Laser and Platelet-Rich Plasma to treat Medication-Related Osteonecrosis of the Jaws (MRONJ): a case report

Medication-related osteonecrosis of the jaw (MRONJ): a review of pathogenesis hypothesis and therapy strategies

Medication-related osteonecrosis of the jaw (MRONJ), a severe side effect caused by antiresorptive antiangiogenic medication, particularly bisphosphonates (BPs), has become a challenging disease with serious and profound effects on the physical and mental health of patients. Although it occurs with high frequency and is harmful, the exact mechanism of MRONJ remains unknown, and systematic and targeted approaches are still lacking. Maxillofacial surgeons focus on the etiology of osteonecrosis in the mandible and maxilla as well as the appropriate oral interventions for high-risk patients. Adequate nursing care and pharmacotherapy management are also crucial. This review provides a current overview of the clinicopathologic feature and research of MRONJ caused by BPs, with an emphasis on the potential mechanisms and current therapy and prevention strategies of the disease. We are of the opinion that an in-depth comprehension of the mechanisms underlying MRONJ will facilitate the development of more precise and efficacious therapeutic approaches, resulting in enhanced clinical outcomes for patients.

Use of Phototherapy and Er-YAG Laser in the Management of Mandible Osteoradionecrosis: A Case Report

Introduction: Osteoradionecrosis (ORN) is a secondary complication from radiotherapy, which is difficult to manage and significantly reduces the life quality of the affected patients. Case Report: A 59-year-old female patient, diagnosed with infiltration by squamous cell carcinoma in the left cervical region, underwent adjuvant cervical-facial radiotherapy with a total dose of 66.6 Gy of radiation. Eight years after the diagnosis, the patient underwent multiple extractions and, subsequently, the installation of osseointegrated implants, evolving to extensive intraoral bone exposure associated with oral cutaneous fistula. The patient was initially exposed to photobiomodulation therapy (PBMT), with a low-power laser at wavelengths of 660 nm and 808 nm, and thereafter to antimicrobial photodynamic therapy (aPDT). After an improvement in the clinical condition and resolution of the oral cutaneous fistula, a surgical procedure with the Er: YAG laser was performed to remove the remaining necrotic bone. Once the ORN condition was completely treated, the patient's oral rehabilitation was implemented by the installation of an upper mucous-supported total prosthesis and a lower implant-supported prosthesis. Conclusion: The patient is in a clinical follow-up and has no signs of bone necrosis recurrence, suggesting that low and high-power laser treatment can be an effective therapeutic alternative to resolve this condition.

Platelet-derived growth factors from a single donor by apheresis and one freeze-thaw cycle for treating medication-related osteonecrosis of the jaw

Aim: To assess whether the use of allogeneic platelet-derived growth factors could serve as a feasible, effective and safe biological therapy for the treatment of medication-related osteonecrosis of the jaw (MRONJ). Materials & methods: Patients with multiple myeloma and MRONJ were included and treated with allogeneic platelet-rich plasma, continued for between 6 and 18 weeks (mean: 9). Results: We observed a treatment success rate of 87.5% (p < 0.05). Assessing the association between healing and treatment duration, we observed a statistically significant relationship (χ² = 8.00; p = 0.018; Cramer's V = 1), confirming that healing was very closely related to the duration of the treatment. Conclusion: Allogeneic platelet-rich plasma could be a recommended treatment for MRONJ. Future research with a large sample to validate our findings is required.

Cross-modality imaging of bisphosphonate-treated murine jawbones

In this proof-of-principle study, we established and implemented a cross-modality imaging (CMI) pipeline to characterize and compare bisphosphonate (BIS)-treated jawbones of Sprague-Dawley rats after tooth extraction after physical therapies (photobiomodulation and extracorporeal shockwave therapy (PBMT and ESWT)). We showcase the feasibility of such a CMI approach and its compatibility across imaging modalities to probe the same region of interest (ROI) of the same jawbone. Jawbones were imaged in toto in 3D using micro-Computed Tomography to identify ROIs for subsequent sequential 2D analysis using well-established technologies such as Atomic Force Microscopy and Scanning Electron Microscopy, and recent imaging approaches in biomedical settings, such as micro-X-Ray Fluorescence Spectroscopy. By combining these four modalities, multiscale information on the morphology, topography, mechanical stiffness (Young's modulus), and calcium, zinc and phosphorus concentrations of the bone was collected. Based on the CMI pipeline, we characterized and compared the jawbones of a previously published clinically relevant rat model of BIS-related osteonecrosis of the jawbone (BRONJ) before and after treatment with BISs, PBMT and ESWT. While we did not find that physical therapies altered the mechanical and elemental jawbone parameters with significance (probably due to the small sample size of only up to 5 samples per group), both ESWT and PBMT reduced pore thicknesses and bone-to-enamel distances significantly compared to the controls. Although focused on BIS-treated jawbones, the established CMI platform can be beneficial in the study of bone-related diseases in general (such as osteoarthritis or -porosis) to acquire complementary hallmarks and better characterize disease status and alleviation potentials.

Plasma-Alginate Composite Material Provides Improved Mechanical Support for Stem Cell Growth and Delivery

Blood plasma-based products have been recently utilized in different tissue engineering applications, ranging from soft tissue repair to bone regeneration. Plasma contains fibrinogen which can be converted to an insoluble fibrin-laden gel in the presence of activated thrombin. In tissue engineering, these plasma-based materials can serve either as a three-dimensional scaffold to deliver therapeutic cells in vivo or as a growth factor-rich supply for tissue regeneration. Unfortunately, plasma-based materials are often mechanically weak and easily deformed, thus limiting their usability in harsh clinical settings. Simpler methods to create sturdier plasma-based materials are therefore needed. To this end, we hypothesized that combining alginate with plasma can create a composite plasma material with improved mechanical properties. Incorporating alginate into plasma produced composite gels with increasing bulk stiffness, as measured by rheology. Specifically, the plasma-alginate composite (PAC) gels with an alginate concentration of 2.86 mg/mL were 10-fold stiffer than pure plasma gels (11 vs 112 Pa). Interestingly, gel lysis rates were unchanged despite increasing alginate concentration (lysis time approximately 50 min). Adipose-derived stem cells cultured in the stiffer PAC gels expressed stemness markers (THY1, ENG, NT5E) at levels comparable to those in the pure plasma gels. Similarly, proangiogenic factor secretion was also constant across all gel conditions. In sum, we envision this PAC gel system will extend the use of plasma gel-based therapies into more rigorous clinical applications.

Conservative Surgical Treatment of Bisphosphonate-Related Osteonecrosis of the Jaw with Er,Cr:YSGG Laser and Platelet-Rich Plasma: A Longitudinal Study

Introduction

The management of bisphosphonate-related osteonecrosis of the jaw (BRONJ), with no evidence-based guidelines, remains controversial. We aimed to evaluate the efficiency of a conservative surgical treatment combining Er,Cr:YSGG laser and platelet-rich plasma (PRP) for the treatment of BRONJ in cancer patients.

Methods

We performed a longitudinal cohort study. Inclusion criteria were (1) age ≥ 18 years; (2) cancer diagnosis; (3) treatment with NBP because of the underlying cancer.

Results

We consecutively recruited ten patients diagnosed with BRONJ in stage I or II. These patients underwent a surgical laser-assisted therapy together with autologous PRP. At the latest follow-up at 12 months, clinical improvement was observed in eight patients. Registration Number is IRCT20180329039159N1.

Conclusion

We could successfully manage the BRONJ utilizing this combined protocol to heal the 30% of surgically treated sites and to improve the 50% of patients' lesions clinically. Our findings suggest that a surgical approach combined with Er,Cr:YSGG laser and PRP benefit cancer patients with general health issues.

Combined Approach to Treat Medication-Related Osteonecrosis of the Jaws

Introduction: The proper therapeutic plan for medication-related osteonecrosis of the Jaw (MRONJ) is still lacking long-term data up to today. They were several high-technological appliances proposed for the different intervention steps, in addition to tissue repair promoters. The reason for proposing an integrated technique is justified, beyond better compliance of the patients associated to the pain and inflammation reduction and bleeding control, there is also achieving better hard and soft tissues healing. Methods: Patients diagnosed with bisphosphonates-related osteonecrosis of the jaws (BRONJ) at the Odontostomatology and Maxillo-Facial Surgery Unit of the Hospital of Piacenza undergone surgical intervention. The intervention was performed by using different devices: Piezosurgery for removing the necrotic bone tissue and for obtaining the bone specimen essential for histological analysis; Er:YAG laser (2940 nm) to vaporize necrotic hard tissue until reaching the bleeding bone; platelet-rich plasma (PRP) to stimulate hard and soft tissue healing; and finally diode laser (808 nm) to perform a biostimulation of the surgical site. Results: All treated patients demonstrated a good postoperative comfort even without using painkillers, no bleeding, and a fast healing process. Most of the patients (92.85%) reached complete healing with a minimum follow up at 6 months. Histological exams demonstrated a good quality without artifacts. Conclusion: Sequential utilization of different high-technologies devices during all the steps of MRONJ treatment allows to perform a faster and less invasive surgery with a more comfortable postoperative healing process and it may represent a new and original approach for treating this severe adverse event.

Platelet-Rich Plasma (PRP) Rinses for the Treatment of Non-Responding Oral Lichen Planus: A Case Report

Platelet-rich plasma (PRP) has been proposed for different applications in the medical field and in maxillofacial surgery thanks to its many growth factors, such as epidermal growth factor (EGF), fibroblast growth factor (FGF), and keratinocyte growth factor (KGF). Oral lichen planus (OLP) is a disease that affects the oral mucosa in a chronic way. This disease frequently worsens the quality of life of patients, particularly when clinical manifestations are of the erythematous or erosive/ulcerative type. The properties of PRP that are supported by scientific literature in both oral medicine and other medical fields have suggested the introduction of PRP in clinical practice for the medical treatment of different soft tissues diseases, such as when OLP patients do not respond to conventional therapies, or when conventional treatments have some contraindications or side effects. The aim of this work is to describe the use of PRP used as an oral rinse for the treatment of a patient diagnosed as affected by OLP at the Dentistry, Special Needs and Maxillo-Facial Surgery Unit of the Hospital of Piacenza. PRP protocol was started after the failure of conventional therapies based on the use of topical and systemic corticosteroids, hydroxychloroquine, and low-level laser therapy applications.