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Gera I, Szücs N. [The recombinant human parathyroid hormone, teriparatide as an alternative remedy for the medication-related osteonecrosis of the jaw]. Orv Hetil 2023; 164:1406-1415. [PMID: 37695713 DOI: 10.1556/650.2023.32861] [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: 06/06/2023] [Accepted: 06/30/2023] [Indexed: 09/13/2023]
Abstract
In developed countries, osteoporosis is one of the most common debilitating conditions in the population over the age of 50. Unfortunately, the pathomechanism of the disease is still not fully understood. Nowadays, the administration of antiresorptive drugs blocking osteoclastic activity is the most commonly used medication to slow down the speed of the bone loss. One of the uncommon side effects of such drugs is the medication-related osteonecrosis of the jaw (MRONJ). Recently, a number of alternative therapeutic approaches has been tested and published, amongst them the recombinant human parathyroid hormone (rhPTH, teriparatide) use, which is turning into a promising treatment modality. According to certain meta-analyses, its pharmacological effect on increasing bone mineral density and controlling pathological vertebral fractures is superior to antiresorptive drugs; however, the so-called "off-label" application of teriparatide remains controversial. As intermittent administration of teriparatide stimulates bone formation, several animal and clinical studies indicated that systemic application of teriparatide shortened fracture healing time and improved quality of the callus and the newly formed bone. Furthermore, recently several clinical studies showed the beneficial effect of the intermittent rhPTH administration in the management of MRONJ. This article reviews the history of the anabolic effect of the low-dose rhPTH discovery, provides evidence-based data from animal and human studies, summarizes its biological mechanisms and the clinical benefits of the anabolic therapy and also their possible role in the management of MRONJ. The majority of the clinical data indicates that, in the case of therapy-resistant osteonecrosis, it may be worthwhile to apply short-term intermittent teriparatide therapy. Notwithstanding, more randomized clinical trials are necessary in order to confirm the efficacy and the safety of the use of teriparatide in the treatment of MRONJ. Orv Hetil. 2023; 164(36): 1406-1415.
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Affiliation(s)
- István Gera
- 1 Semmelweis Egyetem, Fogorvostudományi Kar, Parodontológiai Klinika Budapest, Szentkirályi u. 47., 1088 Magyarország
| | - Nikolette Szücs
- 2 Semmelweis Egyetem, Általános Orvostudományi Kar, Belgyógyászati és Onkológiai Klinika Budapest Magyarország
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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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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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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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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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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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Cavalcante RC, Tomasetti G. Pentoxifylline and tocopherol protocol to treat medication-related osteonecrosis of the jaw: A systematic literature review. J Craniomaxillofac Surg 2020; 48:1080-1086. [DOI: 10.1016/j.jcms.2020.09.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Revised: 06/24/2020] [Accepted: 09/12/2020] [Indexed: 10/23/2022] Open
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Anabtawi M, Tweedale H, Mahmood H. The role, efficacy and outcome measures for teriparatide use in the management of medication-related osteonecrosis of the jaw. Int J Oral Maxillofac Surg 2020; 50:501-510. [PMID: 32800674 DOI: 10.1016/j.ijom.2020.07.021] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Revised: 05/14/2020] [Accepted: 07/21/2020] [Indexed: 10/23/2022]
Abstract
Medication-related osteonecrosis of the jaw (MRONJ) is a complex disease which can be associated with multiple morbidities and is challenging to treat. This review evaluates the literature on the role and efficacy of teriparatide (TPTD) as a treatment for MRONJ. The clinical, radiological, histopathological and serological parameters used to assess treatment response have been described. Electronic databases were searched to retrieve articles (April 2005 and April 2020) based on strict inclusion criteria. Seventeen articles were included in this review. Of the 91 patients treated; only six received TPTD as a standalone treatment. There were significant variations in defining treatment outcomes and measuring treatment response. The longest follow-up period was 26 months, and 12 studies failed to report follow-up. The overall quality of evidence is weak with potential for a high risk of bias, making it difficult to determine the efficacy of TPTD and its long-term effects. However, TPTD may play a role in the treatment of intractable MRONJ in osteoporotic patients or those unfit for surgery. Therefore, randomized clinical trials on larger patient cohorts with long-term follow-up is required to confirm efficacy, safety and inform treatment indications for TPTD in the treatment of MRONJ.
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Affiliation(s)
- M Anabtawi
- Department of Oral and Maxillofacial Surgery, Rotherham General Hospital, Rotherham, UK.
| | - H Tweedale
- Department of Oral and Maxillofacial Surgery, Charles Clifford Dental Hospital, Sheffield, UK
| | - H Mahmood
- Academic Unit of Oral & Maxillofacial Surgery, School of Clinical Dentistry, University of Sheffield, Sheffield, UK
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Endo Y, Funayama H, Yamaguchi K, Monma Y, Yu Z, Deng X, Oizumi T, Shikama Y, Tanaka Y, Okada S, Kim S, Kiyama T, Bando K, Shima K, Suzuki H, Takahashi T. [Basic Studies on the Mechanism, Prevention, and Treatment of Osteonecrosis of the Jaw Induced by Bisphosphonates]. YAKUGAKU ZASSHI 2020; 140:63-79. [PMID: 31902887 DOI: 10.1248/yakushi.19-00125] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Since the first report in 2003, bisphosphonate-related osteonecrosis of the jaw (BRONJ) has been increasing, without effective clinical strategies. Osteoporosis is common in elderly women, and bisphosphonates (BPs) are typical and widely used anti-osteoporotic or anti-bone-resorptive drugs. BRONJ is now a serious concern in dentistry. As BPs are pyrophosphate analogues and bind strongly to bone hydroxyapatite, and the P-C-P structure of BPs is non-hydrolysable, they accumulate in bones upon repeated administration. During bone-resorption, BPs are taken into osteoclasts and exhibit cytotoxicity, producing a long-lasting anti-bone-resorptive effect. BPs are divided into nitrogen-containing BPs (N-BPs) and non-nitrogen-containing BPs (non-N-BPs). N-BPs have far stronger anti-bone-resorptive effects than non-N-BPs, and BRONJ is caused by N-BPs. Our murine experiments have revealed the following. N-BPs, but not non-N-BPs, exhibit direct and potent inflammatory/necrotic effects on soft-tissues. These effects are augmented by lipopolysaccharide (the inflammatory component of bacterial cell-walls) and the accumulation of N-BPs in jawbones is augmented by inflammation. N-BPs are taken into soft-tissue cells via phosphate-transporters, while the non-N-BPs etidronate and clodronate inhibit this transportation. Etidronate, but not clodronate, has the effect of expelling N-BPs that have accumulated in bones. Moreover, etidronate and clodronate each have an analgesic effect, while clodronate has an anti-inflammatory effect via inhibition of phosphate-transporters. These findings suggest that BRONJ may be induced by phosphate-transporter-mediated and infection-promoted mechanisms, and that etidronate and clodronate may be useful for preventing and treating BRONJ. Our clinical trials support etidronate being useful for treating BRONJ, although additional clinical trials of etidronate and clodronate are needed.
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Affiliation(s)
- Yasuo Endo
- Divisions of Pharmacology, Graduate School of Dentistry, Tohoku University.,Divisions of Molecular Regulation, Graduate School of Dentistry, Tohoku University.,Divisions of Oral and Maxillofacial Surgery, Graduate School of Dentistry, Tohoku University
| | - Hiromi Funayama
- Divisions of Pediatric Dentistry, Graduate School of Dentistry, Tohoku University.,Department of Pediatric Dentistry, Tsurumi University School of Dental Medicine
| | - Kouji Yamaguchi
- Divisions of Oral and Maxillofacial Surgery, Graduate School of Dentistry, Tohoku University
| | - Yuko Monma
- Divisions of Pediatric Dentistry, Graduate School of Dentistry, Tohoku University
| | - Zhiqian Yu
- Divisions of Oral Diagnosis, Graduate School of Dentistry, Tohoku University
| | - Xue Deng
- Divisions of Oral Diagnosis, Graduate School of Dentistry, Tohoku University
| | - Takefumi Oizumi
- Divisions of Oral and Maxillofacial Surgery, Graduate School of Dentistry, Tohoku University
| | - Yosuke Shikama
- Divisions of Periodontology and Endodontology, Graduate School of Dentistry, Tohoku University
| | - Yukinori Tanaka
- Divisions of Molecular Regulation, Graduate School of Dentistry, Tohoku University
| | - Satoshi Okada
- Divisions of Oral and Maxillofacial Surgery, Graduate School of Dentistry, Tohoku University
| | - Siyoung Kim
- Divisions of Orthodontics and Dentofacial Orthopedics, Graduate School of Dentistry, Tohoku University
| | - Tomomi Kiyama
- Divisions of Advanced Prosthetic Dentistry, Graduate School of Dentistry, Tohoku University
| | - Kanan Bando
- Divisions of Orthodontics and Dentofacial Orthopedics, Graduate School of Dentistry, Tohoku University
| | - Kazuhiro Shima
- Divisions of Orthodontics and Dentofacial Orthopedics, Graduate School of Dentistry, Tohoku University
| | - Hikari Suzuki
- Divisions of Oral and Maxillofacial Surgery, Graduate School of Dentistry, Tohoku University
| | - Tetsu Takahashi
- Divisions of Oral and Maxillofacial Surgery, Graduate School of Dentistry, Tohoku University
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Heifetz-Li JJ, Abdelsamie S, Campbell CB, Roth S, Fielding AF, Mulligan JP. Systematic review of the use of pentoxifylline and tocopherol for the treatment of medication-related osteonecrosis of the jaw. Oral Surg Oral Med Oral Pathol Oral Radiol 2019; 128:491-497.e2. [DOI: 10.1016/j.oooo.2019.08.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2019] [Revised: 07/27/2019] [Accepted: 08/03/2019] [Indexed: 01/30/2023]
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Yarom N, Shapiro CL, Peterson DE, Van Poznak CH, Bohlke K, Ruggiero SL, Migliorati CA, Khan A, Morrison A, Anderson H, Murphy BA, Alston-Johnson D, Mendes RA, Beadle BM, Jensen SB, Saunders DP. Medication-Related Osteonecrosis of the Jaw: MASCC/ISOO/ASCO Clinical Practice Guideline. J Clin Oncol 2019; 37:2270-2290. [PMID: 31329513 DOI: 10.1200/jco.19.01186] [Citation(s) in RCA: 179] [Impact Index Per Article: 35.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE To provide guidance regarding best practices in the prevention and management of medication-related osteonecrosis of the jaw (MRONJ) in patients with cancer. METHODS Multinational Association of Supportive Care in Cancer/International Society of Oral Oncology (MASCC/ISOO) and ASCO convened a multidisciplinary Expert Panel to evaluate the evidence and formulate recommendations. Guideline development involved a systematic review of the literature and a formal consensus process. PubMed and EMBASE were searched for studies of the prevention and management of MRONJ related to bone-modifying agents (BMAs) for oncologic indications published between January 2009 and December 2017. Results from an earlier systematic review (2003 to 2008) were also included. RESULTS The systematic review identified 132 publications, only 10 of which were randomized controlled trials. Recommendations underwent two rounds of consensus voting. RECOMMENDATIONS Currently, MRONJ is defined by (1) current or previous treatment with a BMA or angiogenic inhibitor, (2) exposed bone or bone that can be probed through an intraoral or extraoral fistula in the maxillofacial region and that has persisted for longer than 8 weeks, and (3) no history of radiation therapy to the jaws or metastatic disease to the jaws. In patients who initiate a BMA, preventive care includes comprehensive dental assessments, discussion of modifiable risk factors, and avoidance of elective dentoalveolar surgery (ie, surgery that involves the teeth or contiguous alveolar bone) during BMA treatment. It remains uncertain whether BMAs should be discontinued before dentoalveolar surgery. Staging of MRONJ should be performed by a clinician with experience in the management of MRONJ. Conservative measures comprise the initial approach to MRONJ treatment. Ongoing collaboration among the dentist, dental specialist, and oncologist is essential to optimal patient care.
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Affiliation(s)
- Noam Yarom
- Sheba Medical Center, Tel Hashomer, Ramat Gan, Israel.,Tel Aviv University, Tel Aviv, Israel
| | | | | | | | - Kari Bohlke
- American Society of Clinical Oncology, Alexandria, VA
| | - Salvatore L Ruggiero
- Hofstra North Shore-LIJ School of Medicine, Hempstead, NY.,Stony Brook School of Dental Medicine, Stony Brook, NY.,New York Center for Orthognathic and Maxillofacial Surgery, New York, NY
| | | | - Aliya Khan
- McMaster University, Hamilton, Ontario, Canada
| | - Archie Morrison
- Dalhousie University, Halifax, Nova Scotia, Canada.,Queen Elizabeth II Health Sciences Centre, Halifax, Nova Scotia, Canada
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12
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Pardiñas López S, Iocca O, Khouly I. Three-dimensional bone evaluation after surgical treatment with plasma rich in growth factors of Medication Related Osteonecrosis of the Jaw (MRONJ): A report of 3 cases. Bone Rep 2019; 10:100208. [PMID: 31193239 PMCID: PMC6522655 DOI: 10.1016/j.bonr.2019.100208] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2019] [Revised: 04/22/2019] [Accepted: 05/02/2019] [Indexed: 12/09/2022] Open
Abstract
Introduction Medication Related Osteonecrosis of the Jaw (MRONJ) is an adverse effect of antiresorptive and antiangiogenic agents that consists of progressive bone destruction in the maxillofacial area. The purpose of this study is to analyze the effect on bone volume of a surgical protocol using plasma rich in growth factors (PRGF) for successfully treating MRONJ. Methods Three patients were treated combining surgical debridement with PRGF. Cone bean computed tomography scans were taken prior to surgery and 12 months after to measure bone volume changes. Biopsies were taken for histology analysis during surgery. Results All patients showed a complete soft tissue and bone healing with pain, discomfort, and neural symptoms resolution for a follow up period of 30 months. A total of 12 to 30% of bone volume gain was found at 12 months after surgery. Conclusions PRGF in combination with surgery may be effective in treating MRONJ. Future trials must be performed to confirm these results, including bone volume analysis.
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Affiliation(s)
- Simón Pardiñas López
- Periodontology and Oral Surgery, Clínica Médico Dental Pardiñas, Real 66, 3°, 15003 A Coruña, Spain.,Cell Therapy and Regenerative Medicine Group, Centre for Advanced Scientific Research (CICA) and Biomedical Research Institute of A Coruña (INIBIC) strategic group, Universidade da Coruña (UDC), University Hospital Complex of A Coruña (CHUAC), Galician Health Service (SERGAS); A Coruña, Spain
| | - Oreste Iocca
- Department of Otolaryngology-Head and Neck Surgery, Humanitas Clinical and Research Hospital, Rozzano, Milano, Italy
| | - Ismael Khouly
- Bluestone Center for Clinical Research, 421 First Avenue, 2nd Floor, New York, NY 10010-4086, United States of America.,Department of Oral and Maxillofacial Surgery, New York University College of Dentistry, 421 First Avenue, 2nd Floor, New York, NY 10010-4086, United States of America
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El-Rabbany M, Lam DK, Shah PS, Azarpazhooh A. Surgical Management of Medication-Related Osteonecrosis of the Jaw Is Associated With Improved Disease Resolution: A Retrospective Cohort Study. J Oral Maxillofac Surg 2019; 77:1816-1822. [PMID: 31054989 DOI: 10.1016/j.joms.2019.03.040] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2019] [Revised: 03/25/2019] [Accepted: 03/27/2019] [Indexed: 01/29/2023]
Abstract
PURPOSE Optimal management approaches for medication-related osteonecrosis of the jaw (MRONJ) using either surgical or nonsurgical approaches remain inconclusive. Our objective was to compare the effects of surgical versus nonsurgical therapy on the resolution of MRONJ. METHODS We conducted a retrospective review of eligible patients with a diagnosis of MRONJ at Mount Sinai Hospital, Toronto, Ontario, Canada, who either were seen in the outpatient clinic from January 2014 to December 2016 or received major surgical intervention from January 2011 to December 2016. A multivariate logistic regression was conducted to evaluate the effects of surgical therapy on disease resolution. RESULTS A total of 78 patients were included in this study. Of these, 56 (72%) received surgical therapy. Antiresorptive agents were being taken for the treatment of osteoporosis by 46 patients (82%) in the surgical group compared with 20 nonsurgical patients (91%) (P = .28). The median follow-up period was 15.5 months (interquartile range, 8.0 to 34.3 months) in the surgical group compared with 11.0 months (interquartile range, 8.0 to 20.5 months) in the nonsurgical group (P = .75). Disease resolution occurred in 39 surgical patients (70%) compared with 8 nonsurgical patients (36%). Surgical therapy was associated with disease resolution compared with nonsurgical therapy alone, after adjustment for age, duration of antiresorptive or antiangiogenic therapy, whether the antiresorptive or antiangiogenic agents were used for oncologic purposes, and the stage of MRONJ at initial presentation (adjusted odds ratio, 4.33; 95% confidence interval, 1.28 to 14.60). CONCLUSIONS Surgical therapy compared with nonsurgical therapy was associated with disease resolution in patients with MRONJ. High-quality evidence of the superiority of any specific surgical approach in the treatment of MRONJ is needed.
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Affiliation(s)
- Mohamed El-Rabbany
- Resident and PhD Student in Oral and Maxillofacial Surgery, University of Toronto, Toronto, Ontario, Canada
| | - David K Lam
- Professor and Chair, Department of Oral & Maxillofacial Surgery, Stony Brook School of Dental Medicine; Professor, Department of Surgery, Stony Brook School of Medicine; and Surgeon-Scientist, Stony Brook Cancer Center, Stony Brook, NY
| | - Prakesh S Shah
- Professor, Department of Pediatrics, Mount Sinai Hospital; University of Toronto; and Institute of Health, Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Amir Azarpazhooh
- Associate Professor, Dental Public Health and Endodontics, University of Toronto; and Head, Divisions of Endodontics and Research, Department of Dentistry, Mount Sinai Hospital, Toronto, Ontario, Canada.
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Wang C, Zang H, Zhou D. Bone morphogenetic protein-2 exhibits therapeutic benefits for osteonecrosis of the femoral head through induction of cartilage and bone cells. Exp Ther Med 2018; 15:4298-4308. [PMID: 29849774 PMCID: PMC5962870 DOI: 10.3892/etm.2018.5941] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2017] [Accepted: 10/20/2017] [Indexed: 12/29/2022] Open
Abstract
Osteonecrosis of the femoral head is an orthopedic disease caused by femoral head damage or insufficient blood supply, which leads to the death of bone cells and bone marrow. Osteonecrosis of the femoral head leads to changes in the structure of the femoral head, femoral head collapse and joint dysfunction. Bone morphogenetic protein-2 (BMP-2) exhibits beneficial effects on bone formation, repair and angiogenesis at the femoral head. In the present study, the therapeutic effects of recombinant human BMP-2 containing an Fc fragment (rBMP-2/Fc) were investigated on a steroid induced mouse model of osteonecrosis of the femoral head. Bone cell viability was used to determine the in vitro effects of rBMP-2/Fc. The therapeutic efficacies of rBMP-2/Fc on mice with osteonecrosis of the femoral head were evaluated using clinical arthritis scores. The expression levels of inflammatory factors in the mice were analyzed by reverse transcription-quantitative polymerase chain reaction. Histological analysis was used to evaluate the effects of rBMP-2/Fc on the femoral head. The results revealed that rBMP-2/Fc treatment significantly increased the IL-6, IL-10, vascular endothelial growth factor and macrophage colony-stimulating factor expression levels in synovial cells compared with the control group (P<0.01). Furthermore, it was observed that rBMP-2/Fc significantly improved the viability and growth of synovial cells (P<0.01) through the nuclear factor (NF)-κB signaling pathway. Treatment with rBMP-2/Fc significantly decreased receptor activator of NF-κB ligand expression levels. Furthermore, in vivo experiments demonstrated that rBMP-2/Fc treatment markedly relieved the arthralgia and damage caused by osteonecrosis of the femoral head. In conclusion, rBMP-2/Fc treatment may be beneficial for articular cartilage repair by the upregulation of angiogenesis factors through the down regulation of the NF-κB signaling pathway in mice with osteonecrosis of the femoral head. This preclinical data suggests that rBMP-2/Fc may be a promising novel agent for treatment of osteonecrosis of the femoral head.
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Affiliation(s)
- Chunhui Wang
- Department of Orthopedics, Shandong Provincial Hospital Affiliated to Shandong University, Jinan, Shandong 250021, P.R. China
| | - Huimei Zang
- Department of Cardiovascular Medicine, Shandong University Qilu Hospital Research Center for Cell Therapy, Key Laboratory of Cardiovascular Remodeling and Function, Jinan, Shandong 250012, P.R. China
| | - Dongsheng Zhou
- Department of Orthopedics, Shandong Provincial Hospital Affiliated to Shandong University, Jinan, Shandong 250021, P.R. China
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Eleutherakis-Papaiakovou E, Bamias A. Antiresorptive treatment-associated ONJ. Eur J Cancer Care (Engl) 2017; 26. [PMID: 29063702 DOI: 10.1111/ecc.12787] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/25/2017] [Indexed: 01/22/2023]
Abstract
Osteonecrosis of the jaw (ONJ) is a severe complication of therapy with antiresorptive agents (e.g. bisphosphonates and denosumab), which are used to manage bone metastases from cancer, to reduce the incidence of skeletal-related events. Available data indicate that 0-27, 5% of patients exposed to antiresorptive agents may develop ONJ, depending on the number of infusions and the duration of therapy. Besides antiresorptive therapy, a number of risk factors for osteonecrosis have been identified. Oral surgical procedures, tooth extractions and infection to the jawbones are considered the main risk factors for developing ONJ, when receiving antiresorptive therapy. However, a growing number of patients develop ONJ without apparent risk factors, raising concern for other predisposing factors. Jaw bone necrosis may be irreversible, resulting in a chronic disease with negative impact on the quality of patients' lives. The role of risk reduction strategies like meticulous dental screening and optimal oral hygiene is fundamental for preventing development of ONJ. ONJ is usually treated conservatively to relieve the symptoms and manage jaw bone necrosis. In certain cases, surgical intervention is required. Future research should emphasize individual predisposition to ONJ, more effective preventive measures and more efficient therapeutic procedures.
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Affiliation(s)
- Evangelos Eleutherakis-Papaiakovou
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, Athens, Greece.,Department of Clinical Therapeutics, Alexandra Hospital, Athens, Greece
| | - Aristotelis Bamias
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, Athens, Greece.,Department of Clinical Therapeutics, Alexandra Hospital, Athens, Greece
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Beth‐Tasdogan NH, Mayer B, Hussein H, Zolk O. Interventions for managing medication-related osteonecrosis of the jaw. Cochrane Database Syst Rev 2017; 10:CD012432. [PMID: 28983908 PMCID: PMC6485859 DOI: 10.1002/14651858.cd012432.pub2] [Citation(s) in RCA: 59] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND Medication-related osteonecrosis of the jaw (MRONJ) is a severe adverse reaction experienced by some individuals to certain medicines commonly used in the treatment of cancer and osteoporosis (e.g. bisphosphonates, denosumab and antiangiogenic agents) and involves the progressive destruction of bone in the mandible or maxilla. Depending on the drug, its dosage, and the duration of exposure, the occurrence of this adverse drug reaction may be rare (e.g. following the oral administration of bisphosphonate or denosumab treatments for osteoporosis, or antiangiogenic agent-targeted cancer treatment) or common (e.g. following intravenous bisphosphonate for cancer treatment). MRONJ is associated with significant morbidity, adversely affects quality of life (QoL), and is challenging to treat. OBJECTIVES To assess the effects of interventions versus no treatment, placebo, or an active control for the prophylaxis of MRONJ in people exposed to antiresorptive or antiangiogenic drugs.To assess the effects of non-surgical or surgical interventions (either singly or in combination) versus no treatment, placebo, or an active control for the treatment of people with manifest MRONJ. SEARCH METHODS Cochrane Oral Health's Information Specialist searched the following databases: Cochrane Oral Health's Trials Register (to 23 November 2016), the Cochrane Central Register of Controlled Trials (CENTRAL) (the Cochrane Library, 2016, Issue 10), MEDLINE Ovid (1946 to 23 November 2016), and Embase Ovid (23 May 2016 to 23 November 2016). The US National Institutes of Health Trials Registry (ClinicalTrials.gov) and the World Health Organization International Clinical Trials Registry Platform were searched for ongoing trials. No restrictions were placed on language or publication status when searching the electronic databases; however, the search of Embase was restricted to the last six months due to the Cochrane Embase Project to identify all clinical trials and add them to CENTRAL. SELECTION CRITERIA We included randomised controlled trials (RCTs) comparing one modality of intervention with another for the prevention or treatment of MRONJ. For 'prophylaxis of MRONJ', the primary outcome of interest was the incidence of MRONJ; secondary outcomes were QoL, time-to-event, and rate of complications and side effects of the intervention. For 'treatment of established MRONJ', the primary outcome of interest was healing of MRONJ; secondary outcomes were QoL, recurrence, and rate of complications and side effects of the intervention. DATA COLLECTION AND ANALYSIS Two review authors independently screened the search results, extracted the data, and assessed the risk of bias in the included studies. For dichotomous outcomes, we reported the risk ratio (RR) (or rate ratio) and 95% confidence intervals (CI). MAIN RESULTS We included five RCTs (1218 participants) in the review. Three trials focused on the prophylaxis of MRONJ. Two trials investigated options for the treatment of established MRONJ. The RCTs included only participants treated with bisphosphonates and, thus, did not cover the entire spectrum of medications associated with MRONJ. Prophylaxis of MRONJOne trial compared standard care with regular dental examinations in three-month intervals and preventive treatments (including antibiotics before dental extractions and the use of techniques for wound closure that avoid exposure and contamination of bone) in men with metastatic prostate cancer treated with zoledronic acid. The intervention seemed to lower the risk of MRONJ: RR 0.10; 95% CI 0.02 to 0.39 (253 participants; low-quality evidence). Secondary outcomes were not evaluated.As dentoalveolar surgery is considered a common predisposing event for developing MRONJ, one trial investigated the effect of plasma rich in growth factors (PRGF) for preventing MRONJ in people with cancer undergoing dental extractions. There was insufficient evidence to support or refute a benefit of PRGF on MRONJ incidence when compared with standard treatment (RR 0.08, 95% CI 0.00 to 1.51; 176 participants; very low-quality evidence). Secondary outcomes were not reported. In another trial comparing wound closure by primary intention with wound closure by secondary intention after dental extractions in people treated with oral bisphosphonates (700 participants), no cases of intraoperative complications or postoperative MRONJ were observed. QoL was not investigated. Treatment of MRONJOne trial analysed hyperbaric oxygen (HBO) treatment used in addition to standard care (antiseptic rinses, antibiotics, and surgery) compared with standard care alone. HBO in addition to standard care did not significantly improve healing from MRONJ compared with standard care alone (at last follow-up: RR 1.56; 95% CI 0.77 to 3.18; 46 participants included in the analysis; very low-quality evidence). QoL data were presented qualitatively as intragroup comparisons; hence, an effect estimate of treatment on QoL was not possible. Other secondary outcomes were not reported.The other RCT found no significant difference between autofluorescence- and tetracycline fluorescence-guided sequestrectomy for the surgical treatment of MRONJ at any timepoint (at one-year follow-up: RR 1.05; 95% CI 0.86 to 1.30; 34 participants included in the analysis; very low-quality evidence). Secondary outcomes were not reported. AUTHORS' CONCLUSIONS Prophylaxis of MRONJOne open-label RCT provided some evidence that dental examinations in three-month intervals and preventive treatments may be more effective than standard care for reducing the incidence of MRONJ in individuals taking intravenous bisphosphonates for advanced cancer. We assessed the certainty of the evidence to be low.There is insufficient evidence to either claim or refute a benefit of either of the interventions tested for prophylaxis of MRONJ (i.e. PRGF inserted into the postextraction alveolus during dental extractions, and wound closure by primary or secondary intention after dental extractions). Treatment of MRONJAvailable evidence is insufficient to either claim or refute a benefit for hyperbaric oxygen therapy as an adjunct to conventional therapy. There is also insufficient evidence to draw conclusions about autofluorescence-guided versus tetracycline fluorescence-guided bone surgery.
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Affiliation(s)
- Natalie H Beth‐Tasdogan
- Ulm UniversityInstitute of Pharmacology of Natural Products & Clinical PharmacologyHelmholtzstr. 20UlmGermany89081
| | - Benjamin Mayer
- Ulm UniversityInstitute of Epidemiology and Medical BiometrySchwabstr. 13UlmGermany89075
| | - Heba Hussein
- Faculty of Dentistry, Cairo UniversityDepartment of Oral Medicine, Diagnosis, and PeriodontologyCairoEgypt
| | - Oliver Zolk
- Ulm UniversityInstitute of Pharmacology of Natural Products & Clinical PharmacologyHelmholtzstr. 20UlmGermany89081
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What is the effect of anti-resorptive drugs (ARDs) on the development of medication-related osteonecrosis of the jaw (MRONJ) in osteoporosis patients: A systematic review. J Craniomaxillofac Surg 2017; 45:1493-1502. [DOI: 10.1016/j.jcms.2017.05.028] [Citation(s) in RCA: 61] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2017] [Revised: 05/03/2017] [Accepted: 05/29/2017] [Indexed: 01/12/2023] Open
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El-Rabbany M, Sgro A, Lam DK, Shah PS, Azarpazhooh A. Effectiveness of treatments for medication-related osteonecrosis of the jaw: A systematic review and meta-analysis. J Am Dent Assoc 2017; 148:584-594.e2. [PMID: 28527518 DOI: 10.1016/j.adaj.2017.04.002] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2017] [Revised: 04/01/2017] [Accepted: 04/05/2017] [Indexed: 01/08/2023]
Abstract
BACKGROUND The effectiveness of management strategies used for the treatment of medication-related osteonecrosis of the jaw (MRONJ) remains poorly understood. The authors evaluated systematically the effectiveness of the various treatment modalities used for MRONJ. TYPES OF STUDIES REVIEWED The authors conducted a comprehensive search of MEDLINE, Embase, the Cochrane Library, and Scopus to identify randomized controlled trials, nonrandomized controlled trials, and prospective cohort studies to evaluate comparatively the effectiveness of management strategies for the treatment of MRONJ. The authors conducted the identification of eligible studies in duplicate and synthesized the extracted data by means of a meta-analysis, when feasible. RESULTS The authors found 13 studies with a medium-to-high risk of bias that met the inclusion criteria of this review. The authors found that, compared with medical treatment of local antimicrobials with or without systemic antimicrobials, the study investigators associated surgical treatment with higher odds of complete resolution of the condition (2 studies; 76 participants; unadjusted odds ratio, 3.55; 95% confidence interval, 1.12 to 11.19). The effectiveness of other therapies, such as bisphosphonate drug holidays, teriparatide, and hyperbaric oxygen, was uncertain. CONCLUSIONS AND PRACTICAL IMPLICATIONS On the basis of the results of an unadjusted analysis, the results of the studies that were deemed to be medium to low quality and to have medium-to-low statistical power suggested that there are higher odds of resolving MRONJ with surgical treatment compared with medical treatment. High-quality research is required for conclusive statements to be made regarding treatment strategies for management of MRONJ.
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Oizumi T, Yamaguchi K, Sato K, Takahashi M, Yoshimura G, Otsuru H, Tsuchiya M, Hagiwara Y, Itoi E, Sugawara S, Takahashi T, Endo Y. A Strategy against the Osteonecrosis of the Jaw Associated with Nitrogen-Containing Bisphosphonates (N-BPs): Attempts to Replace N-BPs with the Non-N-BP Etidronate. Biol Pharm Bull 2017; 39:1549-54. [PMID: 27582334 DOI: 10.1248/bpb.b16-00041] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Bisphosphonate (BP)-related osteonecrosis of the jaw (BRONJ) can occur when enhanced bone-resorptive diseases are treated with nitrogen-containing BPs (N-BPs). Having previously found, in mice, that the non-N-BP etidronate can (i) reduce the inflammatory/necrotic effects of N-BPs by inhibiting their intracellular entry and (ii) antagonize the binding of N-BPs to bone hydroxyapatite, we hypothesized that etidronate-replacement therapy (Eti-RT) might be useful for patients with, or at risk of, BRONJ. In the present study we examined this hypothesis. In each of 25 patients receiving N-BP treatment, the N-BP was discontinued when BRONJ was suspected and/or diagnosed. After consultation with the physician-in-charge and with the patient's informed consent, Eti-RT was instituted in one group according to its standard oral prescription. We retrospectively compared this Eti-RT group (11 patients) with a non-Eti-RT group (14 patients). The Eti-RT group (6 oral N-BP patients and 5 intravenous N-BP patients) and the non-Eti-RT group (5 oral N-BP patients and 9 intravenous N-BP patients) were all stage 2-3 BRONJ. Both in oral and intravenous N-BP patients (particularly in the former patients), Eti-RT promoted or tended to promote the separation and removal of sequestra and thereby promoted the recovery of soft-tissues, allowing them to cover the exposed jawbone. These results suggest that Eti-RT may be an effective choice for BRONJ caused by either oral or intravenous N-BPs and for BRONJ prevention, while retaining a level of anti-bone-resorption. Eti-RT may also be effective at preventing BRONJ in N-BP-treated patients at risk of BRONJ. However, prospective trials are still required.
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Affiliation(s)
- Takefumi Oizumi
- Division of Oral and Maxillofacial Surgery, Graduate School of Dentistry, Tohoku University
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Bermúdez-Bejarano EB, Serrera-Figallo MÁ, Gutiérrez-Corrales A, Romero-Ruiz MM, Castillo-de-Oyagüe R, Gutiérrez-Pérez JL, Machuca-Portillo G, Torres-Lagares D. Analysis of different therapeutic protocols for osteonecrosis of the jaw associated with oral and intravenous bisphosphonates. Med Oral Patol Oral Cir Bucal 2017; 22:e43-e57. [PMID: 27918742 PMCID: PMC5217496 DOI: 10.4317/medoral.21477] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2016] [Accepted: 09/11/2016] [Indexed: 12/02/2022] Open
Abstract
Introduction Chemotherapy-associated osteonecrosis of the jaw caused by bisphosphonates is an exposure of necrotic bone with more than eight weeks of evolution that is attributable to bisphosphonates and no prior radiation therapy. Its etiopathogenesis remains unknown, although there are two hypotheses that may explain it: the drug’s mechanism of action, and the risk factors that can lead to osteonecrosis. There is a wide range of treatment options for managing chemotherapy-associated osteonecrosis of the jaw, from conservative treatments to surgical procedures of varying levels of invasiveness, which are sometimes supplemented with adjuvant therapies. Objectives The objective of this article is to group the therapeutic options for osteonecrosis of the jaw (ONJ) into seven different protocols and to evaluate their effectiveness in relation to stage of ONJ. Material and Methods A literature review was carried out in PubMed following the PRISMA criteria. A total of 47 were collected after compiling a series of variables that define ONJ, applied treatments, and the clinical results obtained. Results and Discussion The 47 articles selected have a low to average estimated risk of bias and are of moderate to good quality. According to the data obtained, Protocol 3 (conservative treatment, clinical and radiological follow-up, minimally invasive surgical treatment, and adjuvant therapies) is the most favorable approach for ONJ lesions caused by oral bisphosphonates. For lesions caused by intravenous bisphosphonates, Protocol 2 (conservative treatment, clinical and radiological follow-up, minimally invasive surgical treatment, and no adjuvant therapies) is the best approach. When comparing the different stages of ONJ, Protocol 1 (conservative treatment, clinical and radiological follow-up) promotes better healing of Stage 1 ONJ lesions caused by orally administered bisphosphonates, and Protocol 3 is recommended for Stage II. For ONJ lesions attributable to intravenous bisphosphonates, Protocol 7 (conservative treatment, clinical and radiological follow-up, and adjuvant therapies) provides the best results in Stage 0; in Stages I, II, and III, Protocol 1 gives better results. Key words:Bisphosphonates, bronj, therapeutic protocol, clinical result.
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de Oliveira CC, Brizeno LAC, de Sousa FB, Mota MRL, Alves APNN. Osteonecrosis of the jaw induced by receptor activator of nuclear factor-kappa B ligand (Denosumab) - Review. Med Oral Patol Oral Cir Bucal 2016; 21:e431-9. [PMID: 26827069 PMCID: PMC4920456 DOI: 10.4317/medoral.21044] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2015] [Accepted: 12/09/2015] [Indexed: 11/05/2022] Open
Abstract
BACKGROUND Denosumab, an anti-resorptive agent, IgG2 monoclonal antibody for human Receptor activator of nuclear factor-kappa B ligand (RANKL), has been related to the occurrence of osteonecrosis of the jaws. Thus, the aim of this study was to review the literature from clinical case reports, regarding the type of patient and the therapeutic approach used for osteonecrosis of the jaws induced by chronic use of Denosumab. MATERIAL AND METHODS For this, a literature review was performed on PubMed, Medline and Cochrane databases, using the keywords "Denosumab" "anti-RANK ligand" and "Osteonecrosis of jaw". To be included, articles should be a report or a serie of clinical cases, describing patients aged 18 years or over who used denosumab therapy and have received any therapy for ONJ. RESULTS Thirteen complete articles were selected for this review, totaling 17 clinical cases. The majority of ONJ cases, patients receiving Denosumab as treatment for osteoporosis and prostate cancer therapy. In most cases, patients affected by ONJ were women aged 60 or over and posterior mandible area was the main site of involvement. Diabetes pre-treatment with bisphosphonates and exodontia were the most often risk factors related to the occurrence of this condition. Systemic and local antibiotic therapy with or without surgical debridement was the most used treatment for ONJ resolution. CONCLUSIONS It is concluded that the highest number of ONJ cases caused by the use of anti-RANKL agents occurred in female patients, aged 60 years or older, under treatment for osteoporosis and cancer metastasis, and the most affected region was the mandible posterior.
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Affiliation(s)
- C-C de Oliveira
- Division of Oral Pathology, Department of Clinical Dentistry, School of Dentistry, Federal University of Ceará, Alexandre Barauna Street, 949, Rodolfo Teofilo, 60430-160, Fortaleza, Ceará, Brazil,
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Lopez-Jornet P, Sanchez Perez A, Amaral Mendes R, Tobias A. Medication-related osteonecrosis of the jaw: Is autologous platelet concentrate application effective for prevention and treatment? A systematic review. J Craniomaxillofac Surg 2016; 44:1067-72. [PMID: 27318752 DOI: 10.1016/j.jcms.2016.05.004] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2015] [Revised: 04/12/2016] [Accepted: 05/09/2016] [Indexed: 10/21/2022] Open
Abstract
PURPOSE To date, no ideal strategy has been established for treating or preventing medication-related osteonecrosis of the jaw (MRONJ). The aim of the present work was to perform a systematic literature review to determine the efficacy of autologous platelet concentrate (APC) application, for prevention or treatment of MRONJ, together with surgical debridement. MATERIAL AND METHODS An electronic search was performed using MEDLINE (PubMed), EMBASE, and Cochrane databases until January 2015 using the following search terms: osteonecrosis, bisphosphonates, antiresorptive, antiangiogenic therapy, BRONJ, platelet concentrate, PRP, PRF, and PRGF. Two reviewers assessed the eligibility of articles independently and extracted key data. The methodology used met PRISMA criteria. The Newcastle-Ottawa scale was used to assess the quality of the articles. RESULTS Preventive applications of platelet-rich plasma (PLP) were reported in 697 dental extractions in patients taking bisphosphonates intravenously, of whom seven patients developed osteonecrosis (five mandibular and two maxillary). In cases of established osteonecrosis, eight studies reported treatment by surgery combined with APC (seven with PRP and one with leukocyte-rich and platelet-rich fibrin) in 123 patients (34 men and 89 women) with ONJ, who received 157 treatments, of which 135 achieved complete resolution (85.98%). CONCLUSION There are no published scientific data to sufficiently support any specific treatment protocol, including the use of APC together with surgical debridement, for the management of MRONJ. Randomized controlled clinical trials of the use of APC are needed.
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Affiliation(s)
- Pia Lopez-Jornet
- Department of Oral Medicine, Faculty of Medicine and Dentistry, University of Murcia, IMIB-ARRIXACA, Murcia, Spain
| | - Arturo Sanchez Perez
- Department of Periodontology, Faculty of Medicine and Dentistry, University of Murcia, Murcia, Spain
| | - Rui Amaral Mendes
- Department of Oral and Maxillofacial Medicine, Case Western Reserve University, Cleveland, OH, USA
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Rollason V, Laverrière A, MacDonald LCI, Walsh T, Tramèr MR, Vogt‐Ferrier NB. Interventions for treating bisphosphonate-related osteonecrosis of the jaw (BRONJ). Cochrane Database Syst Rev 2016; 2:CD008455. [PMID: 26919630 PMCID: PMC7173706 DOI: 10.1002/14651858.cd008455.pub2] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Bisphosphonate drugs can be used to prevent and treat osteoporosis and to reduce symptoms and complications of metastatic bone disease; however, they are associated with a rare but serious adverse event: osteonecrosis of the maxillary and mandibular bones. This condition is called bisphosphonate-related osteonecrosis of the jaw or BRONJ. BRONJ is diagnosed when people who are taking, or have previously taken, bisphosphonates have exposed bone in the jaw area for more than eight weeks in the absence of radiation treatment. There is currently no "gold standard" of treatment for BRONJ. The three broad categories of intervention are conservative approaches (e.g. mouth rinse, antibiotics), surgical interventions and adjuvant non-surgical strategies (e.g. hyperbaric oxygen therapy, platelet-rich plasma), which can be used in combination. OBJECTIVES To determine the efficacy and safety of any intervention aimed at treating BRONJ. SEARCH METHODS We searched the following databases to 15 December 2015: the Cochrane Oral Health Group Trials Register, the Cochrane Breast Cancer Group Trials Register (20 September 2011), the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE via Ovid, EMBASE via Ovid, CancerLit via PubMed, CINAHL via EBSCO and AMED via Ovid. We scanned the references cited in retrieved articles and contacted experts in the field, the first authors of included papers, study sponsors, other bisphosphonates investigators and pharmaceutical companies. We searched for ongoing trials through contact with trialists and by searching the US National Institutes of Health Trials Register (clinicaltrials.gov) and the World Health Organization Clinical Trials Registry Platform. We also conducted a grey literature search to September 2015. SELECTION CRITERIA Randomised controlled trials (RCTs) comparing the effects of any treatment for BRONJ with another treatment or placebo. DATA COLLECTION AND ANALYSIS Two review authors independently screened the search results, assessed the risk of bias in the included trials and extracted data. When in dispute, we consulted a third review author. MAIN RESULTS One small trial at high risk of bias met the inclusion criteria. The trial randomised 49 participants, most of whom had cancer. It compared standard care (defined as surgery, antibiotics and oral rinses at the discretion of the oral-maxillofacial surgeon) to standard care plus hyperbaric oxygen therapy (2 atmospheres twice a day for 40 treatments). The trial measured the percentage of participants who improved or healed at three, six, 12 and 18 months and last contact. It also measured mean weekly pain scores.At three months, the study found that the participants in intervention group were more likely to have an improvement in their osteonecrosis than the standard care group participants (risk ratio (RR) 1.94, 95% confidence interval (CI) 1.01 to 3.74). There was no clear difference between the groups for the outcome 'healed' at three months (RR 3.60, 95% CI 0.87 to 14.82). There was no clear difference between the groups for improvement or healing when they were evaluated at six, 12 and 18 months and last contact.The study did not give any information on adverse events.Although the findings suggest adjunctive hyperbaric oxygen improved BRONJ, the quality of the evidence is very low since the only study was underpowered and was at high risk of bias due to lack of blinding, cross-over of participants between groups and very high attrition (50% at 12 months and 80% at 18 months in this study, which was designed for an intended follow-up of 24 months). AUTHORS' CONCLUSIONS There is a lack of evidence from randomised controlled trials to guide treatment of bisphosphonate-related osteonecrosis of the jaw (BRONJ). One small trial at high risk of bias evaluated hyperbaric oxygen therapy (HBO) as an adjunct to "standard" care and could not confirm or refute the effectiveness of HBO. There are two ongoing trials of teriparatide treatment for BRONJ. We found no randomised controlled trials of any other BRONJ treatments. High quality randomised controlled trials are needed. We provide recommendations for their focus and design.
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Affiliation(s)
- Victoria Rollason
- Geneva University HospitalsDivision of Clinical Pharmacology and Toxicology, Department APSIHopital Cantonal de GeneveGenevaSwitzerland1211
| | - Alexandra Laverrière
- Geneva University HospitalsDivision of Clinical Pharmacology and Toxicology, Department APSIHopital Cantonal de GeneveGenevaSwitzerland1211
| | - Laura CI MacDonald
- School of Dentistry, The University of ManchesterCochrane Oral Health GroupJ R Moore Building, Oxford RoadManchesterUK
| | - Tanya Walsh
- School of Dentistry, The University of ManchesterJR Moore BuildingOxford RoadManchesterUKM13 9PL
| | - Martin R Tramèr
- Geneva University HospitalsDivision of Anaesthesiology, Department APSI4 Gabrielle‐Perret‐GentilGenevaSwitzerland1211
| | - Nicole B Vogt‐Ferrier
- Geneva University HospitalsDivision of Clinical Pharmacology and Toxicology, Department APSIHopital Cantonal de GeneveGenevaSwitzerland1211
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