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Al-Sarraj M, Burns M, Patel V. Pre-existing medication-related osteonecrosis of the jaw before dental extraction. Br Dent J 2023; 235:783-788. [PMID: 38001199 DOI: 10.1038/s41415-023-6447-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Revised: 08/01/2023] [Accepted: 08/08/2023] [Indexed: 11/26/2023]
Abstract
Medication-related osteonecrosis of the jaw (MRONJ) is a severe adverse event, most commonly associated with dental extractions as a predisposing event. However, it is possible that established MRONJ may be existent before dental extractions and is mistaken for odontogenic disease. The provision of a dental extraction will lead to clinically obvious MRONJ with the cause being attributed to tooth removal. We present a case series of ten patients with pre-existing necrosis of the jaw before dental extraction.Retrospective data were collected on ten patients who presented to the oral surgery department between 2017-2021, diagnosed with pre-existing necrosis. A diagnosis of pre-existing MRONJ was made based on the identification of necrotic bone clinically, either with plain film or cone beam computed tomography (CBCT). Patients with pre-existing necrosis presented with a range of symptoms, including pain, swelling and tooth mobility. Plain film imaging revealed a variety of findings, including periapical radiolucency, periodontal ligament widening and bone loss. CBCT imaging confirmed a necrotic pattern of bone destruction confirming a diagnosis of pre-existing MRONJ.There is increasing evidence to suggest that local inflammation can be a predisposing factor for MRONJ development as opposed to surgical intervention. This case series provides early insight into the presentation of pre-existing MRONJ.
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Affiliation(s)
- Mariam Al-Sarraj
- Department of Oral Surgery, Guy´s and St Thomas´ NHS Foundation Trust, London, United Kingdom
| | - Megan Burns
- Department of Oral Surgery, Guy´s and St Thomas´ NHS Foundation Trust, London, United Kingdom
| | - Vinod Patel
- Department of Oral Surgery, Guy´s and St Thomas´ NHS Foundation Trust, London, United Kingdom.
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Watanabe T, Yoshida T, Akizuki S, Yamanaka S, Nakao K, Fukuhara S, Asai K, Uozumi R, Bessho K. Nonexposed antiresorptive agent-related osteomyelitis of the jaw: a single-center cohort study. J Bone Miner Metab 2022; 40:657-662. [PMID: 35534635 DOI: 10.1007/s00774-022-01329-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Accepted: 03/15/2022] [Indexed: 11/27/2022]
Abstract
INTRODUCTION The nonexposed variant of antiresorptive agent-related osteonecrosis of the jaw (ARONJ) presents with nonspecific clinical findings. The diagnosis of nonexposed ARONJ poses a critical challenge, and there is little evidence regarding its treatment and outcomes. This study aimed to examine the clinical outcomes in patients with nonexposed antiresorptive agent-related osteomyelitis of the jaw (AROMJ). The terms ARONJ and AROMJ were used separately in this study. MATERIALS AND METHODS We enrolled patients with nonexposed AROMJ (osteomyelitis of the jaw without bone exposure associated with antiresorptive agents) with partial reference to an existing position paper on ARONJ. The initiating event of osteomyelitis was limited to periodontitis. Based on the findings of bone scintigraphy, panoramic radiography, computed tomography, and histopathological examination, we also used the hierarchical diagnostic criteria (HDC) for osteomyelitis of the jaw. RESULTS There were 58 confirmed cases of nonexposed AROMJ based on the HDC. All patients had sufficient clinical findings to be diagnosed with nonexposed AROMJ as osteomyelitis underwent extraction with bone debridement. The healing rate was 93.1% (54/58). Univariable analysis showed a strong association between the healing status and malignant disease, while multivariable analysis showed no strong association between them. CONCLUSIONS The present study had a relatively large sample size of patients with nonexposed AROMJ. The primary disease in patients with nonexposed AROMJ may not have a strong association with the healed status of the lesion. Based on its high healing rate, extraction with bone debridement in confirmed nonexposed AROMJ may prevent progression.
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Affiliation(s)
- Takuma Watanabe
- Department of Oral and Maxillofacial Surgery, Graduate School of Medicine, Kyoto University, 54 Kawahara-cho, Shogoin, Sakyo-ku, Kyoto, 606-8507, Japan.
| | - Takeshi Yoshida
- Department of Oral and Maxillofacial Surgery, Graduate School of Medicine, Kyoto University, 54 Kawahara-cho, Shogoin, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Sachi Akizuki
- Department of Oral and Maxillofacial Surgery, Graduate School of Medicine, Kyoto University, 54 Kawahara-cho, Shogoin, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Shigeki Yamanaka
- Department of Oral and Maxillofacial Surgery, Graduate School of Medicine, Kyoto University, 54 Kawahara-cho, Shogoin, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Kazumasa Nakao
- Department of Oral and Maxillofacial Surgery, Graduate School of Medicine, Kyoto University, 54 Kawahara-cho, Shogoin, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Shizuko Fukuhara
- Department of Oral and Maxillofacial Surgery, Graduate School of Medicine, Kyoto University, 54 Kawahara-cho, Shogoin, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Keita Asai
- Department of Oral and Maxillofacial Surgery, Graduate School of Medicine, Kyoto University, 54 Kawahara-cho, Shogoin, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Ryuji Uozumi
- Department of Biomedical Statistics and Bioinformatics, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Kazuhisa Bessho
- Department of Oral and Maxillofacial Surgery, Graduate School of Medicine, Kyoto University, 54 Kawahara-cho, Shogoin, Sakyo-ku, Kyoto, 606-8507, Japan
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Medication-Related Osteonecrosis of the Jaw: A Critical Narrative Review. J Clin Med 2021; 10:jcm10194367. [PMID: 34640383 PMCID: PMC8509366 DOI: 10.3390/jcm10194367] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Revised: 09/15/2021] [Accepted: 09/20/2021] [Indexed: 12/24/2022] Open
Abstract
Background: Nearly two decades have passed since a paradoxical reaction in the orofacial region to some bone modifying agents and other drugs was recognized, namely medication-related osteonecrosis of the jaw (MRONJ). Purpose: The aim of this manuscript was to critically review published data on MRONJ to provide an update on key terminology, concepts, and current trends in terms of prevention and diagnosis. In addition, our objective was to examine and evaluate the therapeutic options available for MRONJ. Methods: The authors perused the most relevant literature relating to MRONJ through a search in textbooks and published articles included in several databases for the years 2003–2021. Results and conclusions: A comprehensive update of the current understanding of these matters was elaborated, addressing these topics and identifying relevant gaps of knowledge. This review describes our updated view of the previous thematic blocks, highlights our current clinical directions, and emphasizes controversial aspects and barriers that may lead to extending the accumulating body of evidence related to this severe treatment sequela.
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Otto S, Aljohani S, Fliefel R, Ecke S, Ristow O, Burian E, Troeltzsch M, Pautke C, Ehrenfeld M. Infection as an Important Factor in Medication-Related Osteonecrosis of the Jaw (MRONJ). MEDICINA (KAUNAS, LITHUANIA) 2021; 57:463. [PMID: 34065104 PMCID: PMC8151678 DOI: 10.3390/medicina57050463] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Revised: 04/30/2021] [Accepted: 05/04/2021] [Indexed: 12/12/2022]
Abstract
Medication-related osteonecrosis of the jaw (MRONJ) has become a well-known side effect of antiresorptive, and antiangiogenic drugs commonly used in cancer management. Despite a considerable amount of literature addressing MRONJ, it is still widely accepted that the underlying pathomechanism of MRONJ is unclear. However, several clinical and preclinical studies indicate that infection seems to have a major role in the pathogenesis of MRONJ. Although there is no conclusive evidence for the infection hypothesis yet, available data have shown a robust association between local infection and MRONJ development. This observation is very critical in order to implement policies to reduce the risk of MRONJ in patients under antiresorptive drugs. This critical review was conducted to collect the most reliable evidence regarding the link between local infection and MRONJ pathogenesis.
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Affiliation(s)
- Sven Otto
- Head of Department of Oral and Maxillofacial Surgery, Martin-Luther-University Halle-Wittenberg, 06120 Halle (Saale), Germany
- Department of Oral and Maxillofacial Surgery and Facial Plastic Surgery, Ludwig-Maximilians-University, 80337 Munich, Germany; (R.F.); (S.E.); (M.T.); (C.P.); (M.E.)
| | - Suad Aljohani
- Department of Oral Diagnostic Sciences, Division of Oral Medicine, King Abdulaziz University, 80200 Jeddah, Saudi Arabia;
| | - Riham Fliefel
- Department of Oral and Maxillofacial Surgery and Facial Plastic Surgery, Ludwig-Maximilians-University, 80337 Munich, Germany; (R.F.); (S.E.); (M.T.); (C.P.); (M.E.)
- Experimental Surgery and Regenerative Medicine (ExperiMed), Department of Orthopaedic Surgery, Ludwig-Maximilians-University, 80337 Munich, Germany
- Department of Oral and Maxillofacial Surgery, Alexandria University, Alexandria 21514, Egypt
| | - Sara Ecke
- Department of Oral and Maxillofacial Surgery and Facial Plastic Surgery, Ludwig-Maximilians-University, 80337 Munich, Germany; (R.F.); (S.E.); (M.T.); (C.P.); (M.E.)
| | - Oliver Ristow
- Department of Oral and Maxillofacial Surgery, University of Heidelberg, 69120 Heidelberg, Germany;
| | - Egon Burian
- Department of Neuroradiology, Technical University of Munich, 81675 Munich, Germany;
| | - Matthias Troeltzsch
- Department of Oral and Maxillofacial Surgery and Facial Plastic Surgery, Ludwig-Maximilians-University, 80337 Munich, Germany; (R.F.); (S.E.); (M.T.); (C.P.); (M.E.)
| | - Christoph Pautke
- Department of Oral and Maxillofacial Surgery and Facial Plastic Surgery, Ludwig-Maximilians-University, 80337 Munich, Germany; (R.F.); (S.E.); (M.T.); (C.P.); (M.E.)
| | - Michael Ehrenfeld
- Department of Oral and Maxillofacial Surgery and Facial Plastic Surgery, Ludwig-Maximilians-University, 80337 Munich, Germany; (R.F.); (S.E.); (M.T.); (C.P.); (M.E.)
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Wongratwanich P, Shimabukuro K, Konishi M, Nagasaki T, Ohtsuka M, Suei Y, Nakamoto T, Verdonschot RG, Kanesaki T, Sutthiprapaporn P, Kakimoto N. Do various imaging modalities provide potential early detection and diagnosis of medication-related osteonecrosis of the jaw? A review. Dentomaxillofac Radiol 2021; 50:20200417. [PMID: 33411572 DOI: 10.1259/dmfr.20200417] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
OBJECTIVE Patients with medication-related osteonecrosis of the jaw (MRONJ) often visit their dentists at advanced stages and subsequently require treatments that greatly affect quality of life. Currently, no clear diagnostic criteria exist to assess MRONJ, and the definitive diagnosis solely relies on clinical bone exposure. This ambiguity leads to a diagnostic delay, complications, and unnecessary burden. This article aims to identify imaging modalities' usage and findings of MRONJ to provide possible approaches for early detection. METHODS Literature searches were conducted using PubMed, Web of Science, Scopus, and Cochrane Library to review all diagnostic imaging modalities for MRONJ. RESULTS Panoramic radiography offers a fundamental understanding of the lesions. Imaging findings were comparable between non-exposed and exposed MRONJ, showing osteolysis, osteosclerosis, and thickened lamina dura. Mandibular cortex index Class II could be a potential early MRONJ indicator. While three-dimensional modalities, CT and CBCT, were able to show more features unique to MRONJ such as a solid type periosteal reaction, buccal predominance of cortical perforation, and bone-within-bone appearance. MRI signal intensities of vital bones are hypointense on T1WI and hyperintense on T2WI and STIR when necrotic bone shows hypointensity on all T1WI, T2WI, and STIR. Functional imaging is the most sensitive method but is usually performed in metastasis detection rather than being a diagnostic tool for early MRONJ. CONCLUSION Currently, MRONJ-specific imaging features cannot be firmly established. However, the current data are valuable as it may lead to a more efficient diagnostic procedure along with a more suitable selection of imaging modalities.
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Affiliation(s)
- Pongsapak Wongratwanich
- Department of Oral and Maxillofacial Radiology, Graduate School of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima 734-8553, Japan
| | - Kiichi Shimabukuro
- Department of Oral and Maxillofacial Radiology, Graduate School of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima 734-8553, Japan
| | - Masaru Konishi
- Department of Oral and Maxillofacial Radiology, Hiroshima University Hospital, 1-2-3 Kasumi, Minami-ku, Hiroshima 734-8553, Japan
| | - Toshikazu Nagasaki
- Department of Oral and Maxillofacial Radiology, Graduate School of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima 734-8553, Japan
| | - Masahiko Ohtsuka
- Department of Oral and Maxillofacial Radiology, Graduate School of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima 734-8553, Japan
| | - Yoshikazu Suei
- Department of Oral and Maxillofacial Radiology, Hiroshima University Hospital, 1-2-3 Kasumi, Minami-ku, Hiroshima 734-8553, Japan
| | - Takashi Nakamoto
- Department of Oral and Maxillofacial Radiology, Graduate School of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima 734-8553, Japan
| | - Rinus G Verdonschot
- Department of Oral and Maxillofacial Radiology, Graduate School of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima 734-8553, Japan
| | - Tomohiko Kanesaki
- Department of Oral and Maxillofacial Surgery, Saiseikai Senri Hospital, 1 Chome-1-6 Tsukumodai, Suita, Osaka 565-0862, Japan
| | - Pipop Sutthiprapaporn
- Department of Preventive Dentistry, Faculty of Dentistry, Khon Kaen University, Amphur Muang, Khon Kaen 40002, Thailand
| | - Naoya Kakimoto
- Department of Oral and Maxillofacial Radiology, Graduate School of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima 734-8553, Japan
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Abstract
Medication-related osteonecrosis of the jaw (MRONJ) is a rare, severe debilitating condition from unknown causes. It is characterized by nonhealing exposed bone in a patient with a history of antiresorptive or antiangiogenic agents in the absence of radiation exposure to the head and neck region. The first case of MRONJ was reported in the early 2000s. Diagnostic criteria for MRONJ was developed by the American Association of Oral and Maxillofacial Surgeons (AAOMS) based on pharmacological history as well as clinical and radiographic features. Antiresorptive medications such as bisphosphonate and denosumab are currently considered the treatment of choice in patients with osteoclastic bone disease. These reduce bone turnover and improve bone density, thereby improving bone quality. These agents have also been shown to reduce the risk of osteoporotic fractures due to their potent effect in suppressing osteoclastic activity by slowing the remodeling process and increasing bone density, thereby improving quality of life for most of the patients. Despite the great benefits of bisphosphonates and other antiresorptive medications, osteonecrosis of the jaw (ONJ) due to the effects of these medications in the presence of a local risk factor is a significant drawback. Moreover, antiangiogenic drugs play a major role in developing bone necrosis. They are prescribed in cancer cases to prevent metastasis through the blood and lymph nodes. These drugs interfere with the formation of new blood vessels, resulting in ischemia and eventually ONJ. This risk can be managed by evaluating the route and the duration of administration as such a risk can be considered dose-time dependent. As a preventive measure, dental screening before initiating any type of ONJ-related medications can significantly lower the risk of ONJ. Treatment goals can be achieved through pain and infection control, in addition to the management of bone necrosis and resorption. The aim of this review is to identify all causative agents and summarize the preventive measures, diagnostic criteria, and treatment strategies related to MRONJ.
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Affiliation(s)
| | - Asma BaQais
- Dentistry, King Saud University, Riyadh, SAU
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Medication-Related Osteonecrosis of the Jaws: Two Center Retrospective Cohort Studies. BIOMED RESEARCH INTERNATIONAL 2019; 2019:8345309. [PMID: 31011580 PMCID: PMC6442486 DOI: 10.1155/2019/8345309] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/11/2018] [Accepted: 02/17/2019] [Indexed: 12/15/2022]
Abstract
This retrospective cohort study aims to describe characteristics of patients with MRONJ, to identify factors associated with MRONJ development, and to examine variables associated with favourable outcome. Totally 32 patients were followed and observed: 21 females and 11 males, in the age range 35-84 in the period from 2009 to 2018. Clinical, radiological examination (Orthopantomograph and CBCT) and biopsy were performed in order to achieve diagnosis. Demographic and clinical variables were taken into consideration: sex, age, primary disease, medication type, mode of delivery, anatomic location, drug treatment duration, timing of tooth extraction, chemotherapy, presence of bone metastasis, aetiology of MRONJ, disease stage, and treatment modality. MRONJ developed under osteoporosis and malignant disease in 11 and 21 patients, respectively. MRONJ development was triggered by tooth extraction or trauma in 30 out of 32 cases, whereas the two patients developed MRONJ spontaneously. Stages I, II, and III were confirmed in 5 (16%), 18 (58%), and 9 (28%) patients, respectively. Mandible was affected in 23 (72%) patients. MRONJ was treated in our department by conservative and surgical modality. In this study we found that 65% of all patients were classified in the cured/improvement group and 35% in the stable/progression group. The female gender, osteoporosis as primary disease, oral regime intake, shorter period on BPs, earlier stage of disease, and specific anatomic localisation (frontal and premolar maxilla) were factors associated with better response to therapy and favourable clinical outcome. Comprehensive treatment protocol and further randomized studies are necessary for further improvements.
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Tsuchimochi M, Kurabayashi T. Symposium: Imaging modalities for drug-related osteonecrosis of the jaw (1), role of imaging in drug-related osteonecrosis of the jaw: An up-to-date review (secondary publication). JAPANESE DENTAL SCIENCE REVIEW 2019; 55:1-4. [PMID: 30705708 PMCID: PMC6348294 DOI: 10.1016/j.jdsr.2018.11.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2018] [Accepted: 11/28/2018] [Indexed: 11/24/2022] Open
Abstract
MRONJ/ARONJ is a serious adverse effect of medication, although the incidence of the disease is rare, and there are still controversial issues regarding the pathogenesis of MRONJ/ARONJ. Medications that can lead to MRONJ/ARONJ are commonly used to treat osteoporosis and to prevent bone fractures caused by bone metastasis of malignancies. The long-standing disease state of ONJ deteriorates the quality of life of affected patients. Early detection and prevention of the disease are key to alleviating pain and discomfort. To date, several imaging modalities have been introduced to depict the lesions. Imaging modalities, radiography, CT, MRI and nuclear medicine provide important information for managing this challenging disease.
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Affiliation(s)
- Makoto Tsuchimochi
- The Nippon Dental University (Emeritus Professor), Formerly, Oral and Maxillofacial Radiology, The Nippon Dental University School of Life Dentistry at Niigata, 1-8 Hamaura-cho, Chuo-ku, Niigata 951-8580, Japan
| | - Tohru Kurabayashi
- Department of Oral and Maxillofacial Radiology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo 113-8549, Japan
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Soundia A, Hadaya D, Mallya SM, Aghaloo TL, Tetradis S. Radiographic predictors of bone exposure in patients with stage 0 medication-related osteonecrosis of the jaws. Oral Surg Oral Med Oral Pathol Oral Radiol 2018; 126:537-544. [PMID: 30266375 DOI: 10.1016/j.oooo.2018.08.005] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2018] [Revised: 06/27/2018] [Accepted: 08/14/2018] [Indexed: 10/28/2022]
Abstract
OBJECTIVE The aim of this study was to explore the radiographic appearance of stage 0 medication-related osteonecrosis of the jaws (MRONJ) and examine 5 radiographic parameters (trabecular sclerosis, cortical erosion, periosteal reaction, sequestration, and crater-like defect) as predictors of progression to bone exposure. STUDY DESIGN Twenty-three patients with a history of antiresorptive therapy, no bone exposure, and nonspecific signs and symptoms were included. Intraoral photographs, panoramic and cone beam computed tomography (CBCT) images at initial visit, and follow-up intraoral photographs were reviewed. Three patients had dental disease (DD), 10 patients with stage 0 MRONJ did not progress to bone exposure (NBE), and 10 patients progressed to bone exposure (BE). Radiographic parameters were scored as absent (0), localized (1), or extensive (2), and their sum formed the composite radiographic index (CRI). RESULTS DD patients demonstrated minimal radiographic findings, and their CRI was significantly lower than that of NBE and BE patients. Additionally, BE patients demonstrated a higher radiographic index compared with NBE patients. Intriguingly, sequestration was observed in the initial CBCT of 9 (90%) of 10 BE patients, whereas 80% of NBE patients showed absence of sequestration at initial CBCT examination. CONCLUSIONS CBCT imaging can aid in the differentiation of stage 0 MRONJ from dental disease. Radiographic sequestration at initial presentation can serve as a predictor of future bone exposure in patients with stage 0 MRONJ.
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Affiliation(s)
- Akrivoula Soundia
- Section of Oral and Maxillofacial Radiology, Division of Diagnostic and Surgical Sciences, UCLA School of Dentistry, Los Angeles, CA, USA
| | - Danny Hadaya
- Section of Oral and Maxillofacial Surgery, Division of Diagnostic and Surgical Sciences, UCLA School of Dentistry, Los Angeles, CA, USA
| | - Sanjay M Mallya
- Section of Oral and Maxillofacial Radiology, Division of Diagnostic and Surgical Sciences, UCLA School of Dentistry, Los Angeles, CA, USA
| | - Tara L Aghaloo
- Section of Oral and Maxillofacial Surgery, Division of Diagnostic and Surgical Sciences, UCLA School of Dentistry, Los Angeles, CA, USA.
| | - Sotirios Tetradis
- Section of Oral and Maxillofacial Radiology, Division of Diagnostic and Surgical Sciences, UCLA School of Dentistry, Los Angeles, CA, USA.
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