Risk factors of medication-related osteonecrosis of the jaw: a retrospective study in a Turkish subpopulation

Association Between Malignant Diseases and Medication-Related Osteonecrosis of the Jaw (MRONJ): A Systematic Review and Meta-Analysis

PURPOSE

The aim was to identify whether malignant diseases increase the risk of medication-related osteonecrosis of the jaw (MRONJ) occurrence when patients are exposed to bisphosphonate, antiresorptive or antiangiogenic drugs. To analyze related factors.

METHODS

A systematic literature searching was performed in PubMed, Embase, and Google Scholar for studies with information about whether patients have malignant diseases. Patients involved must be treated with MRONJ-related drugs and at high risk of developing MRONJ.

RESULTS

A total of 6 cohort studies and 3 case-control studies were included. Analysis according 9 studies shows that malignant diseases have significant influence on MRONJ occurrence (risk ratio (RR): 2.62; 95% confidence interval (95% CI): 1.58-4.33; P =0.0002). Subgroup analysis according 6 cohort studies also shows that malignant diseases significantly affect MRONJ occurrence (RR: 3.50; 95% CI: 1.63-7.52; P =0.001). Chemotherapy have no obvious influence on MRONJ occurrence (RR: 1.64; 95% CI: 0.79-3.39; P =0.18). Intravenous drug administration significantly influences MRONJ occurrence (RR: 2.67; 95% CI: 1.27-5.58; P =0.009).

CONCLUSIONS

Patients with malignant diseases have higher risk of MRONJ occurrence when exposed to bisphosphonate, antiresorptive, or antiangiogenic drugs. Cumulative dosages from intravenous drugs administration contribute to MRONJ developing. Prevention of MRONJ in patients with malignancy should be emphasized.

Risk factors for medication-related osteonecrosis of the jaw and salivary IL-6 IN cancer patients

Introduction

Medication-related osteonecrosis of the jaws is a severe complication of the use of antiresorptive and antiangiogenic therapy, with limited treatment options and great impact on patient’s quality pf life.

Objective

The aim of this study was to assess the risk factors associated with medication-related osteonecrosis of the jaws in oncologic patients undergoing bisphosphonate treatment. In addition, salivary levels of interleukin-6, IL-6, were measured to investigate their association with severity and risk of medication-related osteonecrosis of the jaws.

Methods

Case-control study with 74 patients with bone metastases from solid tumors and multiple myeloma was included. Patients were divided into three groups: 1) those undergoing bisphosphonate treatment with medication-related osteonecrosis of the jaws; 2) those undergoing bisphosphonate without medication-related osteonecrosis of the jaws; and 3) those with bisphosphonate pretreatment. The demographic and medical data of the patients were collected to assess risk. The clinical evaluation was performed to diagnose medication-related osteonecrosis of the jaws and unstimulated saliva was collected for quantification of IL-6.

Results

As result, it was observed that patients diagnosed with medication-related osteonecrosis of the jaws were submitted to higher number of bisphosphonate doses (p = 0.001) and monthly infusion protocol (p = 0.044; OR = 7.75). Patients who did not have routine followup with specialized dentists during therapy with bisphosphonate and smoking were associated with medication-related osteonecrosis of the jaws (p = 0.019; OR = 8.25 and p = 0.031; OR = 9.37 respectively). Group 1 had a higher frequency of treatment with chemotherapy and corticosteroids concomitant with bisphosphonate, and surgical dental procedures (p = 0.129). Salivary IL-6 levels showed no statistically significant difference between the groups (p = 0.571) or association with medication-related osteonecrosis of the jaws severity (p = 0.923).

Conclusion

A higher number of bisphosphonate cycles, monthly infusion protocol, no dental follow-up for oral health maintenance and smoking were associated with medication-related osteonecrosis of the jaws. Specialized dental follow up during bisphosphonate treatment has been shown to be an important factor in preventing this complication.

What is the Risk of Developing Medication-Related Osteonecrosis in Patients With Extraction Sockets Left to Heal by Secondary Intention? A Retrospective Case Series Study

PURPOSE

Tooth and root extractions represent trigger factors for medication-related osteonecrosis of the jaw (MRONJ). The best healing modality for postextraction sockets is still debated. The aim of the study was to estimate the incidence of MRONJ after extractions whose sockets were left to heal by secondary intention.

METHODS

A retrospective case series study was performed at the Department of Odontostomatological and Maxillofacial Sciences, Sapienza University of Rome. Only patients who underwent nonsurgical extractions, healed by secondary intention, were included in the study. The following parameters were considered: age, sex, pathologies for which bisphosphonates or other drugs related to MRONJ were prescribed, any local or systemic risk factors, type of drug used, route of administration, number of extractions performed, and number of sessions required to complete the extraction program. The main outcome variable was the occurrence of MRONJ. Statistical analysis was performed with SPSS statistical software.

RESULTS

Two hundred twenty-one patients were treated from 2007 to 2020 with 639 tooth/root extractions. All patients were treated under antibiotic prophylaxis and with anesthesia without vasoconstrictors. No cases of MRONJ occurred. The mean age of patients was 68.02 ± 11.17. Most of the study sample was represented by women (201 = 90.95%) undergoing treatment for osteometabolic pathologies, most frequently postmenopausal osteoporosis. Alendronate was the most frequently prescribed drug, taken mainly orally. Most patients had local and/or systemic risk factors. Each patient had from 1 to 17 tooth/root extractions (mean = 2.87 ± 2.59) during 1 to 4 sessions (mean = 1.41 ± 0.64). Extractions mainly involved single-rooted teeth/roots, equally distributed between the maxilla and mandible.

CONCLUSIONS

Secondary intention healing after nonsurgical tooth extraction does not seem to predispose to MRONJ. It can be advisable to perform extractions under antibiotic prophylaxis using anesthetics without vasoconstrictors and chlorhexidine mouth rinses in the 7 following days.

Antiresorptive medication in oncology: the clinical and dental profile of patients in a reference center

Objectives

: The aim of this study was to evaluate the profile of patients on antiresorptive therapies for cancer treatment and assess presence of oral lesions, oral hygiene status, and knowledge regarding medication-related osteonecrosis of the jaw (MRONJ).

Materials and Methods

This was an observational cross-sectional study that evaluated patients treated with antiresorptive medication at a single cancer hospital. Clinical data were collected and oral examination was performed to assess patient oral health.

Results

From July 2017 to December 2018, 90 patients were assessed; 64 were female and 26 were male, and the mean age was 61 years. The most common drug was an intravenous bisphosphonate, zoledronic acid. Among the 90 patients, 47 presented with some type of oral disease, isolated or associated. Among these 47 patients, 9 patients (10%) developed osteonecrosis. Oral hygiene was evaluated, and most patients, with or without MRONJ, presented with regular to poor condition. Regarding patient knowledge of the risks of MRONJ and the risks associated with dental surgery, 60% stated that they were not aware of the risks.

Conclusion

Identifying the profile of patients and their needs facilitates not only the preventive process, but also the emergence of new therapeutic options. Our study shows that most patients are weakened both by metastatic disease and antineoplastic treatment as well as by issues associated with aging because most were over 60 years of age. Collectively, this information should be considered for management of preventive and therapeutic measures.

Conservative Management of Medication-Related Osteonecrosis of the Jaws (MRONJ): A Retrospective Cohort Study

BACKGROUND

Medication-related osteonecrosis of the jaw (MRONJ) is a severe side effect of bisphosphonates and anti-resorptive drugs prescribed for treatment of severe osteoporosis, Paget's disease, and bone malignancies. The aim of this study was to evaluate the clinical outcome of a combined pharmacological and surgical management strategy on patients affected by MRONJ.

MATERIALS AND METHODS

Medical records of patients with MRONJ were retrospectively examined to collect clinical history data. Conservative management included an initial pharmacological phase with antibiotics and antiseptic agents, followed by surgical intervention to remove bone sequestrum. Primary outcomes were healing from MRONJ at short term (1 month after surgery) and at longer term (3 months after surgery). Secondary outcome was assessment of recurrences at longer-term follow-up.

RESULTS

Thirty-five patients were included in the study with mean follow-up of 23.86 ± 18.14 months. Seven cases showed spontaneous exfoliation of necrotic bone during pharmacological therapy, which in one case did not require any further intervention. At 1-month posttreatment, 31 out of 35 (88.5%) patients showed complete healing. The 25 patients who were followed for at least 3 months revealed a healing rate of 92% (23/25). Recurrences occurred in 7 patients out 23 who showed the long-term healing, after a mean period of 7.29 ± 3.45 months. The prognostic score (University of Connecticut Osteonecrosis Numerical Scale-UCONNS) was significantly higher (p = 0.01) in patients with poor healing as compared to complete healing, both at 1 and 3 months posttreatment.

CONCLUSIONS

A MRONJ treatment approach based on a combined pharmacological and surgical treatment strategy showed a high rate of healing and few recurrences.

Prevention of medication related osteonecrosis of the jaw after dentoalveolar surgery: An institution's experience

Background

Dentoalveolar surgery is a predisposing factor for medication related osteonecrosis of the jaw (MRONJ). The aim of our study was to evaluate the described surgical procedures to prevent the development of MRONJ after dentoalveolar surgery in patients receiving bisphosphonates.

Material and Methods

In this retrospective study, sixty-three dentoalveolar surgeries were performed on 44 patients taking bisphosphonate in accordance with the treatment procedures we described. The following procedures were applied to patients 1) use of antibiotics 2) performed dentoalveolar surgical procedures 3) fill the socket with leukocyte- and platelet-rich fibrin (L-PRF) 4) post-operative application of low level laser therapy through Nd: YAG laser 5) sutures were removed on post-op 14th day 6) long-term results were evaluated.

Results

Healing of all patients was uneventful. Complete mucosal healing was achieved in all patients at 1 month. There is no failure was observed in long-term follow-up.

Conclusions

Because of the pathophysiology of MRONJ is not fully understood and has many risk factors, definitive protocols on prevention and treatment have not been established yet. Personal risk assessment is required for the prevention and treatment of MRONJ. The described surgical protocol may be considered to reduce the risk of developing MRONJ after dentoalveolar surgery due to its high success rate.

Key words:Tooth extraction, medication related osteonecrosis of the jaw, preventive dentistry, L-PRF, low level laser therapy.