[Orthodontic treatment of patients medicated with bisphosphonates-a clinical case report]

The risk of osteonecrosis of the jaw and adverse outcomes in patients using antiresorptive drugs undergoing orthodontic treatment: A systematic review

Objectives

Medication-related osteonecrosis of the jaw (MRONJ) is rare. It is a serious adverse effect of certain drugs, of which bisphosphonates (BPs) are the most widely known. The aim of this systematic review was to analyze all published evidence for the reported adverse outcomes as a result of orthodontic treatment in patients undergoing antiresorptive therapy.

Data

All types of studies involving patients undergoing orthodontic treatment and treated with antiresorptive drugs were considered. A meta-analysis was not conducted due to the high amount of variability and heterogeneity in the reporting and presentation of data among the studies meeting the inclusion criteria.

Sources

A systematic search was performed using 4 databases (PubMed, MEDLINE, EMBASE and CINAHL).

Study selection

Seven studies matched the inclusion criteria for this review, reporting a total of 29 patients. MRONJ was only reported in 1 patient. The adverse outcomes following orthodontic treatment included difficulty achieving root parallelism (n = 4), difficulty achieving complete space closure (n = 3), exaggerated tooth mobility post-debond (n = 2), increased duration of orthodontic treatment beyond expected completion (n = 1), sclerotic alveolar bone changes seen on post-op radiographic images (n = 2), and an increased amount of root resorption (n = 1).

Conclusions

The high amount of heterogeneity and limited evidence precluded a valid interpretation and analysis of the results through pooling of data. Additional data with sufficient quality, a reduction of bias, and a greater prospective cohort of patients is crucial to assess adverse effects, mechanisms of action, and associated risk factors in at-risk patients.

Clinical significance

Based on the limited evidence available in the literature, it is unclear whether orthodontic treatment alone can precipitate MRONJ. However, antiresorptive drug therapy may be associated with a sub-optimal treatment outcome.

Effects of systematic bisphosphonate use in patients under orthodontic treatment: a systematic review

BACKGROUND

Bisphosphonates are a class of drugs prescribed for several osseous related disorders owing to their ability to regulate bone turnover, which could in turn affect orthodontic treatment outcomes.

OBJECTIVE

To examine the effect of bisphosphonate (BP) use on orthodontic patients through clinical and radiographic measurements.

SEARCH METHODS

Systematic and unrestricted search of 17 databases complemented with additional hand-searches were performed up to March 2019.

SELECTION CRITERIA

Articles reporting on human patients with a history of BPs administration that received orthodontic treatment were eligible for inclusion.

DATA COLLECTION AND ANALYSIS

Data regarding the medical profile of the patients, the specific type of malocclusion and the performed treatment plan, as well as the clinical and radiographic outcomes were extracted. Quality assessment was performed by the ROBINS-I tool for the cohort studies and by a slightly modified checklist from the original one proposed by Agbabiaka et al. for the case reports.

RESULTS

7 articles (1 retrospective cohort study and 6 case reports) were eventually included in the present review including 122 subjects (29 patients and 93 controls) reporting on the clinical and radiographic changes following orthodontic treatment of patients during or after BPs use. BPs seem to have a controversial effect on the clinical and patient-reported variables, even though the majority of the included patients presented with compromised treatment results and a rather slow rate of tooth movement. Most radiographic findings revealed mild root resorption, widened periodontal ligament spaces and sclerotic changes on the surrounding alveolar bone. However, these results should be interpreted with caution, due to the limited number of the eligible articles and their limitations.

LIMITATIONS

The included studies were of rather low quality due to study design and incomplete reporting.

CONCLUSIONS AND IMPLICATIONS

BP administration seems to be associated with compromised clinical outcomes, prolonged treatment time, and moderate changes on the roots and surrounding tissues of orthodontic patients.

REGISTRATION

Non-registered.

FUNDING

None.

The effect of bisphosphonate medication on orthodontics and orthognathic surgery in patients with osteogenesis imperfecta

Introduction: Osteogenesis imperfecta (OI) is a genetic disease that primarily affects bone formation and metabolism. Craniofacial malformations belong to the broad spectrum of the OI phenotype. The introduction of bisphosphonate medications was intended to counteract the significant brittleness of the bones of OI patients. In connection with the application of bisphosphonates, drug-associated osteonecrosis of the jaw has become known as an undesirable effect of the therapeutically intended reduction of osteoclast activity. Originally, the pharmacological inhibition of bone loss was mainly used in oncological therapy. For some time now, osteoporosis has also been treated with substances that inhibit bone resorption.

In OI, malposition of the jaws is relatively common, in particular retrognathia of the maxilla and progeny of the mandible. The literature discloses complications of orthognathic surgery in OI patients. Previous literature reviews suggest that bisphosphonate medication has no significant impact on the performance of and healing after oral surgery in OI patients.

Materialandmethods: An essential prerequisite of a therapy adapted to the patient’s condition is the knowledge of the patient's medical history. This case report describes the orthodontic-surgical treatment of an OI patient and the treatment experience derived in dealing with the condition. The unusual circumstance of this case is that the patient had concealed both his underlying disease and his medication during the current treatment period. In addition, the relevant literature is evaluated for combining the keywords OI, orthodontic therapy, bisphosphonates, and orthognathic surgery.

Results: Based on the literature and our own experience, it is concluded that orthodontic treatment with bisphosphonate medication can also be carried out in OI patients. However, considerably greater forces and longer time intervals should be scheduled for each treatment. Orthognathic surgery with bisphosphonate medication turned out to be uncomplicated in our own case, considering the underlying disease in the planning of surgical procedures. However, there have been very few reports of OI patients in whom orthodontic-surgical treatment of jaw malformation has been performed with bisphosphonate medication.

Conclusion: Taking into account the reported experience of severe complications of orthognathic surgery, the multiple documented adjustments to the treatment strategy of OI patients should be taken seriously. The basic condition of therapy adapted to the disease is that the patient informs the practitioner in an appropriate manner about his or her state of health.

Zoledronic acid and alendronate sodium and the implications in orthodontic movement

OBJECTIVE

To evaluate orthodontic tooth movement (OTM) in rats treated with two types of bisphosphonates (BPs), alendronate sodium (A) and zoledronic acid (Z).

DESIGN

In all, 15 male Wistar rats were randomly divided into three groups. Group OTM+A: orthodontic tooth movement and subcutaneous administration of alendronate sodium (2.5 mg/kg); Group OTM+Z: orthodontic tooth movement and subcutaneous administration of zoledronic acid (0.02 mg/kg), and Group OTM: orthodontic tooth movement and subcutaneous injection of saline. The BPs were administered once a day during 25 days before OTM started and during 10 days of OTM. The left upper first molar was moved with a stainless-steel closed coil spring which delivered an initial force of 0.4N. OTM was measured with a digital caliper comparing the moved and the contralateral side. The histomorphometric analysis counted the number of osteoclasts, inflammatory cells, blood vessels and fibroblasts (n/10⁴  m² ) in periodontal ligament (PDL) of the distobuccal root.

RESULTS

A reduction of 58.3% of OTM was found in Group OTM+A and 99.6% in Group OTM+Z, when compared with Group OTM. There was a significant decrease of osteoclasts and inflammatory cells in BP-treated groups. Blood vessels and fibroblastic cells decreased mainly in Group OTM+Z.

CONCLUSION

Alendronate sodium and zoledronic acid have similar effects on the periodontal tissue during orthodontic treatment in rats. Especially, zoledronic acid can affect orthodontic tooth movement.

Mechanical loading influences the effects of bisphosphonates on human periodontal ligament fibroblasts

OBJECTIVES

There is increasing evidence that bisphosphonates affect orthodontic tooth movement. The object of the study was to investigate the changes produced by tensile strain on human periodontal ligament fibroblasts (HPdLFs) treated with clodronate or zoledronate.

MATERIALS AND METHODS

HPdLF were cultured with 5 and 50 μM clodronate or zoledronate for 48 h and applied to tensile strain (TS) (5 and 10 %) for 12 h in vitro. Viability was verified by MTT assay and apoptosis rate via caspase 3/7 assay. Gene expression of receptor activator of nuclear factor kappa-B ligand (RANKL) and osteoprotegerin (OPG) was investigated using real-time PCR. OPG was also analyzed by ELISA and RANKL by immunocytochemical staining.

RESULTS

Zoledronate (50 μM) reduced the viability of HPdLF (76 vs 100 %) and combined with 5 % TS to 53 %. TS of 10 % and clodronate reduced viability to 79 % with increased caspase 3/7 activity. Clodronate (5 μM) led to a slight increase of OPG gene expression, zoledronate (5 μM) to a slight decrease. Combined with 5 % TS, both increased OPG gene expression (2-3-fold) and OPG synthesis. Zoledronate increased gene expression of RANKL (4-fold). Combined with 5 % of TS, this increase was abolished. TS of 10 % in combination amplified increase of RANKL ending up with a 9-fold gene expression by clodronate and high RANKL protein synthesis.

CONCLUSIONS

This study shows for the first time that mechanical loading alters the effects of bisphosphonates on viability, apoptosis rate, and OPG/RANKL system of HPdLF dependent on the applied strength. Low forces and bisphosphonates increase factors for bone apposition, whereas high forces combined with bisphosphonates stimulate osteoclastogenesis.

CLINICAL RELEVANCE

Mechanical loading of periodontal ligament with high strengths should be avoided during bisphosphonate therapy.

Current state of orthodontic patients under bisphosphonate therapy

Background

Bisphosphonates are a common medication for the prevention and therapy of osteoporosis, but are also applied for tumor diseases. They affect bone metabolism, and therefore also orthodontic treatments, but how it does has yet not been definitively clarified. Therefore, the aim of this research was to evaluate and demonstrate the reported effects and the current state of scientific research regarding orthodontic treatment and bisphosphonate medication exclusively in humans.

Material and methods

A systematic research of the literature for selected keywords in the Medline database (Pubmed) as well as a manual search was conducted. The following search terms were used: ‘Bisphosphonate’ in combination with: orthodontic, orthodontic treatment, tooth movement.

Findings

To date, only nine reported patients (case reports/series) and one original article (retrospective cohort study) regarding orthodontic treatment under bisphosphonate medication in humans have been published. Decelerated tooth movement with increased side effects (especially in high-risk patients) and longer treatment duration was reported in some articles. Patients with initial spacing or extraction cases had a higher risk of incomplete space closure and poor root parallelism.

Conclusions

Orthodontic tooth movement under bisphosphonate medication is possible, especially in low-risk patients (low dose and short period of intake). But the treatment is still not predictable, especially in high-risk patients. Therefore, the altered bone metabolism and higher extent of side effects should be considered in treatment planning, especially in extraction cases or high-risk patients. Regardless, longer treatment duration, decelerated tooth movement, and more side effects, e.g., incomplete space closure and poor root parallelism, should be expected, especially in extraction cases or space closure.