Radiographic findings of bisphosphonate-related osteonecrosis of the jaws: Comparison with cone-beam computed tomography and panoramic radiography

The Role of Cone Beam Computed Tomography (CBCT) in the Diagnosis and Clinical Management of Medication-Related Osteonecrosis of the Jaw (MRONJ)

Medication-related osteonecrosis of the jaw (MRONJ) is a debilitating condition associated with antiresorptive and antiangiogenic medications that are frequently used in treating osteoporosis and cancers. With the ability to produce high-resolution images with a lower radiation dose, cone beam computed tomography (CBCT) is an emerging technology in maxillofacial imaging that offers several advantages in evaluating MRONJ. This review aims to summarise the radiological features of MRONJ as observed via CBCT and highlight its advantages over two-dimensional plain films in assessing MRONJ. CBCT has the capability to detect early MRONJ lesions, characterise the extent and nature of lesions, distinguish MRONJ from other osseous pathologies, and assist in treatment planning. By leveraging the advantages of CBCT, clinicians can enhance their understanding of MRONJ, improve decision making, and ultimately optimize patient care.

Diagnostic accuracy comparing OPT and CBCT in the detection of non-vital bone changes before tooth extractions in patients with antiresorptive intake

OBJECTIVES

To compare the diagnostic accuracy in detecting early non-vital bone changes between orthopantomography (OPT) and cone-beam computed tomography (CBCT) in correlation with histopathological findings before tooth extractions in patients with antiresorptive (AR) intake.

SUBJECTS

Patients with an indication tooth extraction who had received OPT and CBCT preoperatively while or after undergoing AR treatment were prospectively enrolled over a 24-month period in the progesterone in spontaneous miscarriage (PRISM) trial. Imaging studies were randomly analyzed by three examiners for early non-vital bone changes using specific predefined characteristics and a 5-level scale (1 definite absence of criteria to 5 definite presence of criteria). Sensitivity and specificity values were calculated in correlation with the histopathologically evaluated bone samples at the time point of tooth extraction.

RESULTS

One hundred thirty patients with 237 treated extraction sites met the inclusion criteria. For all images evaluated by all examiners, CBCT (430/492; 87.4%; receiver operating characteristic [ROC]: area under the curve [AUC] = 0.88; p < 0.001) was more likely to detect histopathologically confirmed non-vital bone than the OPT (132/492; 26.8%; ROC: AUC = 0.562; p = 0.115).

CONCLUSIONS

In the detection of non-vital bone changes, CBCT is superior to OPT in both sensitivity and specificity. Specific imaging characteristics allow for the prediction of early non-vital bone changes already at the time before tooth extractions.

Do various imaging modalities provide potential early detection and diagnosis of medication-related osteonecrosis of the jaw? A review

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.

Use and Evaluation of a Computer-Assisted Examination Method for the Diagnosis and Analysis of Medication-Related Osteonecrosis of the Jaw

The aim of the present study was to analyze the size of the preoperatively calculated defect volume of MRONJ patients (medication-related osteonecrosis of the jaw) and to develop a computer-aided tool based on techniques of AI (artificial intelligence) that facilitates diagnostics of MRONJ. For this purpose, on the basis of 3D (three-dimensional) data sets of 175 MRONJ patients, the outline of the necrosis was marked with the software iPlan 3.0.5 (BrainLAB AG) thus determining the respective volume. The correlation of this volume with other 31 collected parameters was analyzed retrospectively. There was a significant correlation between the defect volume on the one hand, and the MRONJ stage, the number of performed operations, and the therapy invasiveness on the other hand. Furthermore, it could be shown that in one third of the cases no defects could be recognized in the 2D imaging by panoramic radiograph,  while in the 3D data sets defects already had been demarcated. On the basis of these data, a computer-aided tool based on the principles of AI was developed and validated, which might allow the automated calculation of the 3D defect extension and classification of the MRONJ cases into a ranking system. In conclusion, preparation of a 3D image can be recommended for reliably making the diagnosis "MRONJ." Moreover, knowledge of the exact defect volume serves as a decision-making aid with regard to the choice of therapy, ensures intraoperative certitude, and allows an assessment of the prognosis.

Prevalence of radiographic findings on jaws exposed to antiresorptive therapy: a meta-analysis

OBJECTIVES:

Determine the prevalence of radiographic findings (RF) on both jaws among patients receiving antiresorptive bone therapy.

METHODS:

Six electronic databases and partial grey literature were searched. Data was collected based on predetermined criteria. The key features from the included studies were extracted. The MAStARI tool assessed the potential risk of bias (RoB) among the studies, while the GRADE approach determined the level of evidence.

RESULTS:

29 studies were identified and included in the qualitative analysis, totalling 1133 patients. 27 studies had sufficient data to be included in a series of meta-analysis reporting 12 types of radiographic findings, and were split in two groups based on their study design. G1 comprised descriptive observational studies and G2 analytical cross-sectional studies. Two studies presented a high RoB, 16 had a moderate RoB, and 11 had low RoB. The overall level of evidence identified was very low. The most frequent RF were mixed lytic-sclerotic areas (73.88%), followed by osteolytic changes (66.18%), osteosclerosis (65.75%), cortical bone erosion (50.83%), persisting alveolar socket (45.77%), periodontal ligament (PDL) widening (44.69%), and inferior alveolar canal (IAC) involvement (43.40%). Less frequent, but equally important, were the periosteal reaction (34.27%), lamina dura thickening (32.97%), sequestrum (29.94%), pathologic fracture (20.90%), and density confluence of cortical and cancellous bone (16.61%). 20 patients reported no signs.

CONCLUSIONS:

RF prevalence was high and mainly included mixed lytic-sclerotic areas, osteolysis, osteosclerosis, cortical bone erosion, persisting alveolar socket, PDL-widening, IAC-involvement. Due to the very low level of evidence (GRADE) caution should be exercised when considering these findings.

CT imaging features of antiresorptive agent-related osteonecrosis of the jaw/medication-related osteonecrosis of the jaw

OBJECTIVES

Antiresorptive agent-related osteonecrosis of the jaw (ARONJ)/medication-related osteonecrosis of the jaw (MRONJ) include both bisphosphonate-related osteonecrosis of jaw (BRONJ) and denosumab-related osteonecrosis of jaw (DRONJ). The purpose of this study is to study radiological characteristics of ARONJ/MRONJ. These imaging features may serve as one useful aid for assessing ARONJ/MRONJ.

METHODS

CT scans of 74 Japanese patients, who were clinically diagnosed by inclusion criteria of ARONJ/MRONJ, obtained between April 1, 2011 and September 30, 2016, were evaluated. We investigated the CT imaging features of ARONJ/MRONJ, and clarified radiological differentiation between BRONJ and DRONJ, BRONJ due to oral bisphosphonate administration and due to intravenous bisphosphonate administration, BRONJ with respective kinds of medication, BRONJ with long-term administration and short-term administration, BRONJ with each clinical staging respectively. Fisher's exact test, χ² test, Student's t-test and analysis of variance were performed in the statistical analyses.

RESULTS

Unilateral maxillary sinusitis was detected in all patients with upper ARONJ/MRONJ (100%). DRONJ showed large sequestrum more frequently than BRONJ (3/4, 75 vs 3/35, 8.6%, p < 0.05). DRONJ showed periosteal reaction more frequently than BRONJ (4/10, 40 vs 7/65, 10.1%, p < 0.05). Patients of BRONJ resulting from intravenous bisphosphonate administration showed larger and more frequent buccolingual cortical bone perforations than BRONJ resulting from oral bisphosphonate administration (7/8, 87.5 vs 11/30, 36.7%, p < 0.05). There was no significant correlation between CT findings and respective kinds of medication, long/short-term administration, clinical stages of BRONJ.

CONCLUSIONS

ARONJ/MRONJ has characteristic CT image findings which could be useful for its assessment.