The role of Leucocyte-rich and platelet-rich fibrin (L-PRF) in the treatment of the medication-related osteonecrosis of the jaws (MRONJ)

Use of Leukocyte- and Platelet-Rich Fibrin to Prevent Osteonecrosis of the Jaws Associated with the Use of Bisphosphonate Therapy: A Case Series

Medication-related osteonecrosis of the jaws (MRONJ) consists of an area of exposed intraoral or extraoral bone that affects patients with a history of use of antiresorptive and antiangiogenic medications, and who have not undergone head and neck radiotherapy. Leukocyte- and platelet-rich fibrin (L-PRF) is an autologous material of great potential, used as an adjuvant in surgical treatments, especially where healing is compromised. The aim of this article is to report three cases of the use of L-PRF in the prevention of MRONJ in three female Caucasian under bisphosphonates therapy. Patient 1, 86 years old, with osteoporosis, complained of intense pain in tooth 33, which presented edema and periapical lesion and association with MRONJ. Patient 2, 61 years old, undergoing treatment for bone metastases due to breast cancer, reported pain symptoms in tooth 47, as well as suppuration in the dental element, grade I mobility, pain on periapical palpation and radiographically an endoperiodontal lesion was evidenced. Patient 3, 56 years old, also undergoing treatment for breast cancer, presented with severe pain in tooth 36. On clinical examination, she presented pain, mobility and suppuration, and radiographs indicated a furcation lesion on tooth 36. The treatment option in the three cases was the extraction of the affected teeth and the use of L-PRF to promote healing. All patients present a favorable outcome in follow-up. The use of L-PRF can be an adjuvant in the prevention of MRONJ; however, further studies are needed to prove its effectiveness.

Risk of medication-related osteonecrosis of the jaw after dental extractions in patients receiving antiresorptive agents - A retrospective study of 240 patients

This study investigated the incidence, risk factors, and outcome of medication-related osteonecrosis of the jaw after dental extractions in patients receiving antiresorptive agents for osteoporosis or bone metastases. 240 patients with a median drug exposure of 43 months were retrospectively studied. The incidence of MRONJ after dental extraction in the osteoporosis cohort was 2.7 % per person-year (95 % CI 1.6-4.6 %) (n = 13/126), and for the bone metastases cohort 26.4 % per person-year (95 % CI 20.4-34.2 %) (n = 58/114). 92 % of MRONJ cases were stage 1. Dental infection as the reason for extraction increased the osteonecrosis risk in the osteoporosis (OR 22.77; 95 % CI 2.85-181.62; p = 0.003) and bone metastases cohorts (OR 2.72; 95 % CI 1.28-5.81; p = 0.010). Using leukocyte and platelet-rich fibrin reduced this risk by 84 % (p = 0.003), as did antibiotics use by 86-93 % (p = 0.013). Within the bone metastases cohort, an interval since last administration of at least 3 months reduced risk of MRONJ (OR 0.83; 95 % CI 0.72-0.97; p = 0.018). Mucosal healing occurred in 11/13 patients (84.6 %; 95 % CI 54.5-98.1 %) with osteoporosis and 31/58 patients (53.4 %; 95 % CI 40.0-66.7 %) with bone metastases. In conclusion, though the MRONJ risk in this selected population taking antiresorptive agents and presenting to the Oral Maxillofacial Surgery clinic for a dental extraction is considerable and higher in those with dental infections, preventive measures such as antibiotics and use of LRPF membranes may significantly reduce that risk.

[Therapeutic alternatives for drug-associated maxillary osteonecrosis (MRONJ): reports of two clinical cases and review of the literature]

Introduction

Drug-associated Maxillary Osteonecrosis is one of the most relevant adverse effects in treatment with antiresorptive drugs such as bisphosphonates and denosumab. Oncological conditions such as multiple myeloma, breast cancer, prostate, and bone-metabolic disorders such as osteoporosis lead the indications for these antiresorptive therapies. Treatment is complex because the disease is often refractory. Pharmacological, conservative and surgical treatments are described.

Objective

The aim of this study is to report two clinical cases of MRONJ treated with two different therapeutic protocols and the analysis of the available literature on these aspects based on the clinical classification defined by the American Association of Oral and Maxillofacial Surgeons (AAOMS).

Conclusion

Patients who develop clinical signs of great morbidity associated with MRONJ, may see their quality of life conditioned and suffer a worsening of their underlying pathology. MRONJ treatment is conditioned by the stage of the disease, its success depends on interdisciplinary management and strict medical and dental clinical follow-up, as well as rigorous monitoring to prevent or detect future recurrences early.

Retrospective Analysis of Treatment Outcomes of Maxillary Sinusitis Associated with Medication-Related Osteonecrosis of the Jaw

Although maxillary sinusitis often occurs in patients with medication-related osteonecrosis of the jaw (MRONJ) of the upper jaw, there have been few reports on the treatment and outcomes for maxillary sinusitis associated with maxillary MRONJ. This study aimed to retrospectively investigate the treatment outcomes of maxillary sinusitis in patients with MRONJ of the upper jaw. There were 34 patients diagnosed with maxillary MRONJ and sinusitis by preoperative computed tomography who underwent surgery in our institution between January 2011 and December 2019. Age, sex, primary disease, stage of MRONJ, class and administration period of an antiresorptive agent, corticosteroid administration, preoperative leukocyte count and serum albumin level, periosteal reaction, sinusitis grade, maxillary sinus surgical procedure, and treatment outcomes of MRONJ and sinusitis were examined. There were 7 male and 27 female patients (average age, 74.7 years). Complete healing of MRONJ was obtained in 29 of 34 patients (85.3%). Maxillary sinusitis resolved or improved in 21 patients (61.8%) but did not change or worsen in 13 patients (38.2%). We found that complete resection of necrotic bone with intraoperative irrigation of the maxillary sinus may provide good treatment outcomes for maxillary sinusitis associated with MRONJ, although our findings were not statistically significant owing to the small number of patients.

Mesenchymal Stem Cells Based Treatment in Dental Medicine: A Narrative Review

Application of mesenchymal stem cells (MSC) in regenerative therapeutic procedures is becoming an increasingly important topic in medicine. Since the first isolation of dental tissue-derived MSC, there has been an intense investigation on the characteristics and potentials of these cells in regenerative dentistry. Their multidifferentiation potential, self-renewal capacity, and easy accessibility give them a key role in stem cell-based therapy. So far, several different dental stem cell types have been discovered and their potential usage is found in most of the major dental medicine branches. These cells are also researched in multiple fields of medicine for the treatment of degenerative and inflammatory diseases. In this review, we summarized dental MSC sources and analyzed their treatment modalities with particular emphasis on temporomandibular joint osteoarthritis (TMJ OA).

Non-Interventional Prospective Observational Study of Platelet Rich Fibrin as a Therapy Adjunctive in Patients with Medication-Related Osteonecrosis of the Jaw

BACKGROUND

Medication-related osteonecrosis (MRONJ) of the jaw is a severe and feared side effect of antiresorptive therapy in the oncological setting. With growing evidence that impaired angiogenesis may represent a key factor in pathogenesis, the aim of this study was to evaluate an autologous platelet concentrate as a possible additive in surgical therapy to optimize vascularization and, subsequently, resolution rates.

MATERIAL AND METHODS

A non-interventional, prospective, multicenter study was conducted, and all patients with stage I-III MRONJ, undergoing antiresorptive therapy for an oncological indication, were included. The necrosis was treated surgically without (study arm A) or with (arm B) the addition of an autologous platelet concentrate (platelet-rich fibrin, PRF).

RESULTS

After 5, 14, and 42 days postoperative, wound healing (primary outcome: mucosal integrity) as well as downstaging, pain perception, and oral health-related quality of life (secondary outcome) were assessed via clinical evaluation. Among the 52 patients included, primarily with MRONJ stage I and II, the use of PRF as an additive in surgical therapy did not display a significant advantage for wound healing (p = 0.302), downstaging (p = 0.9), pain reduction (p = 0.169), or quality of life (p = 0.9).

SUMMARY

In conclusion, PRF as an adjunct did not significantly optimize wound healing. Further, no significant changes in terms of downstaging, pain sensation, and oral health-related quality of life were found.

Promising results of surgical management of advanced medication related osteonecrosis of the jaws using adjunctive leukocyte and platelet rich fibrin

Background

Leukocyte- and platelet-rich fibrin (L-PRF) is an autologous matrix scaffold which regulates inflammation by stimulating cytokines and growth factors that are involved in the immune response. L-PRF is suggested as a viable adjunctive method to surgical interventions due to its advantages on tissue healing. This study aims to retrospectively evaluate the adjunctive role of L-PRF in surgically treated medication-related osteonecrosis of the jaws (MRONJ) patients.

Methods

Between January 2012 and December 2020, patients with AAOMS stage II and III MRONJ lesions, who were treated surgically with adjunctive use of L-PRF in the authors’ institution were enrolled. Surgical interventions consisted of either marginal resection or sequestrectomy with peripheral ostectomy (SPO) or curettage and L-PRF application. Medical records of these patients were retrospectively reviewed and healing was assessed according to certain parameters including mucosal closure and presence of infection, exposed bone, fistula or radiologic markers of disease progression for a minimum of 12 months.

Results

Thirteen patients (7 women and 6 men) with an average age of 72.4 years (± 10.61, range 54–84) were included in the study, nine of whom had AAOMS stage III and four stage II MRONJ. Three patients had a marginal resection, nine patients had sequestrectomy with peripheral ostectomy (SPO) and one patient underwent a curettage procedure. All marginal resection and six SPO patients showed complete healing while four patients, who had SPO or curettage experienced incomplete healing. Mean follow up was 20.1 ± 18.29 months.

Conclusion

The use of L-PRF may be a favorable adjunctive option in the treatment of MRONJ owing to its favorable effects on tissue repair, ease of application, minimally invasive and cost-effective character and autogenous nature.

Trial registration Retrospectively registered.

Epi-Mucosa Fixation and Autologous Platelet-Rich Fibrin Treatment in Medication-Related Osteonecrosis of the Jaw

Medication-related osteonecrosis of the jaw (MRONJ) frequently affects patients after treatments with bisphosphonates or denosumab, especially with high doses in patients with bone osteoporosis, neoplastic metastases, or possibly anti-angiogenic treatment for cancer. The aim of this article was to show a new treatment planning for stage 2 and stage 3 MRONJ using platelet-rich fibrin (PRF) at the surgical field to enhance healing in association with a new epi-mucosal fixation technique to prevent or treat mandibular fracture. Two cases were treated by epi-mucosa fixation and autologous PRF use for prevention of mandibular fracture risks related to necrotic bone resection or a narrow fracture reduction. Both cases were successfully treated by this new technique of epi-mucosa fixation combined with autologous PRF and achieved good results and good quality of life. Ability to wear prosthesis with good mastication in the absence of side effect such as infection, plate and screw mobilization, pain, and other disabilities or extension of necrosis was reported. After surgical removal of necrotic bone, no infection was detected without any extension of the necrosis.

Adjuvant therapies for MRONJ: A systematic review

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.

Evidence-Based Clinical Efficacy of Leukocyte and Platelet-Rich Fibrin in Maxillary Sinus Floor Lift, Graft and Surgical Augmentation Procedures

Bone augmentation techniques have increasingly been indicated for re-creating adequate bone height and volume suitable for dental implant sites. This is particularly applicable in the severely atrophic posterior maxilla where sinus perforation (ruptured Schneiderian membrane) is a very common complication and sinus floor elevation or lift is frequently considered a standard procedure. The augmentation of the maxillary sinus can be performed with or without grafting biomaterials. Herein, numerous biomaterials and bone substitutes have been proposed, primarily to sustain the lifted space. In addition, cytokines and growth factors have been used to stimulate angiogenesis, enhance bone formation as well as improve healing and recovery period, either as the sole filling material or in combination with bone substitute materials. Within such, is the family of autologous blood extracts, so-called platelet concentrates, which are simply the "product" resulting from the simple centrifugation of collected whole blood samples of the patient, immediately pre-surgery. Platelet-Rich Fibrin (PRF), a sub-family of platelet concentrates, is a three-dimensional (3-D) autogenous biomaterial obtained, without including anti-coagulants, bovine thrombin, additives, or any gelifying agents during the centrifugation process. Today, it is safe to say that, in implant dentistry and oral and maxillofacial surgery, PRFs (particularly, the pure platelet-rich fibrin or P-PRF and leukocyte and platelet-rich fibrin or L-PRF sub-classes) are receiving the most attention, essentially due to their simplicity, rapidness, user-friendliness/malleability, and cost-effectiveness. Whether used as the sole "bioactive" filling/additive material or combined with bone substitutes, the revolutionary second-generation PRFs have been very often associated with promising clinical results. Hence, this review aims to provide a 10-years update on the clinical effectiveness of L-PRF when applied/used as the "sole" biomaterial in maxillary sinus augmentation procedures. An electronic search using specific keywords for L-PRF and maxillary sinus augmentation was conducted in three main databases (PubMed-MEDLINE database, Google Scholar and Cochrane library) for the period between January 2009-February 2020. The quest yielded a total of 468 articles. Based on the pre-established strict inclusion/exclusion criteria, only seven articles were deemed eligible and included in the analysis. Surprisingly, of the 5 studies which used de-proteinized bovine bone mineral (DBBM) in combination with L-PRF, 60% acclaimed no significant effects and only 40% declared positive effects. Of the two articles which had used allogenous bone graft, 50% declared no significant effects and 50% acclaimed positive effects. Only one study had used L-PRF as the sole grafting material and reported a positive effect. Likewise, positive effects were reported in one other study using L-PRF in combination with a collagen membrane. Due to the heterogeneity of the included studies, this review is limited by the inability to perform a proper systematic meta-analysis. Overall, most of the published studies reported impressive results of L-PRF application as a grafting material (sole or adjuvant) in maxillary sinus augmentation and dental implant restorative procedures. Yet, distinct technical processing for L-PRF preparation was noted. Hence, studies should be approached with caution. Here in, in sinus lift and treatment of Schneider membrane, the formation of mature bone remains inconclusive. More studies are eagerly awaited in order to prove the beneficial or detrimental effects of PRFs, in general and L-PRFs, in specific; especially in their tissue regenerative potential pertaining to the promotion of angiogenesis, enhancing of cell proliferation, stimulation of cell migration and autocrine/paracrine secretion of growth factors, as well as to reach a consensus or a conclusive and distinct determination of the effect of leukocytes (and their inclusion) on inflammation or edema and pain; a call for standardization in PRFs and L-PRFs composition reporting and regimenting the preparation protocols.

Development of a Multifunctional Bioerodible Nanocomposite Containing Metronidazole and Curcumin to Apply on L-PRF Clot to Promote Tissue Regeneration in Dentistry

Teeth extractions are often followed by alveolar bone reabsorption, although an adequate level of bone is required for reliable rehabilitations by dental implants. Leukocyte and platelet-rich fibrin (L-PRF) has been widely applied in regenerative procedures and with antibiotic and antioxidant agents could play an essential role in hard and soft tissue healing. In this work, a nanocomposite (Sponge-C-MTR) consisting of a hyaluronate-based sponge loaded with metronidazole (MTR) and nanostructured lipid carriers containing curcumin (CUR-NLC) was designed to be wrapped in the L-PRF™ membrane in the post-extraction sockets and characterized. CUR-NLCs, obtained by homogenization followed by high-frequency sonication of the lipid mixture, showed loading capacity (5% w/w), drug recovery (95% w/w), spherical shape with an average particle size of 112.0 nm, and Zeta potential of -24 mV. Sponge-C-MTR was obtained by entrapping CUR-NLC in a hydrophilic matrix by a freeze-drying process, and physico-chemical and cytocompatibility properties were evaluated. Moreover, the aptitude of CUR and MTR to the penetrate and/or permeate both L-PRF™ and porcine buccal tissue was assessed, highlighting MTR penetration and CUR accumulation promoted by the system. The results positively support the action of nanocomposite in dental tissues regeneration when applied together with the L-PRF™.

Use of Platelet Rich Fibrin (PRF)-Based Autologous Membranes for Tooth Extraction in Patients under Bisphosphonate Therapy: A Case Report

Tooth extraction in patients treated with bisphosphonates (BPs) for osteoporosis or cancer exposes the patient to the risk of osteonecrosis of the jaw. An autologous membrane using platelet-rich fibrin (PRF) is an innovative technique to promote wound healing, which allows obtaining a hermetic closure of the post-extractive surgical site without the need of mucoperiosteal flaps or periosteal releasing incisions. Here, we report the case of a 70-year-old woman, in therapy with alendronate for 12 years, requiring the upper right premolar extraction because of a crown fracture. After the tooth extraction performed under antiseptic and antibiotic coverage, the PRF autologous membrane was placed on the surgical wound to close completely the post-extraction site. Follow-up visits were carried out after one, two, four weeks and two months from the intervention. The complete re-epithelization of the wound was observed without signs of infection. The use of PRF for the closure of post-extraction sockets in patients taking BPs appears to be a promising alternative to the more invasive surgical procedures. Future clinical trials will be pivotal in elucidating the effectiveness of PRF to prevent BP-related osteonecrosis after tooth extraction.