Prevalence of medication related osteonecrosis of the jaw in patients treated with sequential antiresorptive drugs: systematic review and meta-analysis

Incidence of medication-related osteonecrosis of the jaw and associated antiresorptive drugs in adult Finnish population

This retrospective study aimed to evaluate the incidence of medication-related osteonecrosis of the jaw (MRONJ) and associated antiresorptive drugs in the Finnish population. All adult patients (aged 18 years and older) who were prescribed with antiresorptive drugs (AR) during 2013-2015 were included in this study. A total of n = 58,367 patients met the inclusion criteria and were followed up until 2020. The outcome variable was the diagnosis of MRONJ during the study period. Patients' age, gender, type of AR prescribed, reason for using AR drugs, use of corticosteroids, use of vascular endothelial growth factor (VEGF) inhibitors were used as covariates. The incidence of MRONJ was 0.3% in low-dose and 9.0% in high-dose AR recipients in this study population. The risk of developing MRONJ among denosumab users was 5 times higher in both low-dose and high-dose AR recipients compared to bisphosphonates users. Simultaneous use of corticosteroids in addition to AR drug increased the risk of developing MRONJ by 2 times in high-dose recipients and 6 times in low-dose recipients. In conclusion, male, denosumab, any type of cancer diagnosis, high dose of AR drug and simultaneous use of corticosteroids were the most noteworthy risk factors for MRONJ.

The association between lipid accumulation products and bone mineral density in U.S. Adults, a nationally representative cross-sectional study

LAP (lipid accumulation products) is a new indicator that estimates lipid overaccumulation and central obesity in our bodies. Nevertheless, the relationship of LAP with bone mineral density (BMD) has not been well established. This study aims to assess the association of LAP with BMD in U.S. adults. Multivariate linear regression was employed to detect the relationship of LAP with lumbar BMD in adult Americans. Subgroup and interaction tests were employed to detect the robustness of our findings. Restricted cubic spline (RCS) and threshold effect analysis were used to assess the nonlinear correlation of LAP with lumbar BMD. A total of 3883 participants consisted of 2117 (54.52%) men and 1766 (45.48%) women. The mean age of participants was 39.33 ± 11.53 years. After adjusting all covariates, we found a negative association of ln-LAP with lumbar BMD (β= -0.011, 95% CI: -0.019, -0.004). Threshold effect analysis identified the inflection points of 2.846. The results showed no correlation to the left of the saturation point but a significant negative correlation to the right. Interaction analyses indicated that all subgroups have no effect on this association (P > 0.05). Our study reported a nonlinear negative association of LAP with lumbar BMD. A large LAP may be associated with reduced BMD in American adults. These findings support the clinical utility of LAP as a predictor of osteoporosis and provide valuable insights into developing early intervention strategies for osteoporosis populations.

Platelet-Rich Fibrin in MRONJ Management: A Prospective Comparative Study on Its Effectiveness in Prevention and Treatment

Background and Objectives: Medication-related osteonecrosis of the jaw (MRONJ) was first recognized as a disease entity and reported in the literature in 2003. Within a few years, the incidence of MRONJ has increased significantly, to the point where now it can be seen in every dental clinic around the world. Its prevention and management still remain major challenges for dentists and oral and maxillofacial surgeons. Materials and Materials and Methods: This prospective clinical study was conducted at the Oral and Maxillofacial Surgery Clinic in Timisoara for a 6-month period and included a total of 85 patients under chronic antiresorptive and antiangiogenic medication. There were two groups of patients: G1 received PRF growth factors, while the other group, G2, was treated with classical surgical methods. Post-operative wound healing was assessed at 2, 4, and 8 weeks by monitoring the absence of local gingival dehiscence, suprainfection, or loco-regional fistulas, both in cases of dental extractions and sequestrectomies in MRONJ cases. Results: The use of PRF in post-extraction sockets in patients predisposed to developing MRONJ aids in local healing in 96% of cases, compared to cases where it was not used, in which normal healing occurred in only 64.29% of patients; there was a significant difference between the two groups (p = 0.016). In MRONJ confirmed cases, application of PRF after excisional debridement of necrotic bone does not appear to have the same therapeutic value as in post-extractional sockets, with a p-value of 0.299 indicating no statistical significance. Conclusions: PRF use can be considered an effective approach in preventing osteonecrotic complications following dental extractions in patients with antiresorptive treatment. Additional studies are needed to establish its role in MRONJ confirmed cases.

Medication related osteonecrosis (MRONJ) in the management of CTIBL in breast and prostate cancer patients. Joint report by SIPMO AND SIOMMMS

Background

Low-doses of bone modifying agents (LD-BMAs) compared to those used to treat bone metastases are used in breast or prostate cancer patients on adjuvant endocrine therapy to prevent Cancer Treatment Induced Bone Loss (CTIBL). Their use is associated with an increased risk of developing Medication-Related Osteonecrosis of the Jaw (MRONJ). However, there is not clarity about strategies aimed to minimize the MRONJ risk in cancer patients at different conditions as low- vs high-doses of BMA. This joint report from the Italian Societies of Oral Pathology and Medicine (SIPMO) and of Italian Society of Osteoporosis, Mineral Metabolism and Skeletal Diseases (SIOMMMS) aims to define the dental management of breast and prostate cancer patients with CTIBL under LD-BMAs, to reduce their risk to develop MRONJ.

Methods

This interdisciplinary SIPMO-SIOMMMS Expert Italian Panel reviewed the available international scientific literature and developed a set of recommendations to implement strategies of MRONJ prevention in breast (BC) and prostate cancer (PC) patients undertaking LD-BMAs to prevent CTIBL.

Results

The Expert Panel, after addressing some introductive topics (i.e., CTIBL and its management, pharmacology and pharmacodynamics of BMAs, definition and diagnosis of MRONJ), developed a joint report on the following five issues: a) prevention and dental management in cancer patients candidates to LD-BMAs, or under LD-BMAs; b) prophylactic drug holiday; c) MRONJ treatment; d) LD-BMAs therapeutic drug holiday; and e) restart of LD-BMA treatment after successful healing of MRONJ.Finally, ten key questions with answers were prepared and placed at the end of the document.

Conclusions

Despite obvious weaknesses of the available international literature, the Expert Panel recognized the need to tailor separate MRONJ preventive approach for breast and prostate cancer patients on adjuvant endocrine therapy who begin low-dose BMA therapy to prevent CTIBL and provided this practical guidance for bone specialists and oral healthcare providers. In view of a MRONJ risk for BC and PC patients receiving low-dose BMAs, which approximates that of patients with osteoporosis and other non-malignant diseases undergoing similar treatment schedules, the SIPMO-SIOMMMS Expert Panel recognizes the need for less stringent preventive strategies than those already developed for BC or PC patients with bone metastases taking HD-BMAs.

The effect of cold atmospheric plasma on viability of osteoblasts and expression of RANKL and OPG genes in medium with bisphosphonates

Medication-related osteonecrosis of the jaw is a rare but severe complication with challenging treatment protocols. Cold atmospheric plasma (CAP) has shown promising effects in wound healing, cell proliferation and viability. This study investigated the effect of CAP on osteoblasts in a culture medium containing bisphosphonates. Pilot study was designed to determine the optimal setting of CAP. MG-63 cells were exposed to zoledronic acid at a concentration of 10 micromolar for 72 h. Study groups with the best MTT assay results, were chosen for assessing OPG and RANKL genes by RT-PCR. Cell viability was significantly higher in groups 9 kV.1 mm.90 s, 10 kV.1 mm.60 s, and 12 kV.1 mm.60 s (P < 0.05). Expression of RANKL in these groups was significantly lower than the positive control group (medium culture without zoledronic and plasma treatment) and higher than the BP group (culture with zoledronic without plasma treatment), except for the 12 kV.1 mm.60 s group, which did not differ significantly from the positive control group (P > 0.05). OPG decreased in all test groups compared to BP (p < 0.05), except for the 12 kV.1 mm.60 s group, which did not significantly differ from BP (P > 0.05). RANKL/OPG ratio in groups 9 kV.1 mm.90 s and 12 kV.1 mm.60 s significantly increased compared to BP (P < 0.05).CAP treatment may enhance the viability of osteoblasts exposed to bisphosphonates, increase their activity levels, enhance osteoclast activity, and improve bone turnover rates.

Potential role of comprehensive dental care in preventing medication related osteonecrosis of the jaw (MRONJ): a single centre study

OBJECTIVE

Medication-related osteonecrosis of the jaw bones (MRONJ) is a well-known complication of antiresorptive and antiangiogenic drugs. Since the first report, more occurrences of MRONJ have been described worldwide. Dental extraction has been described by many studies as one of the risk factors for MRONJ. Comprehensive dental care (CDC) is a preventive dental method provided to patients prior to drug commencement. This study aims to determine the association between CDC and MRONJ.

PATIENTS AND METHODS

A retrospective analysis was performed on 75 medical records of patients on antiresorptive and/or antiangiogenic drugs between February 2018 and May 2021. Demographics and clinical and radiographic data were collected. Univariate and multivariate analyses were performed to determine the factors associated with MRONJ.

RESULTS

Of the 75 patients who met the inclusion criteria, 11 (14.7%) developed MRONJ. Three out of 11 patients (27.2%) developed MRONJ spontaneously, while eight patients (72.8%) developed it after trauma from dentures or dental extractions. Following a binary logistic regression analysis, the lack of CDC was identified as a significant predictor of MRONJ. Patients who did not receive CDC had an odds ratio of 8.64 (95% confidence interval (CI): 1.27-58.62, p = 0.03). However, dental extraction did not show a statistically significant association with MRONJ in both the univariate and multivariate analyses.

CONCLUSION

CDC before treatment with antiresorptive and antiangiogenic drugs is a potentially effective preventive method for reducing MRONJ. Dental extraction was not a significant factor in relation to MRONJ.

Arbeitsgemeinschaft Gynäkologische Onkologie Recommendations for the Diagnosis and Treatment of Patients with Locally Advanced and Metastatic Breast Cancer: Update 2024

The Breast Committee of the Arbeitsgemeinschaft Gynäkologische Onkologie (German Gynecological Oncology Group, AGO) presents the 2024 update of the evidence-based recommendations for the diagnosis and treatment of patients with locally advanced and metastatic breast cancer.

A real-world study on the prevalence and risk factors of medication related osteonecrosis of the jaw in cancer patients with bone metastases treated with Denosumab

AIM

Assessing the incidence of Medication Related Osteonecrosis of the Jaw (MRONJ) in cancer patients with bone metastases receiving Denosumab (Dmab) and identifying potential risk factors.

METHODS

A retrospective observational study on consecutive cancer patients with bone metastases, who received at least one dose of Dmab and one follow-up visit. MRONJ crude cumulative incidence (CCI) was estimated considering death without MRONJ as competing event. Multiple regression models were used to study the association between MRONJ incidence and potential risk factors: age, cancer diagnosis, previous bisphosphonates, dental treatments before starting Dmab, extraction or other dental treatment during Dmab, chemotherapy, hormone therapy, and antiangiogenic (AA) agents concurrent use.

RESULTS

On 780 patients included (median follow-up 17 months), 54% and 18% had, respectively, breast and prostate cancer. The mean number of Dmab administration was 12. Fifty-six patients developed MRONJ with a 24- and a 48-month crude cumulative incidence of 5.7% (95% Cl: 4.2%-7.8%) and 9.8% (95% CI: 7.6%-12.7%), respectively. Higher MRONJ incidence was significantly associated with middle aged group (>56 and ≤73), both at univariate and multivariate analysis (p = 0.029 and 0.0106). Dental treatments (Hazard Ratio [HR] = 3.67; p = 0.0001), dental extractions (HR = 23.40; p < 0.0001), and previous BP administration (HR = 2.62; p = 0.0024) were significantly associated with higher MRONJ incidence at multivariate Cox analysis. Although not statistically significant, MRONJ incidence was lower for patients receiving chemotherapy or hormone therapy and higher for those receiving AAs.

CONCLUSIONS

The results confirm a clinically relevant incidence of Dmab-induced MRONJ. Dental treatments, especially extraction, during and before Dmab, constitute a serious risk factor. The role of AA concurrent administration deserves further investigations.

AGO Recommendations for the Diagnosis and Treatment of Patients with Locally Advanced and Metastatic Breast Cancer: Update 2023

The Breast Committee of the Arbeitsgemeinschaft Gynäkologische Onkologie (German Gynecological Oncology Group, AGO) presents the 2023 update of the evidence-based recommendations for the diagnosis and treatment of patients with locally advanced and metastatic breast cancer (mBC).

MRONJ in breast cancer patients under bone modifying agents for cancer treatment-induced bone loss (CTIBL): a multi-hospital-based case series

BACKGROUND

Cancer treatment-induced bone loss (CTIBL) is the most common adverse event experienced by patients affected by breast cancer (BC) patients, without bone metastases. Bone modifying agents (BMAs) therapy is prescribed for the prevention of CTIBL, but it exposes patients to the risk of MRONJ.

METHODS

This multicentre hospital-based retrospective study included consecutive non-metastatic BC patients affected by MRONJ related to exposure to low-dose BMAs for CTIBL prevention. Patients' data were retrospectively collected from the clinical charts of seven recruiting Italian centres.

RESULTS

MRONJ lesions were found in fifteen females (mean age 67.5 years), mainly in the mandible (73.3%). The mean duration of BMAs therapy at MRONJ presentation was 34.9 months. The more frequent BMAs was denosumab (53.3%). Ten patients (66.7%) showed the following local risk factors associated to MRONJ development: periodontal disease (PD) in three cases (20%) and the remaining six (40%) have undergone PD-related tooth extractions. One patient presented an implant presence-triggered MRONJ (6.7%). In five patients (33.3%) no local risk factors were observed.

CONCLUSIONS

This is the first case series that investigated BC patients under BMAs for CTIBL prevention suffering from MRONJ. These patients seem to have similar probabilities of developing MRONJ as osteo-metabolic ones. Breast cancer patients under BMAs for CTIBL prevention need a regular prevention program for MRONJ, since they may develop bone metastases and be treated with higher doses of BMAs, potentially leading to a high-risk of MRONJ.

Incidence and risk factors for medication-related osteonecrosis after tooth extraction in cancer patients-A systematic review

OBJECTIVES

Antiresorptive medication has been reported to be associated with medication-related osteonecrosis of the jaw (MRONJ). This systematic review aims at investigating the incidence of and risk factors for MRONJ after tooth extractions in cancer patients treated with high-dose bisphosphonate and denosumab (BP and DS). MATERIAL AND METHODS: The protocol followed the PRISMA statement list and was registered in PROSPERO. Searches were performed for literature published up to April 2021 in the electronic databases PubMed, Embase, Web of Science, and CINAHL and then supplemented by manual research.

RESULTS

The search process resulted in 771 identified articles, of which seven studies fitted the population, intervention, comparison, and outcome framework. All were observational studies and four had control groups. A total of 550 patients treated with BP and DS were identified of whom 271 had received tooth extractions after medication onset. Due to significant heterogenicity in the collected data, only a qualitative analysis was performed. The MRONJ incidence after tooth extractions varied between 11% and 50% at the patient level. MRONJ occurred up to 3 years after the tooth extraction. Teeth affected by inflammation before the extraction and additional osteotomy during the surgical procedure were identified as risk factors.

CONCLUSIONS

Reliable methods of diagnosing MRONJ and adequate follow-up periods are important factors in obtaining the actual incidence of MRONJ after tooth extractions in patients treated with high-dose BP and DS.

Management of Tooth Extraction in Patients Taking Antiresorptive Drugs: An Evidence Mapping Review and Meta-Analysis

BACKGROUND

Medication-related osteonecrosis of the jaw (MRONJ) is a well-known severe adverse reaction of antiresorptive, antiangiogenic or targeted therapies, and usually occurs after tooth extraction. This review is aimed at determining the efficacy of any intervention of tooth extraction to reduce the risk of MRONJ in patients taking antiresorptive drugs, and present the distribution of evidence in these clinical questions.

METHODS

Primary studies and reviews were searched from nine databases (Medline, EMBase, Cochrane Library, Scopus, WOSCC, Inspec, KCI-KJD, SciELO and GIM) and two registers (ICTRP and ClinicalTrials.gov) to 30 November 2022. The risk of bias was assessed with the ROBIS tool in reviews, and the RoB 2 tool and ROBINS-I tool in primary studies. Data were extracted and then a meta-analysis was undertaken between primary studies where appropriate.

RESULTS

Fifteen primary studies and five reviews were included in this evidence mapping. One review was at low risk of bias, and one randomized controlled trial was at moderate risk, while the other eighteen studies were at high, serious or critical risk. Results of syntheses: (1) there was no significant risk difference found between drug holiday and drug continuation except for a subgroup in which drug continuation was supported in the reduced incidence proportion of MRONJ for over a 3-month follow-up; (2) the efficacy of the application of autologous platelet concentrates in tooth extraction was uncertain; (3) there was no significant difference found between different surgical techniques in any subgroup analysis; and (4) the risk difference with antibacterial prophylaxis versus control was -0.57, 95% CI -0.85 to -0.29.

CONCLUSIONS

There is limited evidence to demonstrate that a drug holiday is unnecessary (and may in fact be potentially harmful) in dental practice. Primary closure and antibacterial prophylaxis are recommended despite limited evidences. All evidence have been graded as either of a low or very low quality, and thus further high-quality randomized controlled trials are needed to answer this clinical question.

Medication-Related Osteonecrosis of the Jaw in Cancer Patients: Result from the OneFlorida Clinical Research Consortium

Medication-related osteonecrosis of the jaw (MRONJ) is a rare but severely debilitating drug-induced bone disorder in the jawbone region. The first MRONJ was reported in 2003 after bisphosphonate (BP) exposure. Recently, other drugs, such as receptor activator of NF-κB ligand (RANKL) inhibitor denosumab and antiangiogenic agents, were also associated with MRONJ. The purpose of this study was to evaluate the incidence and risk factors for MRONJ related to BPs or denosumab in cancer patients in real-world clinical settings using data from the OneFlorida Clinical Research Consortium. We queried the electronic health records of participants with prescriptions of intravenous (IV) BPs or denosumab between January 1, 2012, and September 1, 2021, in the OneFlorida Consortium. Time to MRONJ diagnosis was evaluated using the Kaplan-Meier method, and Cox regression analysis was performed to estimate the adjusted hazard ratios (HRs) and 95% confidence intervals (CIs) for MRONJ. A total of 5689 participants had one or more prescriptions of IV BP or denosumab within this study period and were included in this study. Among these participants, 52 (0.9%) had a diagnosis of MRONJ. The overall rate of MRONJ was 0.73%, 0.86%, and 3.50% in the cancer patients treated with IV BPs, denosumab, and sequential IV BPs and denosumab, respectively. The risk of MRONJ was similar in participants treated with denosumab alone compared to those treated with IV BPs alone (HR: 1.25, 95% CI: 0.66-2.34, p = .49). Patients with sequential prescription of IV BP and denosumab were at much higher risk for MRONJ, with an adjusted HR of 4.49, 95% CI of 1.96-10.28, p = .0004. In conclusion, in real-world clinical settings, the rates of MRONJ associated with IV BPs and denosumab were similar, while the sequential treatment of these two drug classes was associated with a much higher risk of MRONJ. © 2022 American Society for Bone and Mineral Research (ASBMR).

Assessment of clinical guidelines for medication-related osteonecrosis of the jaw: current status and future directions

OBJECTIVE

To evaluate the current quality and utility of clinical practice guidelines (CPGs) issued for the diagnosis, prevention, and treatment of medication-related osteonecrosis of the jaw (MRONJ).

STUDY DESIGN

We performed a systematic literature search of guidelines for MRONJ diagnosis, staging, prevention, or management. An appraisal of guidelines was completed using the Appraisal of Guidelines for Research and Evaluation (AGREE II) instrument. Scaled domain scores were calculated for each domain. Key recommendations were abstracted from guidelines distinguished as "high" quality.

RESULTS

Six CPGs were identified from systematic review. Four of 6 (66.7%) guidelines were published within the last 2 years. Each guideline discussed management of antiresorptive and antiangiogenic therapy-associated osteonecrosis of the jaw. The highest-scoring domain was domain 1: "Scope and purpose," with an average score of 85.0% (range: 76.4%-100.0%). The lowest domain score was in domain 5: "Applicability," with an average score of 41.7% (range: 22.9%-92.7%). Only 2 guidelines (33.3%) met the quality threshold of > 60% in 5 or more AGREE II domains, distinguishing them as "high"-quality guidelines. The average kappa statistic calculated across domains was 0.77, suggesting substantial interrater correlation in the CPG appraisal process.

CONCLUSIONS

Despite the increasing recognition of MRONJ as a debilitating consequence of antiresorptive and antiangiogenic therapy, clinical guideline recommendations may be lacking in overall quality and clinical utility.

Incidence of Atypical Femoral Fractures in Patients on Osteoporosis Therapy – a Registry‐based Cohort Study

Atypical femoral fractures (AFFs) have been reported in patients taking bisphosphonates (BPs) for osteoporosis therapy but also in patients with no exposure to these drugs. In contrast, less is known about the incidence of AFFs in patients taking denosumab. This registry‐based cohort study analyzed the incidence of AFFs in patients with suspected or confirmed osteoporosis who were included in the osteoporosis register of the Swiss Society of Rheumatology between January 2015 and September 2019. Statistical analyses included incidence rates, rate ratios, and hazard ratios for AFFs, and considered sequential therapies and drug holidays as time‐dependent covariates. Among the 9956 subjects in the cohort, 53 had subtrochanteric or femoral shaft fractures. Ten fractures occurred under BP or denosumab treatment and two under teriparatide therapy. Five fractures were classified as AFFs based on the revised American Society of Bone and Mineral Research case definition of AFFs from 2014. Three AFFs occurred in women being treated with denosumab at the time of diagnosis, all with prior BP use (10, 7, and 1 years, respectively). One AFF developed in a woman receiving ibandronate and one arose in a woman receiving glucocorticoids rather than antiresorptive therapy. The incidence of AFFs per 10,000 observed patient‐years was 7.1 in patients receiving denosumab and 0.9 in patients with BP‐associated AFFs, yielding a rate ratio of 7.9 (95% confidence interval [CI] 0.63–413), p = 0.073. The risk of AFFs was not significantly higher in patients receiving denosumab therapy compared with BP therapy (hazard ratio = 7.07, 95% CI 0.74–68.01, p = 0.090). We conclude that the risk of AFFs is low in patients taking BPs, denosumab, or both sequentially. All three patients with AFFs under denosumab therapy had undergone prior BP therapy. © 2022 The Authors. JBMR Plus published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research.

One changing and challenging scenario: the treatment of cancer patients with bone metastases by bisphosphonates and denosumab, the cost-benefit evaluation of different options, and the risk of medication-related osteonecrosis of the jaw (MRONJ)

Antiresorptive drugs (bisphosphonates and denosumab) have become the cornerstone of medical supportive treatment of bone metastases in solid cancer patients. In the beginning, the choice of available antiresorptive agents was limited to bisphosphonates and the treatment options restricted principally to monthly pamidronate and monthly zoledronic acid. Introduction of new antiresorptive therapies (monthly denosumab) and schedules (zoledronic acid every 3 months, upfront or after initial period of monthly infusion) in the last decade increased the range of available options, thus challenging treatment decision making. Direct and indirect costs of very different treatment options are difficult to interpret in a global cost-benefit analysis. In addition, awareness of the increased risk of medication-related osteonecrosis of the jaw (MRONJ) in bone metastatic cancer patients receiving long-term antiresorptive medications is likely to influence therapy choice in the real-life scenario. We discuss the possible threat of MRONJ risk underestimation and the need for long-term risk stratification of patients based on actuarial data, the role of bisphosphonates and denosumab in that scenario, and the emerging role of surgical therapy to successfully cure MRONJ, in the light of the improved quality of life and survival of patients with bone metastases from solid cancers.

The Role of Geranylgeraniol in Managing Bisphosphonate-Related Osteonecrosis of the Jaw

Medication-related osteonecrosis of the jaw (ONJ) is a rare but significant adverse side effect of antiresorptive drugs. Bisphosphonate-related ONJ (BRONJ) is the most prevalent condition due to the extensive use of the drug in cancer and osteoporosis treatment. Nitrogen-containing bisphosphonates suppress osteoclastic resorption by inhibiting farnesyl pyrophosphate synthase in the mevalonate pathway, leading to deficiency of the substrate for GTPase prenylation. The bone remodelling process is uncoupled, subsequently impairing bone healing and causing ONJ. Targeted administration of geranylgeraniol (GGOH) represents a promising approach to mitigate BRONJ because GGOH is a substrate for GTPase prenylation. In the current review, the in vitro effects of GGOH on osteoclasts, osteoblasts and other related cells of the jaw are summarised. We also present and appraise the current in vivo evidence of GGOH in managing BRONJ in animal models. Lastly, several considerations of using GGOH in the clinical management of BRONJ are highlighted. As a conclusion, GGOH is a promising topical agent to manage BRONJ, pending more research on an effective delivery system and validation from a clinical trial.

Osteonecrosis of the Jaw and Antiresorptive Agents in Benign and Malignant Diseases: A Critical Review Organized by the ECTS

CONTEXT

Antiresorptive therapy significantly reduces fracture risk in patients with benign bone disease and skeletal-related events (SREs) in patients with bone metastases (BM). Osteonecrosis of the jaw (ONJ) is a rare but severe condition manifested as necrotic bone lesion or lesions of the jaws. ONJ has been linked to the use of potent antiresorptive agents, termed medication-related ONJ (MRONJ).

OBJECTIVE

We aimed to identify the differences various aspects of MRONJ among distinct patient categories and provide recommendations on how to mitigate the risk and optimally manage MRONJ in each of them.

METHODS

A working group of the European Calcified Tissue Society (ECTS) and 2 experts performed an updated detailed review of existing literature on MRONJ incidence, characteristics, and treatment applied in bone diseases with variable severity of skeletal insult, ranging from osteoporosis to prevention of cancer treatment-induced bone loss and SREs in cancer patients with BM.

RESULTS

The risk for MRONJ is much higher in patients with advanced malignancies compared to those with benign bone diseases because of the higher doses and more frequent administration of antiresorptive agents in individuals with compromised general health, along with coadministration of other medications that predispose to MRONJ. The overall risk for MRONJ is considerably lower than the benefits in all categories of patients.

CONCLUSION

The risk for MRONJ largely depends on the underlying bone disease and the relevant antiresorptive regimen applied. Physicians and dentists should keep in mind that the benefits of antiresorptive therapy far outweigh the risk for MRONJ development.

A Retrospective Data Analysis for the Risk Evaluation of the Development of Drug-Associated Jaw Necrosis through Dentoalveolar Interventions

This study aimed to analyse the development of medication-related osteonecrosis of the jaw (MRONJ) in patients who underwent surgical intervention to identify potential risk factors between three different groups sorted by the type of oral surgery (single tooth extraction, multiple extraction, osteotomy). Data from patients with this medical history between 2010 and 2017 were retrospectively analysed. The following parameters were collected: sex, age, medical status, surgical intervention location of dentoalveolar intervention and form of medication. A total of 115 patients fulfilled the criteria and underwent 115 dental surgical interventions (female n = 90, male n = 25). In total, 73 (63.47%) of them had metastatic underlying diseases, and 42 (36.52%) had osteoporotic ones. MRONJ occurred in 10 patients (8.70%) (female n = 5, male n = 5). The occurrence of MRONJ was significantly correlated (p ≤ 0.05) with the mandible site and male sex. Tooth removal at the mandible site remains the main risk factor for the development of MRONJ. The risk profile of developing MRONJ after dentoalveolar interventions could be expected as follows: tooth osteotomy > multiple extractions > single tooth extraction.

Risk of Osteonecrosis of the Jaw Under Denosumab Compared to Bisphosphonates in Patients With Osteoporosis

Osteonecrosis of the jaw (ONJ) is a rare but serious adverse event associated with antiresorptive treatment. There is little evidence regarding the incidence of ONJ among patients with osteoporosis who are treated with denosumab versus bisphosphonates (BPs). The aim of this study was to determine the risk of ONJ in a real-world population. Subjects who underwent at least one dual-energy X-ray absorptiometry (DXA) examination were included in the osteoporosis register of the Swiss Society of Rheumatology between January 1, 2015, and September 30, 2019. Statistical analyses included incidence rates, rate ratios, and hazard ratios for ONJ, considering sequential therapies and drug holidays as covariates. Among 9956 registered patients, 3068 (89% female, median age 69 years [63 to 76]) were treated with BPs or denosumab for a cumulative duration of 11,101 and 4236 patient-years, respectively. Seventeen cases of ONJ were identified: 12 in patients receiving denosumab at the time of ONJ diagnosis and 5 in patients receiving oral or intravenous BP therapy. The diagnosis of ONJ was confirmed by independent and blinded maxillofacial surgeons, using the American Association of Oral and Maxillofacial Surgeons case definition of ONJ. The incidence of ONJ per 10,000 observed patient-years was 28.3 in patients receiving denosumab and 4.5 in patients with BP-associated ONJ, yielding a rate ratio of 6.3 (95% confidence interval [CI] 2.1 to 22.8), p < 0.001. Nine of 12 patients who developed ONJ during denosumab treatment had been pretreated with BPs, but none of the 5 patients with BP-related ONJ had previously received denosumab. The risk of ONJ was higher in patients receiving denosumab therapy compared with BPs (hazard ratio 3.49, 95% CI 1.16 to 10.47, p = 0.026). Previous BP therapy before switching to denosumab may be an additional risk factor for ONJ development. © 2021 American Society for Bone and Mineral Research (ASBMR).

Medication-Related Osteonecrosis of the Jaw (MRONJ): A Review of Pathophysiology, Risk Factors, Preventive Measures and Treatment Strategies

Medication-related osteonecrosis of the jaw (MRONJ) is a major problem that can occur in people taking certain medications such bisphosphonates and denosumab. It can be used to treat osteoporosis or cancer. Bisphosphonate exposure, dental diseases and procedures, age, sex, anatomical factors, medical issues, and hereditary factors are all variables that enhance the risk of MRONJ. Even though MRONJ and antiresorptive medications have a close association, the pathophysiology of MRONJ is unknown. Careful dental preparation and oral hygiene instructions significantly minimize the risk of osteonecrosis of the jaw (ONJ). It is ideal to start antiresorptive treatment after the completion of required dental treatment; it is not contraindicated and carries low risk in patients who are on oral antiresorptive medications for less than three years. Drug holidays are one proposed solution to address MRONJ. However, there is still inadequate evidence to support their effectiveness. The objectives of this literature review are to recognize the main diagnostic principles and risk factors and to review the pathophysiology, protective procedures and treatment modalities related to MRONJ.

The following topics are covered in the review: epidemiology, diagnostic criteria, risk factors, pathogenesis and mechanism, MRONJ staging and symptoms, clinical and radiographic findings, treatment strategies, prevention and drug holiday.

Medication Related Osteonecrosis of the Jaw: 2021 Position Statement of the Korean Society for Bone and Mineral Research and the Korean Association of Oral and Maxillofacial Surgeons

Antiresorptives are the most widely prescribed drugs for the treatment of osteoporosis. They are also used in malignant bone metastases, multiple myeloma, and Paget's disease, and provide therapeutic efficacy on those diseases. However, it was reported that the occurrence of osteonecrosis of the jaw (ONJ) could be related to antiresorptive exposures, and there have been many cases regarding this issue. Therefore, a clearer definition and treatment guidelines were needed for this disease. The American Society for Bone and Mineral Research and the Amnerican Association of Oral and Maxillofacial Surgeons reported statements on bisphosphonate-related ONJ (BRONJ), and a revised version was recently presented. In the revised edition, the diagnosis BRONJ was changed to medication-related ONJ (MRONJ), which reflects consideration of the fact that ONJ also occurs for denosumab, a bone resorption inhibitor of the receptor activator of the nuclear factor-κB ligand antibody family, and bevacizumab, an anti-angiogenesis inhibitor. The Korean Society for Bone and Mineral Research and the Korean Association of Oral and Maxillofacial Surgeons had collectively formed a task force for the preparation of an official statement on MRONJ based on a previous position paper in 2015. The task force reviewed current knowledge and coordinated dental and medical opinions to propose the guideline customized for the local Korean situation.

Medication-Related Osteonecrosis of the Jaw in Patients Treated Concurrently with Antiresorptive and Antiangiogenic Agents: Systematic Review and Meta-Analysis

Introduction

Medication-related osteonecrosis of the jaws (MRONJ) is a known adverse event related to the use of antiresorptive (AR) drugs. More recently, an association between antiangiogenic (AA) drugs and MRONJ has been suggested. This review aimed to investigate the overall prevalence and relative risk of MRONJ in patients treated concurrently with AA and AR agents in comparison with a single AA or AR drug.

Methods

A review protocol was registered with PROSPERO (ID: CRD42020214244). A systematic literature search, study selection, quality assessment, and data extraction were carried out following PRISMA guidelines. Random-effects meta-analysis models were used to summarize relative estimates for the outcomes, namely prevalence and relative risk of MRONJ. Exposure variable included type of drug, specifically AA and AR agents administered either concurrently or individually.

Results

Eleven studies were included in the final qualitative and quantitative syntheses. The overall pooled weighted prevalence of MRONJ with concurrent AA-AR drugs was 6% (95% CI: 3–8%), compared with 0% (95% CI: 0–0%) for AA only and 5% (95% CI: 0–10%) for AR only. However, high heterogeneity was noted among included studies. Retrospective cohort studies showed a higher pooled prevalence of 13% (95% CI: 10–17%) for concurrent AA-AR therapy. The pooled risk ratio for MRONJ revealed a risk with concurrent AA-AR drugs 2.57 times as high as with AR only (95% CI: 0.84–7.87); however, this difference was not statistically significant. Concurrent AA-AR drugs had a risk for MRONJ 23.74 times as high as with AA only (95% CI: 3.71–151.92).

Conclusions

High-quality, representative studies are needed for accurate estimation of relative risk of MRONJ with concurrent AA and AR therapy.

Medication-Related Osteonecrosis of the Jaw: A Critical Narrative Review

Background: Nearly two decades have passed since a paradoxical reaction in the orofacial region to some bone modifying agents and other drugs was recognized, namely medication-related osteonecrosis of the jaw (MRONJ). Purpose: The aim of this manuscript was to critically review published data on MRONJ to provide an update on key terminology, concepts, and current trends in terms of prevention and diagnosis. In addition, our objective was to examine and evaluate the therapeutic options available for MRONJ. Methods: The authors perused the most relevant literature relating to MRONJ through a search in textbooks and published articles included in several databases for the years 2003–2021. Results and conclusions: A comprehensive update of the current understanding of these matters was elaborated, addressing these topics and identifying relevant gaps of knowledge. This review describes our updated view of the previous thematic blocks, highlights our current clinical directions, and emphasizes controversial aspects and barriers that may lead to extending the accumulating body of evidence related to this severe treatment sequela.

Oral and Maxillo-Facial Manifestations of Systemic Diseases: An Overview

Many systemic (infective, genetic, autoimmune, neoplastic) diseases may involve the oral cavity and, more generally, the soft and hard tissues of the head and neck as primary or secondary localization. Primary onset in the oral cavity of both pediatric and adult diseases usually represents a true challenge for clinicians; their precocious detection is often difficult and requires a wide knowledge but surely results in the early diagnosis and therapy onset with an overall better prognosis and clinical outcomes. In the current paper, as for the topic of the current Special Issue, the authors present an overview on the most frequent clinical manifestations at the oral and maxillo-facial district of systemic disease.