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Abdolrahmani A, Epstein JB, Samim F. Medication-related osteonecrosis of the jaw: evolving research for multimodality medical management. Support Care Cancer 2024; 32:212. [PMID: 38443685 DOI: 10.1007/s00520-024-08388-4] [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: 09/30/2023] [Accepted: 02/16/2024] [Indexed: 03/07/2024]
Abstract
PURPOSE Medication-related osteonecrosis of the jaw (MRONJ) is a debilitating side effect of antiresorptive and antiangiogenic agents that can lead to progressive bone destruction in the maxillofacial region. Dental surgery, including tooth extractions, commonly trigger the onset of MRONJ. While guidelines suggest avoiding extraction when possible, complete avoidance is not always feasible, as necrosis can develop from dental and periodontal disease without dental procedures. The goal of this article is to provide an update review of current preventive and therapeutic approaches for MRONJ. METHODS A comprehensive electronic search was conducted on PubMed/MEDLINE, Embase, and Scopus databases. All English articles encompassing randomized controlled trials, systematic reviews, observational studies, and case studies were reviewed. The current medical treatments and adjuvant therapies for managing MRONJ patients were critically assessed and summarized. RESULTS Pentoxifylline and alpha tocopherol (PENT-E), teriparatide, photobiomodulation (PBM), photodynamic therapy (PDT), and the use of growth factors have shown to enhance healing in MRONJ patients. Implementing these methods alone or in conjunction with surgical treatment has been linked to reduced discomfort and improved wound healing and increased new bone formation. DISCUSSION While several adjuvant treatment modalities exhibit promising results in facilitating the healing process, current clinical practice guidelines predominantly recommend antibiotic therapy as a non-surgical approach, primarily addressing secondary infections in necrotic areas. However, this mainly addresses the potential infectious complication of MRONJ. Medical approaches including PENT-E, teriparatide, PBM, and PDT can result in successful management and should be considered prior to taking a surgical approach. Combined medical management for both preventing and managing MRONJ holds potential for achieving optimal clinical outcomes and avoiding surgical intervention, requiring further validation through larger studies and controlled trials.
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Affiliation(s)
- Ali Abdolrahmani
- Oral Medicine & Oral Pathology Clinic, Montreal General Hospital, Montreal, QC, Canada
| | - Joel B Epstein
- Department of Surgery, City of Hope National Cancer Center, Duarte, CA, USA
- Cedars-Sinai Medical Center, Samuel Oschin Comprehensive Cancer Institute, Los Angeles, CA, USA
| | - Firoozeh Samim
- Faculty of Dental Medicine and Oral Health, McGill University, Montreal, QC, Canada.
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Sildenafil reduces bisphosphonate-induced jaw osteonecrosis in rats. Clin Oral Investig 2023; 27:2437-2448. [PMID: 36764974 DOI: 10.1007/s00784-023-04890-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Accepted: 02/01/2023] [Indexed: 02/12/2023]
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Valamvanos K, Valamvanos TF, Toumazou S, Gartzouni E. The combined use of photobiomodulation therapy and platelet-rich fibrin for the management of two MRONJ stage II cases: An alternative approach. FRONTIERS IN DENTAL MEDICINE 2022. [DOI: 10.3389/fdmed.2022.973738] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Medication-related osteonecrosis of the jaws (MRONJ) is a relatively rare but serious adverse drug reaction in patients under bone-targeting or antiangiogenic medication for malignant or osteometabolic diseases. The pathogenesis of MRONJ is multifactorial with the inhibition of osteoclasts and angiogenesis considered to play a keyrole in an individually susceptible environment, thus its prevalence is highly differentiated according to each study. Even though MRONJ has been reported since 2003 and the literature is expanding rapidly about possible risk factors, prevention and treatment options, the successful management with no recurrence is still under controversy. The conservative non-surgical (optimal oral hygiene, systemic antibiotic therapy) and surgical procedures (debridement, sequestrectomy or bone resection) are considered the treatment of choice especially at the early stages. Adjuvant therapies have been proposed to further stimulate bone and tissue healing such as teriparatide, bone morphogenic proteins, platelet concentrates, hyperbaric oxygen, ozone therapy, photodynamic therapy and lasers with promising results. The need to develop minimally invasive treatment protocols using novel technologies in particular for those patients with severe medical history has been highlighted in the literature. The clinical protocol that has been developed in our dental department, which is effectively contributing to MRONJ management and associates Photobiomodulation therapy (PBMT) with platelet-rich fibrin (A-PRF), will be presented in this article.
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Razavi P, Jafari A, Vescovi P, Fekrazad R. Efficacy of Adjunctive Photobiomodulation in the Management of Medication-Related Osteonecrosis of the Jaw: A Systematic Review. Photobiomodul Photomed Laser Surg 2022; 40:777-791. [PMID: 36507770 DOI: 10.1089/photob.2022.0084] [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: 12/15/2022] Open
Abstract
Background: Medication-related osteonecrosis of the jaw (MRONJ) is a severe adverse medication response that manifests as progressive bone necrosis in the craniofacial area. There is still no clear treatment protocol for the management of MRONJ. The purpose of this study was to conduct a systematic review to assess the efficacy of photobiomodulation (PBM) as an adjunct to MRONJ therapy. Methods: In line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement, a literature search was performed on PubMed/MEDLINE, Scopus, Web of Science, and Cochrane databases. Two examiners examined eligibility and risk of bias separately before extracting data. Results: Two hundred sixty-nine articles were found through electronic search, out of which only 11 met the inclusion criteria and were included in qualitative synthesis (9 retrospectives, 1 prospective, and 1 case series). A total number of 759 patients and a mean age ranging from 54 to 74 years were reviewed. Females were the most frequent gender in all of the selected studies (72% females to 28% males), and the most frequent stage in the studies mentioned above was stage II (66%). Most of the studies had shown a significant improvement when PBM was used as an adjunctive treatment. Conclusions: Based on the results of this study, PBM as an adjuvant therapy can significantly improve the outcomes of each treatment plan. However, surgical intervention for the complete healing of the lesions is suggested.
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Affiliation(s)
- Pouyan Razavi
- Student Research Committee, Dental Faculty, Tehran Medical Sciences, Islamic Azad University, Tehran, Iran
| | - Aryan Jafari
- Student Research Committee, Dental Faculty, Tehran Medical Sciences, Islamic Azad University, Tehran, Iran
| | - Paolo Vescovi
- Unit of Oral Medicine, Oral Surgery and Laser therapy, Department of Medicine and Surgery, University Center of Dentistry, University of Parma, Parma, Italy
| | - Reza Fekrazad
- Radiation Sciences Research Center, Laser Research Center in Medical Sciences, AJA University of Medical Sciences, Tehran, Iran.,International Network for Photo Medicine and Photodynamic Therapy (INPMPDT), Universal Scientific Education and Research Network (USERN), Tehran, Iran
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Delfrate G, Mroczek T, Mecca LEA, Andreis JD, Fernandes D, Lipinski LC, Claudino M, Franco GCN. Effect of pentoxifylline and α-tocopherol on medication-related osteonecrosis of the jaw in rats: Before and after dental extraction. Arch Oral Biol 2022; 137:105397. [DOI: 10.1016/j.archoralbio.2022.105397] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2021] [Revised: 02/25/2022] [Accepted: 03/06/2022] [Indexed: 11/16/2022]
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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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Reier S, Turyanskaya A, Heimel P, Frischauf N, Meusburger D, Heuser T, Drexler N, Janovszky Á, Streli C, Slezak P, Plochberger B, Dungel P, Szabó A, Walter A. Cross-modality imaging of bisphosphonate-treated murine jawbones. Analyst 2021; 146:4683-4699. [PMID: 34195707 DOI: 10.1039/d0an02373f] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
In this proof-of-principle study, we established and implemented a cross-modality imaging (CMI) pipeline to characterize and compare bisphosphonate (BIS)-treated jawbones of Sprague-Dawley rats after tooth extraction after physical therapies (photobiomodulation and extracorporeal shockwave therapy (PBMT and ESWT)). We showcase the feasibility of such a CMI approach and its compatibility across imaging modalities to probe the same region of interest (ROI) of the same jawbone. Jawbones were imaged in toto in 3D using micro-Computed Tomography to identify ROIs for subsequent sequential 2D analysis using well-established technologies such as Atomic Force Microscopy and Scanning Electron Microscopy, and recent imaging approaches in biomedical settings, such as micro-X-Ray Fluorescence Spectroscopy. By combining these four modalities, multiscale information on the morphology, topography, mechanical stiffness (Young's modulus), and calcium, zinc and phosphorus concentrations of the bone was collected. Based on the CMI pipeline, we characterized and compared the jawbones of a previously published clinically relevant rat model of BIS-related osteonecrosis of the jawbone (BRONJ) before and after treatment with BISs, PBMT and ESWT. While we did not find that physical therapies altered the mechanical and elemental jawbone parameters with significance (probably due to the small sample size of only up to 5 samples per group), both ESWT and PBMT reduced pore thicknesses and bone-to-enamel distances significantly compared to the controls. Although focused on BIS-treated jawbones, the established CMI platform can be beneficial in the study of bone-related diseases in general (such as osteoarthritis or -porosis) to acquire complementary hallmarks and better characterize disease status and alleviation potentials.
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Affiliation(s)
- Susanne Reier
- Austrian BioImaging/CMI, Vienna BioCenter Core Facilities GmbH (VBCF), Vienna, Austria.
| | | | - Patrick Heimel
- Ludwig Boltzmann Institute for Experimental and Clinical Traumatology in the AUVA Trauma Research Center, Austrian BioImaging/CMI, Vienna, Austria and Core Facility Hard Tissue and Biomaterial Research, Karl Donath Laboratory, University Clinic of Dentistry, Medical University Vienna, Vienna, Austria
| | - Nikolaus Frischauf
- University of Applied Sciences Upper Austria, Austrian BioImaging/CMI, Vienna, Austria
| | - Daria Meusburger
- Austrian BioImaging/CMI, Vienna BioCenter Core Facilities GmbH (VBCF), Vienna, Austria.
| | - Thomas Heuser
- Austrian BioImaging/CMI, Vienna BioCenter Core Facilities GmbH (VBCF), Vienna, Austria.
| | - Nicole Drexler
- Austrian BioImaging/CMI, Vienna BioCenter Core Facilities GmbH (VBCF), Vienna, Austria.
| | - Ágnes Janovszky
- Department of Oral and Maxillofacial Surgery, University of Szeged, Hungary
| | | | - Paul Slezak
- Ludwig Boltzmann Institute for Experimental and Clinical Traumatology in the AUVA Trauma Research Center, Austrian BioImaging/CMI, Vienna, Austria
| | - Birgit Plochberger
- University of Applied Sciences Upper Austria, Austrian BioImaging/CMI, Vienna, Austria
| | - Peter Dungel
- Ludwig Boltzmann Institute for Experimental and Clinical Traumatology in the AUVA Trauma Research Center, Austrian BioImaging/CMI, Vienna, Austria
| | - Andrea Szabó
- Institute of Surgical Research, Faculty of Medicine, University of Szeged, Hungary
| | - Andreas Walter
- Austrian BioImaging/CMI, Vienna BioCenter Core Facilities GmbH (VBCF), Vienna, Austria.
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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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