑, Kiefer- und Gesichtschirurgie, Martin-Luther-Universität Halle-Wittenberg, Halle, Deutschland
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Sanda K, Ayukawa Y, Yasunami N, Adachi N, Furuhashi A, Imai M, Matsunaka K, Koyano K. Therapeutic effect of fluvastatin on medication-related osteonecrosis of the jaw. J Periodontol 2021; 93:837-846. [PMID: 34510440 DOI: 10.1002/jper.21-0294] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Revised: 08/24/2021] [Accepted: 09/03/2021] [Indexed: 12/18/2022]
Abstract
BACKGROUND Refractory jaw osteonecrosis that occurs in osteoporotic or cancer patients treated with bisphosphonates is called medication-related osteonecrosis of the jaw but its underlying mechanism is unclear. Statins, therapeutic agents for dyslipidemia, lower blood low-density lipoprotein cholesterol. Fluvastatin promotes the healing of tooth extraction sockets and reduces the risk of developing medication-related osteonecrosis of the jaw-like lesions. We used a rat model to investigate whether injecting fluvastatin at extraction sites promoted the healing of medication-related osteonecrosis of the jaw-like lesions. METHODS Upper first molars of rats administered zoledronate and dexamethasone for 2 weeks were extracted. Two weeks after tooth extraction, rats with medication-related osteonecrosis of the jaw-like lesions (bone exposure) were included in this study. A single injection of fluvastatin was administered in the vicinity of the medication-related osteonecrosis of the jaw-like onset site in rats. RESULTS The distance between the edges of the epithelia, the length of the necrotic bone exposed toward the oral cavity, the area of the necrotic bone, and the necrotic bone ratio were significantly smaller in the fluvastatin-administered group compared with the saline group. A single application of fluvastatin near the site of medication-related osteonecrosis of the jaw onset showed a tendency to close the epithelium, reduce necrotic bone, and form new bone, even when symptoms had already developed. CONCLUSION This study suggests that a single topical administration of fluvastatin may be a novel treatment for medication-related osteonecrosis of the jaw.
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Affiliation(s)
- Koma Sanda
- Section of Implant and Rehabilitative Dentistry, Division of Oral Rehabilitation, Faculty of Dental Science, Kyushu University, Fukuoka, Japan
| | - Yasunori Ayukawa
- Section of Implant and Rehabilitative Dentistry, Division of Oral Rehabilitation, Faculty of Dental Science, Kyushu University, Fukuoka, Japan
| | - Noriyuki Yasunami
- Section of Implant and Rehabilitative Dentistry, Division of Oral Rehabilitation, Faculty of Dental Science, Kyushu University, Fukuoka, Japan
| | - Naomi Adachi
- Section of Implant and Rehabilitative Dentistry, Division of Oral Rehabilitation, Faculty of Dental Science, Kyushu University, Fukuoka, Japan
| | - Akihiro Furuhashi
- Section of Implant and Rehabilitative Dentistry, Division of Oral Rehabilitation, Faculty of Dental Science, Kyushu University, Fukuoka, Japan
| | - Mikio Imai
- Section of Implant and Rehabilitative Dentistry, Division of Oral Rehabilitation, Faculty of Dental Science, Kyushu University, Fukuoka, Japan
| | - Ken Matsunaka
- Section of Implant and Rehabilitative Dentistry, Division of Oral Rehabilitation, Faculty of Dental Science, Kyushu University, Fukuoka, Japan
| | - Kiyoshi Koyano
- Division of Advanced Dental Devices and Therapeutics, Faculty of Dental Science, Kyushu University, Fukuoka, Japan
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The Treatment of Medication-Related Osteonecrosis of the Jaw (MRONJ): A Systematic Review with a Pooled Analysis of Only Surgery versus Combined Protocols. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18168432. [PMID: 34444181 PMCID: PMC8392050 DOI: 10.3390/ijerph18168432] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 07/30/2021] [Accepted: 08/03/2021] [Indexed: 01/03/2023]
Abstract
Medication-related osteonecrosis of the jaw (MRONJ) is a serious adverse reaction of antiresorptive and antiangiogenic agents, and it is also a potentially painful and debilitating condition. To date, no specific studies have prospectively evaluated the efficacy of its treatment and no robust standard of care has been established. Therefore, a systematic review (2007–2020) with a pooled analysis was performed in order to compare MRONJ surgical techniques (conservative or aggressive) versus combined surgical procedures (surgery plus a non-invasive procedure), where 1137 patients were included in the pooled analysis. A statistically significant difference in the 6-month improvement rate, comparing combined conservative surgery versus only aggressive (91% versus 72%, p = 0.05), was observed. No significant difference regarding any group with respect to the 6-month total resolution rate (82% versus 72%) was demonstrated. Of note, conservative surgery combined with various, adjuvant, non-invasive procedures (ozone, LLLT or blood component + Nd:YAG) was found to achieve partial or full healing in all stages, with improved results and the amelioration of many variables. In conclusion, specific adjuvant treatments associated with minimally conservative surgery can be considered effective and safe in the treatment of MRONJ, although well-controlled studies are a requisite in arriving at definitive statements
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Choosing the Right Partner for Medication Related Osteonecrosis of the Jaw: What Central European Dentists Know. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18094466. [PMID: 33922326 PMCID: PMC8122803 DOI: 10.3390/ijerph18094466] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Revised: 04/20/2021] [Accepted: 04/20/2021] [Indexed: 12/26/2022]
Abstract
Medication-related osteonecrosis of the jaw (MRONJ) is a side effect of antiresorptive drugs. In this online survey, the awareness and knowledge of dentists regarding MRONJ was evaluated, and potential implications for oncologists are discussed. Questionnaires were emailed to dentists from Germany, Austria, Switzerland, and South Tyrol to evaluate disease-related knowledge and management. In addition to the overall score, a separate score was calculated for knowledge (maximum score: 15 points) and management (maximum score: 6 points) questions, and 1197 valid replies with completed questionnaires were received. The mean overall score was 10.45 ± 3.97 points, the mean knowledge score was 7.68 ± 3.05 points, and the mean management score was 2.76 ± 1.77 points. Factors influencing the outcome of the overall score were age, specialization, continuous professional education, and the number of dental screening exams in patients before antiresorptive therapy. Due to the considerable lack of knowledge regarding MRONJ among dentists, MRONJ patients and subjects at risk should be guided towards specialists for dental screening, treatment, and follow-up. This is important from an oncologic point of view to avoid any delay for treatment start of antiresorptives, and to reveal a potentially emerging osteonecrosis at an early stage, thus, avoiding the need for interruption or even cancellation of antiresorptive therapy.
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Hamidi A, Bayhaqi YA, Canbaz F, Navarini AA, Cattin PC, Zam A. Long-range optical coherence tomography with extended depth-of-focus: a visual feedback system for smart laser osteotomy. BIOMEDICAL OPTICS EXPRESS 2021; 12:2118-2133. [PMID: 33996219 PMCID: PMC8086437 DOI: 10.1364/boe.414300] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Revised: 02/18/2021] [Accepted: 02/18/2021] [Indexed: 06/02/2023]
Abstract
This work presents a long-range and extended depth-of-focus optical coherence tomography (OCT) system using a Bessel-like beam (BLB) as a visual feedback system during laser osteotomy. We used a swept-source OCT system (λ c = 1310 nm) with an imaging range of 26.2 mm in the air, integrated with a high energy microsecond Er:YAG laser operating at 2.94 µm. We demonstrated that the self-healing characteristics of the BLB could reduce the imaging artifacts that may arise during real-time monitoring of laser ablation. Furthermore, the feasibility of using long-range OCT to monitor a deep laser-induced incision is demonstrated.
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Affiliation(s)
- Arsham Hamidi
- Biomedical Laser and Optics Group (BLOG), Department of Biomedical Engineering, University of Basel, CH-4123 Allschwil, Switzerland
| | - Yakub A Bayhaqi
- Biomedical Laser and Optics Group (BLOG), Department of Biomedical Engineering, University of Basel, CH-4123 Allschwil, Switzerland
| | - Ferda Canbaz
- Biomedical Laser and Optics Group (BLOG), Department of Biomedical Engineering, University of Basel, CH-4123 Allschwil, Switzerland
| | - Alexander A Navarini
- Digital Dermatology, Department of Biomedical Engineering, University of Basel, CH-4123 Allschwil, Switzerland
| | - Philippe C Cattin
- Center for medical Image Analysis and Navigation (CIAN), Department of Biomedical Engineering, University of Basel, CH-4123 Allschwil, Switzerland
| | - Azhar Zam
- Biomedical Laser and Optics Group (BLOG), Department of Biomedical Engineering, University of Basel, CH-4123 Allschwil, Switzerland
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Escobedo MF, Junquera S, Gonzalez C, Vasatyuk S, Gallego L, Barbeito E, Junquera LM. Efficacy of complementary treatment with autologous platelet concentrates and/or mesenchymal stem cells in chemical osteonecrosis of the jaw. Systematic review of the literature. JOURNAL OF STOMATOLOGY, ORAL AND MAXILLOFACIAL SURGERY 2021; 123:51-58. [PMID: 33609789 DOI: 10.1016/j.jormas.2021.01.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/12/2020] [Revised: 01/20/2021] [Accepted: 01/28/2021] [Indexed: 12/22/2022]
Abstract
The aim of this systematic review was to establish the current status of the subject and find out what scientific evidence we have on the use of autologous plasma concentrates (APCs) and mesenchymal stem cells (MSCs) as complementary therapies at the management of Medication-related Osteonecrosis of the jaw (MRONJ). We performed a literature search of articles published between December 2019 to January 2020 in electronic databases, in accordance to PRISMA system. The variables analyzed were: the number of patients, age, sex, medical history, origin of MRONJ, imaging studies, treatment performed, and evolution of MRONJ. The articles included in the review were grouped into two groups (Group A "Therapy with APCs" and Group B "Therapy with APCs and MSCs"). Newcastle-Ottawa scale (NOS) was used to assess the quality of the articles. Fisher's exact test was used to evaluate eventual differences between groups. Of the 306 patients who were included, 297 belonged to Group A and 9 to Group B. In our sample, women predominated against men and no significant differences in age were observed. Osteoporosis was the most frequent underlying disease in both groups. The most common origin of MRONJ was oral surgery in group A. Conservative surgery was performed in all patients, but complementary treatment was applied in different ways in each group. The resolution of the pathology was achieved in 90% of cases in both groups without significant differences between them. The mean score of the reviewed studies at NOS was 4. There are currently no published scientific data that can sufficiently support the use of APCs and MSCs for the treatment of established MRONJs.
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Affiliation(s)
- M F Escobedo
- Faculty of Odontology, Oviedo University, Principado de Asturias, Spain.
| | - S Junquera
- Department of Radiology, Santiago of Compostela University Hospital, Spain
| | - C Gonzalez
- Faculty of Odontology, Oviedo University, Principado de Asturias, Spain
| | - S Vasatyuk
- Faculty of Odontology, Oviedo University, Principado de Asturias, Spain
| | - L Gallego
- Department of Maxillofacial Surgery, Cabueñes University Hospital, Spain
| | - E Barbeito
- Department of Gastroenterology, Lucus Augusti University Hospital, Spain
| | - L M Junquera
- Faculty of Odontology, Oviedo University, Principado de Asturias, Spain; Department of Maxillofacial Surgery, Oviedo University, Principado de Asturias, Spain
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Yüce MO, Adalı E, Işık G. The effect of concentrated growth factor (CGF) in the surgical treatment of medication-related osteonecrosis of the jaw (MRONJ) in osteoporosis patients: a randomized controlled study. Clin Oral Investig 2021; 25:4529-4541. [PMID: 33392802 DOI: 10.1007/s00784-020-03766-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Accepted: 12/21/2020] [Indexed: 02/06/2023]
Abstract
OBJECTIVES The purpose of this present study was to evaluate the efficiency of the growth factors delivered by concentrated growth factor (CGF) on the healing process of osteoporotic patients with medication-related osteonecrosis of the jaws (MRONJ). METHODS This randomized controlled study was composed of osteoporotic female patients who were treated with oral bisphosphonates (BPs) and diagnosed with MRONJ. For the CGF group, each patient was treated with a local application of CGF at the surgical site after removing the necrotic bone, while the surgical area was primarily closed as traditional surgical therapy for the control group. The patients underwent clinical examinations for 6 months postoperatively to check the presence of infection and dehiscence. RESULTS Complete healing was achieved in 19 patients of 28 patients (mean age: CGF group, 73.57 ± 5.1; control group, 73.64 ± 5.49) diagnosed with MRONJ. There was no significant difference in post-op healing data between groups during healing periods (p > 0.05). In the CGF group (n = 14) in three cases, bone exposure without infection was detected, and one of them showed a recurrent infection. In the control group (n = 14) in six cases, bone exposure without infection was detected, and three of them also showed recurrent infection. CONCLUSION Although our results were not statistically significant, our findings suggest that the local application of CGF appears to be an effective approach to the surgical treatment of MRONJ in osteoporosis patients by improving tissue regeneration. CLINICAL RELEVANCE A specific treatment protocol to manage MRONJ is still controversial. This study justifies that CGF can be used in combination with surgical treatment.
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Affiliation(s)
- Meltem Ozden Yüce
- Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Ege University, Izmir, Turkey
| | - Emine Adalı
- Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Izmir Democracy University, Izmir, Turkey.
| | - Gözde Işık
- Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Ege University, Izmir, Turkey
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Anitua E, Fernández-de-Retana S, Alkhraisat MH. Platelet rich plasma in oral and maxillofacial surgery from the perspective of composition. Platelets 2020; 32:174-182. [PMID: 33350883 DOI: 10.1080/09537104.2020.1856361] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
The application of platelet-rich plasma (PRP) in oral and maxillofacial surgery has been thoroughly studied in the last two decades. Currently, different types of PRP are applied in the clinical practice, being the presence or absence of leukocytes one of the classification criteria. However, there is poor evidence assessing the influence of the PRP composition in their efficacy. In this context, the aim of this narrative review is to compile the existing evidence covering the efficacy of PRP in oral and maxillofacial surgery, starting from a systematic literature search and to qualitatively describe the efficacy outcomes from the composition perspective. According to the results of this review, the application of PRP in oral and maxillofacial surgery is a potential strategy to improve soft- and hard-tissue regeneration, observing differences in the efficacy of PRP depending on its composition and the studied application. P-PRP (the absence of leukocytes) has been more consistent in achieving beneficial effects in alveolar ridge preservation, management of post-extraction complications, bone augmentation and temporomandibular joint disorders. For that, the composition and methodology used to prepare the PRP should be a critical point when evaluating the efficacy of PRP.
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Affiliation(s)
- Eduardo Anitua
- Regenerative Medicine Department, BTI Biotechnology Institute, Vitoria, Spain.,Clinical research, University Institute for Regenerative Medicine and Oral Implantology (UIRMI), Vitoria, Spain
| | - Sofía Fernández-de-Retana
- Regenerative Medicine Department, BTI Biotechnology Institute, Vitoria, Spain.,Clinical research, University Institute for Regenerative Medicine and Oral Implantology (UIRMI), Vitoria, Spain
| | - Mohammad H Alkhraisat
- Regenerative Medicine Department, BTI Biotechnology Institute, Vitoria, Spain.,Clinical research, University Institute for Regenerative Medicine and Oral Implantology (UIRMI), Vitoria, Spain
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Govaerts D, Piccart F, Ockerman A, Coropciuc R, Politis C, Jacobs R. Adjuvant therapies for MRONJ: A systematic review. Bone 2020; 141:115676. [PMID: 33022455 DOI: 10.1016/j.bone.2020.115676] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Revised: 09/29/2020] [Accepted: 10/01/2020] [Indexed: 12/22/2022]
Abstract
OBJECTIVE Medication-related osteonecrosis of the jaw (MRONJ) is a severe adverse reaction caused by the use of antiresorptive antiangiogenic medication. Treating MRONJ is difficult and besides standard treatments, which are conservative medical and surgical approaches, there are some adjuvant therapies that might further stimulate healing. The aim of this systematic review is to compare outcome and effectiveness of currently available adjuvant therapies for MRONJ. METHODS This systematic review was conducted following the PRISMA guidelines. Articles focusing on mucosal healing in patients treated with an adjuvant therapy for MRONJ were selected and analysed. Inclusion was not limited to randomized controlled trials to present a complete review of the current literature. RESULTS A search was performed in Pubmed, Embase, Web of Science and Cochrane Central Register of Controlled Trials. Thirty articles out of 3297 were included. Laser ablation had a success of 60-95% for complete healing. The controlled trials of leukocyte- and platelet-rich-fibrine (LPRF) showed 60-100% success for the same outcome. Fluorescence guided surgery had a complete healing percentage of 85-90%. CONCLUSIONS The results suggest that laser ablation, LPRF and fluorescence guided surgery might have a potential in improving the healing process. Interpreting the results should however be done with great care and a critical point of view, as most articles had a medium to high risk of bias. More randomized controlled trials are necessary to define the most beneficial therapy protocols. CLINICAL RELEVANCE It seems that adjuvant surgical therapies for treating MRONJ are beneficial for mucosal healing, but there is only low scientific evidence.
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Affiliation(s)
- Dries Govaerts
- OMFS-IMPATH Research Group, Department of Imaging and Pathology, Faculty of Medicine, Catholic University Leuven, Belgium; Department of Oral and Maxillofacial Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Frederik Piccart
- OMFS-IMPATH Research Group, Department of Imaging and Pathology, Faculty of Medicine, Catholic University Leuven, Belgium; Department of Oral and Maxillofacial Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Anna Ockerman
- OMFS-IMPATH Research Group, Department of Imaging and Pathology, Faculty of Medicine, Catholic University Leuven, Belgium
| | - Ruxandra Coropciuc
- OMFS-IMPATH Research Group, Department of Imaging and Pathology, Faculty of Medicine, Catholic University Leuven, Belgium; Department of Oral and Maxillofacial Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Constantinus Politis
- OMFS-IMPATH Research Group, Department of Imaging and Pathology, Faculty of Medicine, Catholic University Leuven, Belgium; Department of Oral and Maxillofacial Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Reinhilde Jacobs
- OMFS-IMPATH Research Group, Department of Imaging and Pathology, Faculty of Medicine, Catholic University Leuven, Belgium; Department of Dental Medicine, Karolinska Institute, Stockholm, Sweden.
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Tenore G, Zimbalatti A, Rocchetti F, Graniero F, Gaglioti D, Mohsen A, Caputo M, Lollobrigida M, Lamazza L, De Biase A, Barbato E, Romeo U. Management of Medication-Related Osteonecrosis of the Jaw (MRONJ) Using Leukocyte- and Platelet-Rich Fibrin (L-PRF) and Photobiomodulation: A Retrospective Study. J Clin Med 2020; 9:jcm9113505. [PMID: 33138266 PMCID: PMC7693575 DOI: 10.3390/jcm9113505] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Revised: 10/23/2020] [Accepted: 10/26/2020] [Indexed: 11/18/2022] Open
Abstract
Background. The aim of this study was to compare retrospectively the effect of three different treatment protocols on the healing outcome in patients with established medication-related osteonecrosis of the jaw (MRONJ). Methods. A total of 34 MRONJ patients were recruited from the Department database and were divided according to the treatment protocols in a study group (G1) and two control groups (G2 and G3). G1 was treated with antibiotic therapy, surgery, leukocyte- and platelet-rich fibrin (L-PRF), and photobiomodulation; G2 was treated with antibiotic therapy and surgery; G3 was treated with antibiotic therapy and photobiomodulation. Various clinical variables and treatment protocols were analyzed to determine their correlation with the healing outcome at three and six months of follow-up. Results. There was a significant association between the different treatment protocols and the outcomes at both three and six months follow-up (p = 0.001 and p = 0.002, respectively). No significant association was observed between the outcomes and MRONJ localization, MRONJ stage, duration of drug treatment, gender, diabetes, corticosteroid therapy, smoking habits, underlying disease, and history of chemotherapy at both three and six months follow-up. Conclusions. Our results show that the combination of antibiotic therapy, surgery, L-PRF, and photobiomodulation may effectively contribute to MRONJ management.
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Albanese M, Zotti F, Capocasale G, Bonetti S, Lonardi F, Nocini PF. Conservative non-surgical management in medication related osteonecrosis of the jaw: A retrospective study. Clin Exp Dent Res 2020; 6:512-518. [PMID: 32614524 PMCID: PMC7545224 DOI: 10.1002/cre2.303] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Revised: 05/21/2020] [Accepted: 05/24/2020] [Indexed: 12/20/2022] Open
Abstract
Objectives To date, the best treatment for Medication Related Osteonecrosis of the jaw (MRONJ) is controversial. Recent studies suggest different therapies, considering the stage of MRONJ; however, sometimes patients, although with remarkable extension of disease, cannot undergo surgery. The purpose of present preliminary study was to evaluate the efficacy of conservative non‐surgical treatment of MRONJ lesions in a cohort of patients ineligible for surgery or refusing any surgical treatment for stage II and III of MRONJ. Materials and methods Patients with MRONJ (staging II or III) ineligible for surgical treatment were selected for a retrospective study. A conservative non‐surgical therapy (antibiotics and antiseptic) was administered for 1 year. Five scheduled checks were performed to assess changes in signs and symptoms during the observational period. Results Our observation was carried out on 12 patients. Improvement of signs and symptoms of disease were observed in population. Conclusion This study suggests that non‐surgical treatment may be a valid therapeutic option in patients ineligible for surgery. The sample size is small, further studies should be carried out to satisfy the aim of a conservative non‐surgical treatment protocol establishment.
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Affiliation(s)
- Massimo Albanese
- Section of Dentistry and Maxillofacial Surgery, Department of Surgical Sciences, Paediatrics and Gynecology, University of Verona, Verona, Italy
| | - Francesca Zotti
- Section of Dentistry and Maxillofacial Surgery, Department of Surgical Sciences, Paediatrics and Gynecology, University of Verona, Verona, Italy
| | - Giorgia Capocasale
- Section of Dentistry and Maxillofacial Surgery, Department of Surgical Sciences, Paediatrics and Gynecology, University of Verona, Verona, Italy
| | | | - Fabio Lonardi
- Section of Dentistry and Maxillofacial Surgery, Department of Surgical Sciences, Paediatrics and Gynecology, University of Verona, Verona, Italy
| | - Pier Francesco Nocini
- Section of Dentistry and Maxillofacial Surgery, Department of Surgical Sciences, Paediatrics and Gynecology, University of Verona, Verona, Italy
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Platelet-Rich Plasma (PRP) in Dental Extraction of Patients at Risk of Bisphosphonate-Related Osteonecrosis of the Jaws: A Two-Year Longitudinal Study. APPLIED SCIENCES-BASEL 2020. [DOI: 10.3390/app10134487] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Dental extraction has often been described as the main trigger event of osteonecrosis of the jaws (ONJ). This longitudinal hospital-based study aimed to evaluate the outcome at 2 years of a standardized medical-surgical protocol for dental extraction, combined with platelet rich-plasma (PRP) application, compared with conventional protocol not combined with PRP or any other autologous platelet concentrate in cancer (ONC) and osteometabolic (OST) patients, at risk of bisphosphonate (BP)-related ONJ. Twenty patients were consecutively recruited: six received BPs for cancer skeletal-related events (34.17 ± 19.97 months), while fourteen received BPs for metabolic bone disease (74.5 ± 34.73 months). These patients underwent a standardized protocol for dental extraction, combined with autologous PRP application in the post-extraction socket. A total of 63 dental extractions were performed (24 and 39 in ONC and OST groups, respectively). As controls, historical cases, derived from the literature and including 171 ONC and 734 OST patients, were considered. The outcome of the surgical treatment was successful in all patients treated with PRP: two years after extraction, no patient had clinical or radiological signs of ONJ. When this datum was compared with historical controls, no statistically significant differences were found (p > 0.1). The combination of a standardized medical-surgical protocol with PRP application may contribute to limit the occurrence of BP-related ONJ, in both ONC and OST patients. Additional prospective studies with a larger patient sample are necessary to confirm this datum.
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Abbasi H, Beltrán Bernal LM, Hamidi A, Droneau A, Canbaz F, Guzman R, Jacques SL, Cattin PC, Zam A. Combined Nd:YAG and Er:YAG lasers for real-time closed-loop tissue-specific laser osteotomy. BIOMEDICAL OPTICS EXPRESS 2020; 11:1790-1807. [PMID: 32341848 PMCID: PMC7173907 DOI: 10.1364/boe.385862] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/12/2019] [Revised: 02/26/2020] [Accepted: 02/26/2020] [Indexed: 06/11/2023]
Abstract
A novel real-time and non-destructive method for differentiating soft from hard tissue in laser osteotomy has been introduced and tested in a closed-loop fashion. Two laser beams were combined: a low energy frequency-doubled nanosecond Nd:YAG for detecting the type of tissue, and a high energy microsecond Er:YAG for ablating bone. The working principle is based on adjusting the energy of the Nd:YAG laser until it is low enough to create a microplasma in the hard tissue only (different energies are required to create plasma in different tissue types). Analyzing the light emitted from the generated microplasma enables real-time feedback to a shutter that prevents the Er:YAG laser from ablating the soft tissue.
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Affiliation(s)
- Hamed Abbasi
- Biomedical Laser and Optics Group (BLOG), Department of Biomedical Engineering, University of Basel, CH-4123 Allschwil, Switzerland
| | - Lina M Beltrán Bernal
- Biomedical Laser and Optics Group (BLOG), Department of Biomedical Engineering, University of Basel, CH-4123 Allschwil, Switzerland
| | - Arsham Hamidi
- Biomedical Laser and Optics Group (BLOG), Department of Biomedical Engineering, University of Basel, CH-4123 Allschwil, Switzerland
| | - Antoine Droneau
- Biomedical Laser and Optics Group (BLOG), Department of Biomedical Engineering, University of Basel, CH-4123 Allschwil, Switzerland
- Grenoble INP, Grenoble Alpes University, Phelma, France
| | - Ferda Canbaz
- Biomedical Laser and Optics Group (BLOG), Department of Biomedical Engineering, University of Basel, CH-4123 Allschwil, Switzerland
| | - Raphael Guzman
- Department of Neurosurgery, University Hospital Basel, CH-4056 Basel, Switzerland
| | - Steven L Jacques
- Department of Bioengineering, University of Washington, Seattle, Washington 98195, USA
| | - Philippe C Cattin
- Center for medical Image Analysis and Navigation (CIAN), Department of Biomedical Engineering, University of Basel, CH-4123 Allschwil, Switzerland
| | - Azhar Zam
- Biomedical Laser and Optics Group (BLOG), Department of Biomedical Engineering, University of Basel, CH-4123 Allschwil, Switzerland
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Li FL, Wu CB, Sun HJ, Zhou Q. Effectiveness of laser-assisted treatments for medication-related osteonecrosis of the jaw: a systematic review. Br J Oral Maxillofac Surg 2020; 58:256-267. [DOI: 10.1016/j.bjoms.2019.12.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2019] [Accepted: 12/05/2019] [Indexed: 12/20/2022]
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Adachi N, Ayukawa Y, Yasunami N, Furuhashi A, Imai M, Sanda K, Atsuta I, Koyano K. Preventive effect of fluvastatin on the development of medication-related osteonecrosis of the jaw. Sci Rep 2020; 10:5620. [PMID: 32221325 PMCID: PMC7101417 DOI: 10.1038/s41598-020-61724-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2019] [Accepted: 03/01/2020] [Indexed: 12/23/2022] Open
Abstract
Medication-related osteonecrosis of the jaw (MRONJ) occurs in patients undergoing oral surgery while medicated with bisphosphonate, denosumab or anti-angiogenic agents. We employed a MRONJ-like rat model to investigate whether injecting fluvastatin at extraction sites prevents MRONJ-like lesion. A MRONJ-like model was created by treating rats with zoledronate and dexamethasone, extracting teeth, and immediately injecting fluvastatin at the extraction site. The experimental group comprised three subgroups treated with low (0.1 mg/kg; FS-L), medium (1.0 mg/kg; FS-M) and high concentrations (10 mg/kg; FS-H) of fluvastatin. Necrotic bone exposure was significantly lower in the FS-M (p = 0.028) and FS-H (p = 0.041) groups than in the MRONJ group. The distance between the edges of the epithelial surfaces was significantly shorter in the FS-M (p = 0.042) and FS-H (p = 0.041) groups. The area of necrotic bone and the necrotic bone ratio were significantly smaller in the FS-H group (p = 0.041 and p = 0.042 respectively). Bone volume fraction calculated on μ-CT images was significantly larger in the FS-H group than in the MRONJ group (p = 0.021). Our findings suggest that a single local injection of fluvastatin following tooth extraction can potentially reduce the chance of developing MRONJ-like lesion in rats.
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Affiliation(s)
- Naomi Adachi
- Section of Implant and Rehabilitative Dentistry, Division of Oral Rehabilitation, Faculty of Dental Science, Kyushu University, Fukuoka, Japan
| | - Yasunori Ayukawa
- Section of Implant and Rehabilitative Dentistry, Division of Oral Rehabilitation, Faculty of Dental Science, Kyushu University, Fukuoka, Japan.
| | - Noriyuki Yasunami
- Section of Implant and Rehabilitative Dentistry, Division of Oral Rehabilitation, Faculty of Dental Science, Kyushu University, Fukuoka, Japan.,Department of Reconstructive Science, School of Dental Medicine, University of Connecticut, CT, USA
| | - Akihiro Furuhashi
- Section of Implant and Rehabilitative Dentistry, Division of Oral Rehabilitation, Faculty of Dental Science, Kyushu University, Fukuoka, Japan
| | - Mikio Imai
- Section of Implant and Rehabilitative Dentistry, Division of Oral Rehabilitation, Faculty of Dental Science, Kyushu University, Fukuoka, Japan
| | - Koma Sanda
- Section of Implant and Rehabilitative Dentistry, Division of Oral Rehabilitation, Faculty of Dental Science, Kyushu University, Fukuoka, Japan
| | - Ikiru Atsuta
- Division of Advanced Dental Devices and Therapeutics, Faculty of Dental Science, Kyushu University, Fukuoka, Japan
| | - Kiyoshi Koyano
- Section of Implant and Rehabilitative Dentistry, Division of Oral Rehabilitation, Faculty of Dental Science, Kyushu University, Fukuoka, Japan
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Fortunato L, Bennardo F, Buffone C, Giudice A. Is the application of platelet concentrates effective in the prevention and treatment of medication-related osteonecrosis of the jaw? A systematic review. J Craniomaxillofac Surg 2020; 48:268-285. [PMID: 32063481 DOI: 10.1016/j.jcms.2020.01.014] [Citation(s) in RCA: 68] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Revised: 01/19/2020] [Accepted: 01/26/2020] [Indexed: 01/20/2023] Open
Abstract
The aim of this systematic review was to answer the question: Is the application of autologous platelet concentrates (APCs) effective in the prevention and treatment of medication-related osteonecrosis of the jaw (MRONJ)? A literature search of PubMed, Scopus, and Web of Science databases (articles published until June 30, 2019) was conducted, in accordance with the PRISMA statement, using search terms related to "platelet concentrate" and "osteonecrosis". The Jadad scale was used to assess the quality of the articles. Fisher's exact test was used to evaluate eventual differences between groups. Of 594 articles, 43 were included in the review (8 for MRONJ prevention and 35 for MRONJ treatment). Out of a total of 1219 dental extractions recorded (786 with APCs), only 12 cases of MRONJ have been reported (1%), all in patients with a history of high-dose antiresorptive treatment, and regardless of the use of APCs (p = 0.7634). Regarding MRONJ treatment, there were no statistically significant differences in terms of improvement between APC application and surgical treatment alone (p = 0.0788). Results are not sufficient to establish the effectiveness of APCs in the prevention and treatment of MRONJ. Randomized controlled trials with large sample size are needed.
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Affiliation(s)
- Leonzio Fortunato
- Department of Health Sciences, Magna Graecia University of Catanzaro, Italy
| | - Francesco Bennardo
- Department of Health Sciences, Magna Graecia University of Catanzaro, Italy
| | - Caterina Buffone
- Department of Health Sciences, Magna Graecia University of Catanzaro, Italy
| | - Amerigo Giudice
- Department of Health Sciences, Magna Graecia University of Catanzaro, Italy.
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28
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Qu X, Wang Z, Wu K, Wang Y, Shan L. Zoledronate inhibits the differentiation potential of adipose-derived stem cells into osteoblasts in repairing jaw necrosis. Mol Cell Probes 2020; 51:101525. [PMID: 31982509 DOI: 10.1016/j.mcp.2020.101525] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2019] [Revised: 01/13/2020] [Accepted: 01/21/2020] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To explore the inhibitory effects of zoledronate (ZOL) on adipose-derived stem cells (ADSCs) into osteoblasts for repairing jaw necrosis. METHODS ADSCs were induced to differentiate into osteoblasts. The differentiation characteristics of osteoblasts was observed under inverted microscope by alizarin red staining. The transwell assay was performed to evaluate the migration of ADSCs co-cultured with osteoblasts and divided into ZOL group treated with ZOL and N-ZOL group without ZOL treatment. The differentiation and proliferation characteristics of ADSCs differentiated osteoblasts were observed respectively. The expression of CTSK (Cathepsin K) and FGFR3 (Fibroblast growth factor receptor 3) in osteoblasts were analyzed by immunofluorescence and western blot. RESULTS The differentiation degree and proliferation of ADSCs to osteoblasts in N-ZOL group were both higher than those in ZOL group. The migratory cell number in ADSCs differentiation in ZOL group was higher than that of N-ZOL group. The protein expression of CTSK and FGFR3 in ADSCs differentiated to osteoblasts in ZOL group was higher than that in N-ZOL group. CONCLUSION The differentiation of ADSCs into osteoblasts is significantly inhibited by ZOL. Due to this reason, it may be difficult to achieve good results by ZOL induced ADSCs into osteoblasts in repairing jaw necrosis.
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Affiliation(s)
- Xingzhou Qu
- Department of Oral & Maxillofacial-Head Neck Oncology, Ninth People's Hospital, College of Stomatology, Shanghai JiaoTong University, School of Medicine, Shanghai, 200011, China
| | - Zhen Wang
- Department of Oral & Maxillofacial-Head Neck Oncology, Ninth People's Hospital, College of Stomatology, Shanghai JiaoTong University, School of Medicine, Shanghai, 200011, China
| | - Kailiu Wu
- Department of Oral & Maxillofacial-Head Neck Oncology, Ninth People's Hospital, College of Stomatology, Shanghai JiaoTong University, School of Medicine, Shanghai, 200011, China
| | - Yang Wang
- Department of Oral & Maxillofacial-Head Neck Oncology, Ninth People's Hospital, College of Stomatology, Shanghai JiaoTong University, School of Medicine, Shanghai, 200011, China.
| | - Liancheng Shan
- Department of Orthopedics, Tong Ren Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200336, China.
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29
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Al-Hamed FS, Mahri M, Al-Waeli H, Torres J, Badran Z, Tamimi F. Regenerative Effect of Platelet Concentrates in Oral and Craniofacial Regeneration. Front Cardiovasc Med 2019; 6:126. [PMID: 31552270 PMCID: PMC6733887 DOI: 10.3389/fcvm.2019.00126] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2019] [Accepted: 08/12/2019] [Indexed: 01/11/2023] Open
Abstract
Platelet concentrates (PCs) are biological autologous products derived from the patient's whole blood and consist mainly of supraphysiologic concentration of platelets and growth factors (GFs). These GFs have anti-inflammatory and healing enhancing properties. Overall, PCs seem to enhance bone and soft tissue healing in alveolar ridge augmentation, periodontal surgery, socket preservation, implant surgery, endodontic regeneration, sinus augmentation, bisphosphonate related osteonecrosis of the jaw (BRONJ), osteoradionecrosis, closure of oroantral communication (OAC), and oral ulcers. On the other hand, no effect was reported for gingival recession and guided tissue regeneration (GTR) procedures. Also, PCs could reduce pain and inflammatory complications in temporomandibular disorders (TMDs), oral ulcers, and extraction sockets. However, these effects have been clinically inconsistent across the literature. Differences in study designs and types of PCs used with variable concentration of platelets, GFs, and leucocytes, as well as different application forms and techniques could explain these contradictory results. This study aims to review the clinical applications of PCs in oral and craniofacial tissue regeneration and the role of their molecular components in tissue healing.
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Affiliation(s)
| | - Mohammed Mahri
- Faculty of Dentistry, McGill University, Montreal, QC, Canada.,Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Jazan University, Jazan, Saudi Arabia
| | - Haider Al-Waeli
- Faculty of Dentistry, McGill University, Montreal, QC, Canada
| | - Jesus Torres
- Faculty of Dentistry, Universidad Complutense, Madrid, Spain
| | - Zahi Badran
- Faculty of Dentistry, McGill University, Montreal, QC, Canada.,Department of Periodontology (CHU/Rmes Inserm U1229/UIC11), Faculty of Dental Surgery, University of Nantes, Nantes, France
| | - Faleh Tamimi
- Faculty of Dentistry, McGill University, Montreal, QC, Canada
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Murgia D, Mauceri R, Campisi G, De Caro V. Advance on Resveratrol Application in Bone Regeneration: Progress and Perspectives for Use in Oral and Maxillofacial Surgery. Biomolecules 2019; 9:E94. [PMID: 30857241 PMCID: PMC6468380 DOI: 10.3390/biom9030094] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2019] [Revised: 03/02/2019] [Accepted: 03/04/2019] [Indexed: 12/22/2022] Open
Abstract
The natural polyphenol Resveratrol (RSV) claims numerous positive effects on health due to the well documented biological effects demonstrating its potential as a disease-preventing agent and as adjuvant for treatment of a wide variety of chronic diseases. Since several studies, both in vitro and in vivo, have highlighted the protective bone aptitude of RSV both as promoter of osteoblasts' proliferation and antagonist of osteoclasts' differentiation, they could be interesting in view of applications in the field of dentistry and maxillofacial surgery. This review has brought together experimental findings on the use of RSV in the regeneration of bone tissue comprising also its application associated with scaffolds and non-transfusional hemocomponents.
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Affiliation(s)
- Denise Murgia
- Department of Biological, Chemical and Pharmaceutical Sciences and Technologies, University of Palermo, 90123 Palermo, Italy.
- Department of Surgical, Oncological and Oral Sciences, University of Palermo, 90127 Palermo, Italy.
| | - Rodolfo Mauceri
- Department of Surgical, Oncological and Oral Sciences, University of Palermo, 90127 Palermo, Italy.
| | - Giuseppina Campisi
- Department of Surgical, Oncological and Oral Sciences, University of Palermo, 90127 Palermo, Italy.
| | - Viviana De Caro
- Department of Biological, Chemical and Pharmaceutical Sciences and Technologies, University of Palermo, 90123 Palermo, Italy.
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