Osteonecrosis of the jaw in patients treated with denosumab for metastatic tumors to the bone: A series of thirteen patients

Bisphosphonates and osteonecrosis of the jaws: Clinical and forensic aspects

OBJECTIVE

This manuscript aims to provide a comprehensive review of the current knowledge in the pathophysiology, diagnosis, prevention, and other relevant clinical and forensic aspects of a potentially severe complication known as medication-related osteonecrosis of the jaw (MRONJ) while synthesizing state-of-the-art information on bisphosphonates and introducing a possible differential diagnosis.

DESIGN

An extensive search was conducted in PubMed (U.S. National Library of Medicine) without a time or language constraint, focusing on the epidemiology, pathophysiology, risk factors, site specificity, signs and symptoms, differential diagnosis, prevention, and forensic aspects of MRONJ. All types of original articles, reviews, case reports, short communications, opinion articles, guidelines, and letters to editors were considered to produce a complete review on this subject.

RESULTS

MRONJ prevention relies on a multidisciplinary approach and is critical since truly effective treatments are lacking. This therapeutic challenge is partly due to uncertainty regarding this condition's pathophysiology. Differential diagnosis of osteonecrosis of the jaws associated with krokodil abuse, one of the most dangerous and homemade psychoactive illicit substances, should be considered.

CONCLUSIONS

Further research into the etiology and site specificity of MRONJ is encouraged, aiming to develop novel treatment prospects. Indeed, comprehending this would allow for increased efficacy and therapeutic options while emphasizing the importance of prevention. In addition, we advocate for greater consensus among the various societies regarding MRONJ's treatment and management.

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.

Anti-VEGFR therapy is one of the healing inhibitors of antiresorptive-related osteonecrosis of the jaw

INTRODUCTION

Antiresorptive-related osteonecrosis of the jaw (ARONJ) is a rare but serious adverse event associated with bone-modifying agents (BMAs) and affects patients in the terminal stages of cancer. Molecular targeting drugs (MTDs), anti-vascular endothelial growth factor receptor (VEGFR), and anti-epidermal growth factor receptor (EGFR) drugs are essential in various cancer treatments, although MTDs are risk factors for ARONJ. However, the mechanism through which MTDs affect treatment prognosis of ARONJ remains unclear. Therefore, we investigated the potential inhibitory factors for healing in the conservative therapy of ARONJ with a focus on MTDs.

MATERIALS AND METHODS

Sixty patients who were administered BMAs for the treatment of malignancies and who underwent conservative treatment for ARONJ were assessed. The healing rate of ARONJ for each risk factor was retrospectively evaluated.

RESULTS

Among the 60 patients, 27 were male and 33 were female. The median age was 67 years, and the median follow-up period was 292 (range 91-1758) days. The healing rate was lower in those treated with both zoledronic acid (Za) and denosumab (Dmab) than in those treated with Za or Dmab alone (0% vs. 28.8%, p = 0.03). Regarding the administration of MTDs, the treatment rate with anti-VEGFR drugs was 7.1% (p = 0.04), anti-EGFR drugs was 12.5% (p = 0.18), and without MTDs was 36.8%.

CONCLUSION

In the conservative treatment of ARONJ, the administration of several BMAs and anti-VEGFR drugs was the factor contributing to the inhibition of healing.

New-generation anticancer drugs and medication-related osteonecrosis of the jaw (MRONJ): Late onset 3 years after ipilimumab endovenous administration with a possible role of target therapy

Association of immunotherapy and/or chemotherapy and/or targeted therapy, in sequence or as single therapies, may induce osteonecrosis of the jaw. Multidisciplinary team management of these patients should be provided.

[Progress on medication-related osteonecrosis of the jaw]

Medication-related osteonecrosis of the jaw (MRONJ) is a severe complication of bisphosphonates (BPs) or other targeted agent therapies. MRONJ appears as exposed bone, pus, and swelling in the oral and maxillofacial regions. However, neither surgery nor conservative therapy can eliminate symptoms thoroughly. In addition to BPs, several antiresorptive and antiangiogenic agents, such as denosumab and bevacizumab, as well as targeted agents, such as sunitinib and temsirolimus, can cause osteonecrosis of  the  jaw according to the literature. This review aims to summarize the research progress on these new drugs.

Osteonecrosis of the jaw in patients transitioning from bisphosphonates to denosumab treatment for osteoporosis

Antiresorptive-related osteonecrosis of the jaw (ARONJ) is a rare but severe side effect of antiresorptive treatment with bisphosphonates or RANKL-antibody denosumab in patients with malignant diseases or osteoporosis. Whilst osteonecrosis of the jaw (ONJ) related to the administration of bisphosphonates (BPs) has been investigated for more than 1 decade now, only few data are available on denosumab-related ONJ, especially in patients with osteoporosis. From 2008 to 2016, 52 osteoporosis patients were treated with ARONJ in the Department of Oral and Maxillofacial Surgery, University Medical Center Freiburg, Germany. In all patients, a surgical regimen consisting of complete removal of necrotic bone, primary wound closure and perioperative i.v. antibiotic therapy was applied. Of the 52 patients, 38 developed ARONJ after BP monotherapy; in 11 patients, antiresorptive therapy had been transitioned from BPs to denosumab and 3 patients had received denosumab monotherapy. From July 2013, when the first patient with ONJ and transitioning therapy from BPs to denosumab presented to our department, to October 2016, we found recurrences in 17.6% of the patients with BP monotherapy and in 45.5% of the patients with transitioning therapy from BPs to denosumab. Transitioning antiresorptive therapy from BPs to denosumab may be an additional risk factor for developing ARONJ. In these patients, treatment of ARONJ-lesions seems to provoke more complications. An additional dental screening before transitioning should be initiated. Further studies are needed to evaluate if a first-line treatment with denosumab decreases the incidence of ARONJ in patients with osteoporosis and simplifies its treatment.

Medication-related osteonecrosis of the jaw: An update on the memorial sloan kettering cancer center experience and the role of premedication dental evaluation in prevention

OBJECTIVE

The aim of this study was to investigate the relationship between type of antiresorptive medication and medication-related osteonecrosis of the jaw (MRONJ) onset and the role of premedication dental evaluation (PMDE) in the prevention of MRONJ.

STUDY DESIGN

Our database of patients with MRONJ was reviewed. The Kruskal-Wallis test was used to analyze the onset dose of the 3 frequent medication types associated with MRONJ. To evaluate the role of PMDE in the prevention of MRONJ, all patients on antiresorptive and/or antiangiogenic medications seen in the Dental Service of Memorial Sloan Kettering Cancer Center during a 10-year period were subclassified into 2 groups. Group I comprised patients seen for PMDE before the commencement of A/A and group II patients seen after prior exposure to antiresorptive and/or antiangiogenic medications. Fischer's exact test was used to compare the incidence of MRONJ in both groups.

RESULTS

Patients on denosumab developed MRONJ earlier compared with zoledronate and pamidronate (P = .003). Group I had a significantly reduced incidence of MRONJ (0.9%) compared with group II (10.5%) (P < .0001). Dentoalveolar trauma as a precipitating factor between groups I and II was not statistically significant.

CONCLUSIONS

Denosumab was associated with an earlier occurrence of MRONJ compared with zoledronate and pamidronate. The role of PMDE may be an effective preventive strategy in reducing the incidence of MRONJ.

Meth Mouth-A Growing Epidemic in Dentistry?

In the past two decades, the synthetic style and fashion drug “crystal meth” (“crystal”, “meth”), chemically representing the crystalline form of the methamphetamine hydrochloride, has become more and more popular in the United States, in Eastern Europe, and just recently in Central and Western Europe. “Meth” is cheap, easy to synthesize and to market, and has an extremely high potential for abuse and dependence. As a strong sympathomimetic, “meth” has the potency to switch off hunger, fatigue and, pain while simultaneously increasing physical and mental performance. The most relevant side effects are heart and circulatory complaints, severe psychotic attacks, personality changes, and progressive neurodegeneration. Another effect is “meth mouth”, defined as serious tooth and oral health damage after long-standing “meth” abuse; this condition may become increasingly relevant in dentistry and oral- and maxillofacial surgery. There might be an association between general methamphetamine abuse and the development of osteonecrosis, similar to the medication-related osteonecrosis of the jaws (MRONJ). Several case reports concerning “meth” patients after tooth extractions or oral surgery have presented clinical pictures similar to MRONJ. This overview summarizes the most relevant aspect concerning “crystal meth” abuse and “meth mouth”.

Rapid onset of osteonecrosis of the jaw in patients switching from bisphosphonates to denosumab

OBJECTIVE

The aim of this study was to determine whether osteonecrosis of the jaw (ONJ) developed more rapidly in patients who switched from bisphosphonates (BP) treatment to denosumab than in patients who received only denosumab.

STUDY DESIGN

This was a retrospective cohort study conducted at a tertiary referral center. Thirty-one patients with ONJ met the inclusion criteria.

RESULTS

Twenty-two patients who had been on BP were switched to denosumab (BP + D), whereas 9 patients received only denosumab. Both groups were similar for the known ONJ risk factors, that is, age, diabetes mellitus, and smoking. The number and cumulative doses of denosumab before the onset of ONJ symptoms were significantly lower among the BP + D group compared with the denosumab-only group (P = .025 and .018, respectively). In the BP + D group, ONJ symptoms developed in 9 patients (41%) following the administration of ≤3 denosumab doses compared with ONJ developing in only 1 patient (11%) who was naïve to BP. ONJ developed spontaneously without any known triggering event in 72.7% of patients in the BP + D group and in 77.8% of patients in the denosumab-only group.

CONCLUSIONS

Denosumab-induced ONJ might develop rapidly in patients previously treated with BP. ONJ developed spontaneously in most patients treated with denosumab. In light of our sample being small, there is need for further investigation on our conclusions.

Denosumab: Current Use in the Treatment of Primary Bone Tumors

Denosumab, a human monoclonal antibody that inhibits bone resorption by binding on the receptor activator of the nuclear factor kappa-β ligand, has recently emerged as an additional option in the treatment of musculoskeletal osteolytic tumors. This article focuses on the recent literature regarding the effectiveness of denosumab in the management of giant cell tumor, multiple myeloma, aneurysmal bone cyst, and osteosarcoma. The mechanism of action of denosumab in the management of these tumors and the associated side effects are discussed in detail. [ Orthopedics. 2017; 40(4):204-210.].

Denosumab-related osteonecrosis of the jaw in a patient with bone metastases of prostate cancer: A case report and literature review

Denosumab, a human monoclonal antibody directed against the receptor activator of nuclear factor-κβ ligand (RANKL), is used for the treatment of patients with metastatic cancer of the bone or osteoporosis. Recent reports have demonstrated that denosumab can induce osteonecrosis of the jaw (ONJ), but reported cases of this are uncommon. The present study reports the case of an 86-year-old male with prostate cancer patient exhibiting bone metastases who developed ONJ whilst receiving denosumab. To elucidate the influence of denosumab on the development of ONJ, the present study also reviewed the literature, including clinical trials and case reports. In the clinical trials, the prevalence of denosumab-related ONJ was higher in patients with cancer compared with those with osteoporosis. The high risk of ONJ in patients with cancer was thought to be associated with the differing dose and frequency of denosumab administration. The prevalence of ONJ was not significantly different between patients receiving denosumab and bisphoshonate (BP). In the reported cases, denosumab-related ONJ had a similar clinical presentation to BP-related ONJ. There was also a tendency for denosumab-related ONJ to develop in the mandible of elderly patients. Previous invasive dental treatment was a commonly shared characteristic of patients with denosumab-related ONJ. A complex medical history was also suspected to affect the prevalence. No clear association between the dose or duration of denosumab treatment and the development of ONJ was observed. Although conservative treatments are given for denosumab-related ONJ, non-improving cases were managed surgically with primarily positive results. Because denosumab may offer superior results compared with BP for the treatment of metastatic cancer of the bone or osteoporosis, the use of denosumab is expected to increase in the near future. Clinicians should also be aware of the risk factors for denosumab-related ONJ, in order to aid in its diagnosis. In addition, patients treated with denosumab should receive prophylactic treatment to maintain their oral health prior to, during and after denosumab treatment.

Pentoxifylline and tocopherol in the management of cancer patients with medication-related osteonecrosis of the jaw: an observational retrospective study of initial case series

OBJECTIVE

Very few studies have evaluated the efficacy of pentoxifylline and tocopherol (PENT-E) in the management of medication-related osteonecrosis of the jaw (MRONJ), although some studies have shown the therapeutic and prophylactic benefit of PENT-E in the management of osteoradionecrosis. We report the outcomes of MRONJ managed with PENT-E in patients with metastatic bone disease or multiple myeloma.

STUDY DESIGN

Seven patients diagnosed with established cases of refractory MRONJ caused by antiresorptive medications for the management of metastatic bone tumors or multiple myeloma were administered PENT-E for a mean period of 16.8 months (range 3-48 months).

RESULTS

At the latest follow-up visit, all patients demonstrated relief of symptoms. There was radiographic evidence of new bone fill of prior radiolucent defect in all patients. Two patients had resolution of exposed bone, two patients had partial resolution, one patient had no change in exposed bone, and one patient with three sites of exposed bone before starting PENT-E had resolution in one site, partial resolution in another site, and no change in the third site. PENT-E was well tolerated in all patients.

CONCLUSIONS

Our case series demonstrated that PENT-E was well tolerated and may be an effective adjunct in the management of MRONJ.