Medication-related osteonecrosis of the jaw (MRONJ) stage III: Conservative and conservative surgical approaches versus an aggressive surgical intervention: A systematic review

Evaluating the efficacy of surgical and non-surgical treatment modalities in the management of medication-related osteonecrosis of the jaw: a retrospective study

OBJECTIVE

Our primary goal is to examine the efficacy of surgical and non-surgical therapy in treating Medication-related osteonecrosis of the jaw (MRONJ).

STUDY DESIGN

Retrospective data were obtained from patients treated between 1st June 2011 to 1st December 2021. Included patients were classified into surgical and non-surgical therapy. The primary outcome measure is to assess the treatment's effect on the disease stage. Secondary outcome measures include the time to mucosalisation, exposed bone area, presence of infection, improvement in pain and paraesthesia, and qualitative assessment of radiographic presentation.

RESULTS

48 patients with 57 MRONJ sites were included in this study. The mean follow-up duration was 30.2 months (SD = 25 months). Neither smoking, alcohol use, nor any of the comorbidities significantly affected the treatment outcome of the disease. The drug administration mode influenced the treatment outcome (p = 0.00413). MRONJ lesions that were treated with surgery displayed statistically significant improvement (p = 0.018) in disease staging. The time taken for mucosalisation was faster after surgery (p = 0.00052). Regarding secondary outcomes, surgical therapy resulted in a significant improvement in the resolution of purulence (p = 0.041). No significant difference was observed for radiographic healing, exposed bone area, or pain.

CONCLUSION

Surgical therapy results in significant clinical improvement of MRONJ lesions compared to non-surgical therapy. However, non-surgical therapy can effectively prevent disease progression. Depending on the therapeutic goals, both treatment modalities are appropriate for managing MRONJ.

Fibula flap reconstruction for maxillary stage 3 medication-related osteonecrosis of the jaw from recipient and donor site perspectives: a preliminary single-center study

BACKGROUND

While the surgical treatment of mandibular stage 3 medication-related osteonecrosis of the jaw (MRONJ) is well-documented, research on maxillary stage 3 MRONJ is limited. Antiresorptive medications can induce MRONJ and atypical femoral fracture (AFF), but their impact on the feasibility of using fibula flaps for reconstruction remains controversial. This study aimed to assess the surgical outcomes and functional recovery of fibula flap reconstruction for maxillary stage 3 MRONJ, considering both recipient and donor site outcomes.

METHODS

This retrospective study included patients with maxillary stage 3 MRONJ who underwent fibula flap reconstruction. Demographic and clinical features, postoperative complications, long-term outcomes and functional recovery of both recipient and donor sites were analyzed. Long-term outcomes included the survival of fibula flaps, the incidence of fibula graft or tibia fractures, recurrence of MRONJ, and patient survival status. Function assessments focused on speech, swallowing, and ankle joint.

RESULTS

Seven patients (two with multiple myeloma, five with bone metastases) were included. Two patients experienced delayed healing at the donor site, both of whom recovered within two months postoperatively. All fibula flaps survived with primary healing. There were no recurrences of MRONJ or fractures of fibula graft or tibia. The mean speech function score was 28.00 ± 12.03, the mean swallowing function score was 2.86 ± 2.79, the mean pain score of donor site was 2.71 ± 2.29, and the mean ankle function score was 94.43 ± 4.35.

CONCLUSION

Fibula flap reconstruction is feasible for maxillary stage 3 MRONJ, yielding satisfactory surgical outcomes and functional recovery.

Management of Medication-Related Osteonecrosis of the Jaw: An Overview of National and International Guidelines

There is variability amongst clinicians in the management of medication-related osteonecrosis of the jaw (MRONJ) though numerous guidelines are available. The aim of this critical review is to appraise current international and national guidelines on MRONJ to evaluate areas of consensus or inconsistency, identify areas lacking evidence, and discuss recommendations with agreement and variability across guidelines. A literature search was performed to identify all national and international guidelines published until May 2022 on the prevention and treatment of MRONJ. Included guidelines were compared and critically appraised with Appraisal of Guidelines for Research and Evaluation II (AGREE II). The included sixteen guidelines were published from ten different countries, two of which had international collaborations. AGREE II assessment found four guidelines of high quality. There is consensus to optimise oral health prior to and during therapy, to conservatively manage established MRONJ in earlier stages and consider surgery at advanced stages. There is disparity on strategies to reduce the risk of osteonecrosis such as the avoidance of invasive dental procedures, therapy suspension, and techniques to reduce the impact of invasive surgery. The authors recommend an international lead in the development of dental guidelines to establish a global standardised management approach aiming for better health equality.

Implant presence-triggered osteonecrosis: A scoping review

Unlike medication-related osteonecrosis of the jaw (MRONJ), implant presence-triggered osteonecrosis of the jaw (IPTO) is not well appreciated. Recent reports have suggested a mechanical aetiology unique to osseointegrated dental implants that may be responsible for this phenomenon. A scoping review was performed to consolidate the available evidence. Two reviewers independently searched the PubMed, EMBASE, CINAHL, and Cochrane Library databases. The study was performed according to the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) extension for scoping reviews. Studies that described or evaluated the development of IPTO in osseointegrated implants, which were placed prior to the commencement of anti-resorptive or anti-angiogenic agents, were included. Twenty-three (23) articles were included in this study. Patient characteristics, aetiopathogenesis, presentation, and treatment of the disease were evaluated. Most studies suggested a 6-month period between dental implant insertion and the commencement of anti-resorptive therapy as a criterion for IPTO. Both infective and mechanical processes were reported to be involved in the pathogenesis of IPTO. Most patients required surgical intervention to achieve resolution. While there are several knowledge gaps regarding IPTO, the evidence points towards a continuum in the pathogenesis of the disease, whereby there is a mechanical cause followed by secondary infection. Similar to typical MRONJ, the severity and treatment required also vary. Persistent peri‑implantitis features around a dental implant should alert the clinician to the possibility of IPTO in patients taking anti-resorptive or anti-angiogenic agents. Prompt identification of the disease may play a role in timely management or appropriate referrals.

Analysis of bone single-photon emission CT/CT and diffusion-weighted MR imaging in medication-related osteonecrosis of the jaw: focusing on the correlation between standardized uptake values and apparent diffusion coefficient values

The purpose of this study is to investigate bone SPECT/CT and diffusion-weighted MR imaging (DWI) in medication-related osteonecrosis of the jaw (MRONJ), focusing on the correlation between standardized uptake values (SUVs) and apparent diffusion coefficient (ADC) values. Twenty-nine patients with MRONJ who underwent SPECT/CT and DWI were included in this study. SUVs (maximum and mean) with SPECT/CT, and ADC values (maximum, mean and minimum) with DWI were analyzed on characteristics in MRONJ, such as stage, location, medication and underlying disease, by Mann-Whitney U test. Furthermore, the correlation between SUVs and ADC values for characteristics in MRONJ were assessed by Spearman's rank correlation test for nonparametric data. A p-value lower than 0.05 was considered as statistically significant. SUVs and ADC values have no significant differences for all characteristics in MRONJ. Negative correlations were found in all cases and in stage 2 cases, and no correlations were found in stage 3 cases. In addition, negative correlations were found in maxillary cases, mandibular cases, non-bisphosphonate cases, osteoporosis cases, and malignant tumor cases. In conclusion, this study found multiple correlations between SUVs and ADC values in MRONJ, especially in stage 2. Suggesting that ADC values and SUVs may change with disease progression and the possibility of predicting MRONJ progression by SUVs and ADC values.

Mitigating jaw osteonecrosis: bioactive glass and pericardial membrane combination in a rat model

Objectives

Bisphosphonates (BFs) show clinical effectiveness in managing osteoporosis and bone metastases but pose risks of bisphosphonate-related jaw osteonecrosis (BRONJ). With no established gold standard for BRONJ treatment, our focus is on symptom severity reduction. We aimed to assess the preventive effects of bioactive glass and/or pericardial membrane in a preclinical BRONJ model, evaluating their potential to prevent osteonecrosis and bone loss post-tooth extractions in zoledronic acid (ZA)-treated animals.

Methods

Rats, receiving ZA or saline biweekly for four weeks, underwent 1st and 2nd lower left molar extractions. Pericardial membrane alone or with F18 bioglass was applied post-extractions. Microarchitecture analysis and bone loss assessment utilized computerized microtomography (CT) and positron emission tomography (PET) with 18F-FDG and 18F-NaF tracers. Histological analysis evaluated bone injury.

Results

Exclusive alveolar bone loss occurred post-extraction in the continuous ZA group, inducing osteonecrosis, osteolysis, osteomyelitis, and abscess formation. Concurrent pericardial membrane with F18 bioglass application prevented these outcomes. Baseline PET/CT scans showed no discernible uptake differences, but post-extraction 18F-FDG tracer imaging revealed heightened glucose metabolism at the extraction site in the ZA-treated group with membrane, contrasting the control group.

Conclusion

These findings suggest pericardial membrane with F18 bioglass effectively prevents BRONJ in the preclinical model.

Preoperative Assessment of Medication-Related Osteonecrosis of the Jaw Using [18F]fluoride Positron Emission Tomography (PET)/CT and [18F]fluorodeoxyglucose PET/MRI in Correlation with Histomorphometry and Micro-CT-A Prospective Comparative Study

OBJECTIVES

The purpose of this study was to investigate the imaging characteristics of medication-related osteonecrosis of the jaw (MRONJ) using [18F]fluoride positron emission tomography/computed tomography (PET/CT) and [18F]fluorodeoxyglucose (FDG) PET/magnetic resonance imaging (MRI) for preoperative assessment and to correlate them with microarchitectural and histomorphometric data with respect to clinical findings.

METHODS

Twelve patients (five female; mean age 75 ± 7.6 yr) with symptomatic MRONJ underwent both scans on the same day, and imaging findings were used to plan surgical interventions for seven patients. Bone tracer uptake was classified as high, medium, or low, and surgical samples were evaluated using Micro-CT and histomorphometric analysis.

RESULTS

CT showed medullary sclerosis in all patients, and MRI revealed gadolinium enhancement in four patients. PET imaging revealed remarkably elevated [18F]fluoride uptake and moderately increased [18F]FDG uptake in MRONJ compared to healthy jawbones, with both differences being statistically significant. [18F]fluoride uptake was associated with necrosis, bacteria, and inflammatory tissue. Micro-CT data did not show significant differences, but histomorphometric analysis revealed higher osteocyte and lacunae densities in the high [18F]fluoride uptake group, and more necrotic bone in the medium [18F]fluoride uptake group. Bacteria were observed in all areas.

CONCLUSIONS

In summary, [18F]fluoride PET accurately identified MRONJ extent, revealing functional changes in jawbone remodeling not visible on CT. [18F]FDG PET showed differences in bone and soft tissue, though less pronounced. This method aids in evaluating disease activity and guiding treatment planning, requiring further research for optimal surgical approaches based on tracer uptake.

Navigating the complexities and controversies of medication-related osteonecrosis of the jaw (MRONJ): a critical update and consensus statement

OBJECTIVES

To provide a critical update identifying the knowledge gaps and controversies in medication-related osteonecrosis of the jaw (MRONJ) within the Belgian healthcare context and outline opportunities for improvement and research in these areas.

METHODS

A literature review was performed to identify guidelines from international clinical societies in oncology or oral and maxillofacial surgery on diagnosing, preventing, and treating MRONJ. The recommendations were critically assessed in light of recent developments in the field and confronted with the clinical experience of experts.

RESULTS

Despite progress in the diagnostic criteria of MRONJ, the continued need for an 8-week timeout period should be reconsidered. Furthermore, 3D imaging techniques should be introduced to improve diagnosis and staging. The staging system remains ambiguous regarding Stage 0 MRONJ, and ongoing confusion exists regarding the term non-exposed MRONJ. The prevention of MRONJ should be tailored, considering the individual patient's risk of MRONJ, frailty, and life expectancy. More research seems needed into the efficacy and safety of drug holidays, considering the risks of rebound remodeling on fractures. With renewed interest in surgical and adjunct management techniques, adequately designed clinical studies are needed to help translate trial outcomes into universally applicable treatment guidelines taking into account individual patient characteristics.

CONCLUSIONS

Important knowledge gaps remain and hamper the development of clinical guidelines. Several controversies were identified where consensus is lacking, and further harmonization between stakeholders is necessary. Finally, the need for randomized controlled comparative clinical trials in MRONJ resonates harder than ever to identify the best treatment for individual patients.

Oral Health-Related Quality of Life and Mental Health Impairment in Patients Affected by Medication-Related Osteonecrosis of the Jaws: A Case-Control Pilot Study

In the present case-control study, the impact of medication-related osteonecrosis of the jaws (MRONJ) on patients' oral health-related quality of life (OHRQoL), overall quality of life (QoL), and psychological status was evaluated using a set of questionnaires. These questionnaires included the Oral Health Impact Profile-14 (OHIP-14), the Short Form 36 Health Survey Questionnaire (SF-36), and the hospital anxiety and depression scale (HADS). A total of 25 MRONJ patients and 25 controls were included in the study. The results showed that MRONJ patients had a significantly poorer OHRQoL (OHIP-14 score p-value: 0.003) and lower general QoL, particularly in the domains of "physical functioning", "physical role", "body pain", "general health", and "vitality" in the SF-36 questionnaire (p-values: 0.001, 0.001, 0.013, 0.001, and 0.020). Although there were no significant differences between the groups in the SF-36 domains of "social functioning", "emotional role", and "mental health", the mean sub-scores of the HADS, specifically the depression and anxiety scores (HADS-D and HADS-A), were significantly higher in MRONJ patients (p-values: 0.002 and 0.009). However, the "mental health" domain of the SF-36 questionnaire showed a correlation with both HADS-A and HADS-D scores (p-values: 0.003 and 0.031). Therefore, a comprehensive clinical examination of MRONJ patients should include the assessment of OHRQoL, overall QoL, and psychological profile using different questionnaires. This approach aims to gather detailed information about patients' physical and psychological well-being, enabling the development of tailored treatments.

Management of Medication-Related Osteonecrosis of the Jaw with Photobiomodulation and Minimal Surgical Intervention

Medication-related osteonecrosis of the jaw (MRONJ) is a relatively common pathology occurring in around 5% of patients taking bisphosphate and other antiresorptive or anti-angiogenic medications. Despite the efforts, as of today there is still no consensus on its management. In this case report, the successful management of stage II MRONJ was performed for an eighty-three-year-old female patient suffering from pain and alteration in her normal oral functions (swallowing and phonation). The treatment consisted of three sessions of photobiomodulation therapy (PBM), followed by minimal surgical intervention and three other sessions of PBM. PBM was applied on the sites of osteonecrosis with the follow parameters: 4 J/cm²; a power of 50 mW; 8 mm applicator diameter; a continuous contact mode. Irradiation was performed on three points, including the vestibular, occlusal and lingual parts of each of the bone exposure areas. Each point was irradiated for 40 s, and, in total, nine points were made per session, and nine sessions were conducted. To assess the pain, a visual analogue scale was used in which zero represented no pain at all and ten represented the greatest pain. At the first session and before any intervention, the patient stated that her pain was 8 out of 10. At the end of the treatment, a significant reduction in VAS was noted (2/10) and, clinically, a healing of the soft tissue in the previously exposed bone was observed. This case report suggests that the combination of PBM with surgical intervention is promising in the management of MRONJ.

The preventive care of medication-related osteonecrosis of the jaw (MRONJ): a position paper by Italian experts for dental hygienists

PURPOSE

The prevention and early diagnosis of medication-related osteonecrosis of the jaw (MRONJ) is fundamental to reducing the incidence and progression of MRONJ. Many in the field believe that dental hygienists should play an integral role in primary and secondary MRONJ prevention. However, to date, very few publications in the literature have proposed standardised MRONJ protocols, which are dedicated to dental hygienists. The aim of this study was to provide guidance to the health care providers managing MRONJ.

METHODS

The expert opinion in this study was developed by dental hygienists from the main Italian technical-scientific associations (Italian Dental Hygienists Association, AIDI and National Union of Dental Hygienists, UNID) and authors of the latest Italian recommendations regarding MRONJ from the field of dentistry and maxillofacial surgery.

RESULTS

The oral care protocol outlined in this position paper is focused on the role of dental hygienist in patients at risk or affected by MRONJ, and it regards 3 main issues: primary prevention, secondary prevention and supporting the treatment of MRONJ. Each issue contains easy-to-apply indications and procedures, as described by the authors, regarding the role of the dental hygienist.

CONCLUSION

Referring to the main issues under consideration (primary prevention, secondary prevention and the treatment of MRONJ), a clinical examination of periodontal tissue is critical in preventing MRONJ. It is the opinion of the authors of this study that the application of a periodontal screening score is fundamental in defining personalised strategies for patients at risk of MRONJ. By means of these basic procedures, a protocol for assisting the health care provider and the presentation of a practical approach for patients at risk or affected by MRONJ are described in this study.

Nonexposed antiresorptive agent-related osteomyelitis of the jaw: a single-center cohort study

INTRODUCTION

The nonexposed variant of antiresorptive agent-related osteonecrosis of the jaw (ARONJ) presents with nonspecific clinical findings. The diagnosis of nonexposed ARONJ poses a critical challenge, and there is little evidence regarding its treatment and outcomes. This study aimed to examine the clinical outcomes in patients with nonexposed antiresorptive agent-related osteomyelitis of the jaw (AROMJ). The terms ARONJ and AROMJ were used separately in this study.

MATERIALS AND METHODS

We enrolled patients with nonexposed AROMJ (osteomyelitis of the jaw without bone exposure associated with antiresorptive agents) with partial reference to an existing position paper on ARONJ. The initiating event of osteomyelitis was limited to periodontitis. Based on the findings of bone scintigraphy, panoramic radiography, computed tomography, and histopathological examination, we also used the hierarchical diagnostic criteria (HDC) for osteomyelitis of the jaw.

RESULTS

There were 58 confirmed cases of nonexposed AROMJ based on the HDC. All patients had sufficient clinical findings to be diagnosed with nonexposed AROMJ as osteomyelitis underwent extraction with bone debridement. The healing rate was 93.1% (54/58). Univariable analysis showed a strong association between the healing status and malignant disease, while multivariable analysis showed no strong association between them.

CONCLUSIONS

The present study had a relatively large sample size of patients with nonexposed AROMJ. The primary disease in patients with nonexposed AROMJ may not have a strong association with the healed status of the lesion. Based on its high healing rate, extraction with bone debridement in confirmed nonexposed AROMJ may prevent progression.

The Necessity of Antibiotics in the Management of Surgically Treated Mandibular Osteomyelitis: A Systematic Review

OBJECTIVES

Mandibular osteomyelitis remains an incompletely understood entity, and treatment of its various presentations remains diverse. The purpose of this study was to review the necessity of antibiotic therapy after surgical treatment of mandibular osteomyelitis.

STUDY DESIGN

A systematic review of published articles on surgical management of mandibular osteomyelitis with or without postoperative antibiotic therapy was performed to answer the question, "Does the use of postoperative antibiotics compared with surgery alone alter the success rate in treating mandibular osteomyelitis?" The most recent evidence was sought by searching PubMed, Embase, and Scopus databases. Article appraisal was performed by 2 reviewers.

RESULTS

Forty-five articles were found that met the inclusion criteria, with all studies being retrospective cohort or case series designs. Only 13 articles used Zurich classification designations of acute osteomyelitis, secondary chronic osteomyelitis, or primary chronic osteomyelitis, and the general heterogeneity of these articles made comparison difficult. No study made an intentional statistical assessment of various antibiotic protocols.

CONCLUSIONS

Limited evidence suggested that resection may have better success rates than other forms of surgical intervention, regardless of antibiotic therapy. This systematic review questions the perceived necessity of intermediate- or long-term antibiotic therapy in the management of mandibular osteomyelitis after surgical resection.

Medication-Related Osteonecrosis of the Jaw—A Continuing Issue

Introduction: Medication-related osteonecrosis of the jaw (MRONJ) is a condition that is becoming more common in the everyday practice of both dental and maxillofacial surgeons. Materials and methods: This paper aims to provide a comprehensive and easy to read by clinicians presentation of comprehensive, accessible, and up-to-date data on MRONJ. The individual chapters focus on the etiology, epidemiology, diagnosis, prevention, treatment, and recurrence of MRONJ. Results and discussion: It has been observed over the years that among drugs that increase the risk of the disease, apart from bisphosphonates, angiogenesis inhibitors and anti-RANKL monoclonal antibodies should also be included. A thorough physical and subjective examination, periodic correction of dental prostheses, and an adequate preparation for even the simplest of procedures in the oral cavity area can prevent or minimize the risk of MRONJ. Conclusions: It is extremely difficult to treat once it occurs and oftentimes is a recurring problem that leads to a multitude of symptoms that gradually decrease the quality of a patient’s life.

Medication-related osteonecrosis of the jaw in a patient with multiple myeloma: an unusual case with tumor in the surgical specimen

Multiple myeloma is characterized by a neoplastic proliferation of plasma cells primarily in the bone marrow. Neoplastic plasma cells stimulated osteoclasts, and destroy bone tissue, causing bone pain, pathological fractures, paralysis due to spinal cord compression, and hypercalcemia. Bisphosphonates are used as supportive therapy in the management of multiple myeloma. Medication-related osteonecrosis of the jaw (MRONJ) is a well-known complication of treatment with bisphosphonates, denosumab, and other drugs, such as anti-angiogenic agents and novel anti-cancer drugs. We report MRONJ in a patient with multiple myeloma, especially an unusual case with tumor in the surgical specimen. A 73-year-old woman presented with pain on the left side of the mandible within 3 months. On clinical examination, an exposed bone without purulent drainage presented on the left side of the mandible. Before 2 years, she received chemotherapy of zoledronate for multiple myeloma at another hospital. Panoramic imaging showed radiopacities of bone in the left side of the mandibular molar area. Multidetector computed tomography (MDCT) with axial, multiplanar reformation (MPR) and three-dimensional (3D) images showed the sequestrum without periosteal reaction. She was diagnosed as MRONJ, and underwent surgery. Finally, the surgical specimen was diagnosed as multiple myeloma in the sequestrum. This case suggests that the evaluation of the surgical specimen of MRONJ could be essential for detection of primary tumor.

Recurrence-Related Factors of Medication-Related Osteonecrosis of the Jaw: A Five-Year Experience

PURPOSE

The treatment of medication-related osteonecrosis of the jaw (MRONJ) is greatly challenging for surgeons. In this study, we reviewed patients with MRONJ treated in our hospital in the past 5 years and explored the risk factors of recurrence.

METHODS

A retrospective cohort study was conducted to review the patients with MRONJ from January 1, 2016 to December 31, 2020. All patients received a monthly intravenous application of zoledronic acid. The primary outcome variable was the treatment outcome during follow-up. The predictor variables were local and systemic factors related to the treatment outcome. Multivariate logistic regression analysis was performed to identify the risk factors of recurrence after MRONJ treatment.

RESULTS

A total of 58 patients (62 sites) were included in this study. In multivariate regression analysis, the risk factor associated with recurrence after MRONJ treatment was the duration of medication of more than 18 months (odds ratio = 7.346; 95% confidence interval: 1.461-36.946; P = .016).

CONCLUSIONS

Using zoledronic acid over 18 months may increase the risk of recurrence in MRONJ patients.

18F-Fluoride PET/CT Imaging of Medication-Related Osteonecrosis of the Jaw in Conservative Treatment-A Case Report

Medication-related osteonecrosis of the jaw (MRONJ) is a serious side effect in antiresorptive treatment. Treatment of MRONJ is considered primarily conservative with oral mouth rinses and antibiotics but may demand surgery, depending on the complaints and general condition of the patient, the extent of the necrosis, and the overall prognosis with respect to the underlying disease. A 77 year old female patient with invasive ductal breast cancer and bone metastases was treated with intravenous bisphosphonate (BP) zoledronic acid. During therapy, she developed MRONJ in the mandible with severe pain. Clinical examination revealed confluent exposed bone of the lower left jaw and a fistula at the right molar region. The panoramic radiograph revealed a mandibular osseous involvement with diffuse radiopaque areas between radiolucent areas. For preoperative planning, ¹⁸F-fluoride positron emission tomography/computed tomography (PET/CT) of the jaw was performed, showing substantially increased ¹⁸F-fluoride uptake in regions 38 to 47 of the mandible with a focal gap in region 36 (area of clinically exposed bone). CT revealed medullary sclerosis and cortical thickening with confluent periosteal reaction and focal cortical erosion in the regions 37 to 42, whereas the regions 43 to 47 were only subtly sclerotic without cortical thickening. After systemic antibiotic therapy with sultamicillin following significant symptom and pain relief, ¹⁸F-fluoride PET/CT imaging was performed again after 5 months. No changes in either CT and PET were observed in regions 38 to 42, whereas the bony sclerosis was slightly increased in regions 43 to 47 with a slight reduction of ¹⁸F-fluoride uptake. ¹⁸F-fluoride PET/CT showed no significant changes assessing the extent of MRONJ prior and after systemic antibiotic therapy, providing no evidence that conservative treatment reduced the extent of the MRONJ-affected jawbone. The additional information of ¹⁸F-fluoride PET enables to identify the true extent of MRONJ which may be underestimated by CT imaging alone. Patients with MRONJ undergoing conservative treatment could benefit because additional imaging may be avoided as the pre-therapeutic ¹⁸F-fluoride PET/CT delivers all information needed for further treatment. Our findings support the recommendation of a surgical approach as long-term antibiotics cannot downsize the extent of MRONJ.

Analysis of medication-related osteonecrosis of the jaw with bone SPECT/CT: relationship between patient characteristics and maximum standardized uptake value

Objective:

To analyze medication-related osteonecrosis of the jaw (MRONJ) with bone single photon emission computed tomography (SPECT)/CT, especially relationship between patient characteristics and maximum standardized uptake value (SUV).

Methods:

48 patients with MRONJ who underwent bone SPECT/CT were prospectively included. MRONJ patients were included 34 osteoporosis and 14 bone metastases from 6 lung cancer, 6 breast cancer and 2 rectal cancer. The maximum SUV of the MRONJ patient characteristics were analyzed such as gender, location, underlying disease, medication and staging of MRONJ by Mann–Whitney U test. P-values lower than 0.05 indicate significant differences.

Results:

Regarding underlying disease, maximum SUV of patients with osteoporosis (18.69 ± 8.57) were significantly higher than those with bone metastases (12.28 ± 4.32, p = 0.005). Furthermore, maximum SUV of MRONJ was a significant difference for medication (denosumab: 13.62 ± 5.70 and minodronate: 22.98 ± 11.73, p = 0.009) and staging of MRONJ (Stage 2: 15.59 ± 8.06 and Stage 3: 21.51 ± 7.15, p = 0.014).

Conclusion:

Maximum SUV assessed by SPECT/CT was significantly increased in MRONJ patients with osteoporosis and Stage 3. Bone SPECT/CT could be an effective tool for the analysis of MRONJ.

Combined approach to treatment of advanced stages of medication-related osteonecrosis of the jaw patients

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Removal of necrotic bone is important in the treatment of medication- related osteonecrosis of the jaw.

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Surgical treatment is more successful than conservative treatment in advanced stages (stage 2–3) of the medication- related osteonecrosis of the jaw.

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Relatively less invasive and supportive treatments are recommended in patients with advanced medication- related osteonecrosis of the jaw.

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Patient follow-up, good oral hygiene and patient motivation increase the success rate of the treatment.

Introduction

Increased incidence of localized osteonecrosis in the jaw bones caused by bisphosphanate use and reduced quality of life of the patients led researchers to diagnose the disease in the early period and to investigate the effective treatment modality.

Objective

Treatment of medication-related osteonecrosis of the jaw patients is based on individual protocols from clinical experience, as there are no definitive treatment guidelines. In view of the lack of consensus on the effectiveness of medication-related osteonecrosis of the jaw treatments in the literature, the aim of this study was to evaluate the surgical technique described in the treatment of advanced stages of medication-related osteonecrosis of the jaw patients.

Methods

Twenty-one patients affected by Stage 2–3 medication-related osteonecrosis of the jaw were treated with ultrasonic piezoelectric bone surgery for necrotic bone removing, leukocyte and platelet-rich fibrin concentrate obtained from the patient’s peripheral blood and Nd:YAG laser for biostimulation. Success was assessed as the maintenance of full mucosal coverage without signs of residual infection at 1-month (T1), 3-months (T2), 6-months (T3) and 1-year (T4) after surgery. Logistic regressions were used to evaluate the association between the different independent variables and treatment outcomes.

Results

Two Stage 3 patients had delayed healing at 1 month after the operation. Complete mucosal healing was achieved in all patients at the third month. Multivariate analysis demonstrated that different variables were not significantly correlated with delayed healing (p > 0.05).

Conclusion

The surgical protocol presented in this study shows promising results for surgical management of advanced stages of medication-related osteonecrosis of the jaw patients.

Various Therapeutic Methods for the Treatment of Medication-Related Osteonecrosis of the Jaw (MRONJ) and Their Limitations: A Narrative Review on New Molecular and Cellular Therapeutic Approaches

Medication-related osteonecrosis of the jaw (MRONJ) is one of the most interesting diseases in the field of maxillofacial surgery. In addition to bisphosphonates, the use of antiresorptive and antiangiogenic agents is known to be the leading cause. However, the exact pathogenesis of MRONJ has not been established, and various hypotheses have been proposed, such as oxidative stress-related theory. As a result, a definitive treatment protocol for MRONJ has not been identified, while various therapeutic approaches are applied to manage patients with MRONJ. Although the surgical approach to treat osteomyelitis of the jaw has been proven to be most effective, there are limitations, such as recurrence and delayed healing. Many studies and clinical trials are being conducted to develop another effective therapeutic modality. The use of some materials, including platelet concentrates and bone morphogenetic proteins, showed a positive effect on MRONJ. Among them, teriparatide is currently the most promising material, and it has shown encouraging results when applied to patients with MRONJ. Furthermore, cell therapy using mesenchymal stem cells showed promising results, and it can be the new therapeutic approach for the treatment of MRONJ. This review presents various treatment methods for MRONJ and their limitations while investigating newly developed and researched molecular and cellular therapeutic approaches along with a literature review.

Retrospective evaluation of pathologic fractures in medication related osteonecrosis of the jaw

The aim of this study was to focus on the MRONJ-related pathologic fractures, their incidence, and to analyze possible causative factors for their occurrence. Pathologic fracture in patients suffering frm MRONJ were identified, examined in detail, and the patient characteristics were evaluated. In 116 patients (73 female and 43 male; mean age 62.08 ± 13.6 years), pathologic fracture incidence was found to be 4.31%. Zoledronic acid was the most commonly used anti-resorptive drug (77.8%). Median antiresorptive usage was 24 months. Five patients had pathologic fractures in the mandible. Four fracture patients had metastatic prostate cancer, and one had metastatic renal cell cancer. This case series study can provide clinical insight into which factors are associated with pathologic fractures. Cancer type, medical comorbidities, additive toxicity of the combination of antiresorptive and antiangiogenic drugs, specific pathogens, and dento-alveolar surgical procedures may be some of the important factors that need to be considered. Since MRONJ-related pathologic fracture management can be complicated, it may be good to focus on the causative factors and prevent occurrence with regular follow-up as often as possible in line with these factors.

Microarchitecture of medication-related osteonecrosis of the jaw (MRONJ); a retrospective micro-CT and morphometric analysis

Medication-related osteonecrosis of the jaw (MRONJ) is a severe side effect of antiresorptive (AR) drugs such as bisphosphonates (BP) and denosumab (Dmab). Although several risk factors are described, the etiology of MRONJ is still not fully elucidated. Bone-strengthening is the primary aim of antiresorptive therapy; however, overly increased bone mass and microcrack accumulation are also discussed in MRONJ etiologies. The aim of this study is to evaluate the microarchitecture of jaw bones with micro-computed tomography (micro-CT) in AR-treated patients with or without MRONJ. Human jaw bone samples of AR-treated patients were separated into 11 groups by AR treatment bisphosphonate (BP), denosumab (Dmab), both (M) and control groups. Subgroups were divided according to the clinical localization as AR-exposed vital jaw bone (BP_exp, Dmab_exp, M_exp), osteonecrosis-margin of a sequestrum (BPO_mar, DmabO_mar, MO_mar) and osteonecrosis-sequestrum (BPO_seq, DmabO_seq, MO_seq). Healthy jaw bone (C_HB) and osteoporotic jaw bone (C_OP) represent control groups. Samples underwent retrospective micro-CT and morphometric analysis in representative units by bone volume fraction (BV/TV), bone surface density (BS/BV), trabecular thickness (Tr.Th.), trabecular number (Tr.N.), trabecular space (Tr.Sp.), Euler characteristic for bone connectivity, bone mineral density (BMD) and tissue mineral density (TMD). A total of 141 samples from 78 patients were analyzed. BV/TV of M_exp group (mean: 0.46 ± 0.27) was significantly higher than in the C_OP group (mean: 0.14 ± 0.05; p = 0.0053). Tr.Th. differed significantly between the BP_exp group (mean: 0.32 ± 0.15) and the M_exp group (mean: 0.57 ± 0.20; p = 0.0452) as well as between the BPO_seq group (mean: 0.25 ± 0.10) and the MO_seq group (mean: 0.39 ± 0.18; p = 0.0417). Signs of trabecular thickening and unorganized trabecular microarchitecture from AR-exposed- to sequestrum groups, were analyzed in 3D reconstructions. However, BS/BV, Tr.N., and Tr.Sp. showed no significant differences. Euler characteristic of the BPO_seq group (median: 7.46) doubled compared to that of the BP_exp group (median: 14.97; p = 0.0064). Mineralization parameters BMD and TMD were similar in all groups. Findings show evidence of enhanced bone mass and suspect microarchitecture in some AR-treated jaw bone compared to osteoporotic jaw bone. Despite increased bone mass, some MRONJ samples showed decreased trabecular connectivity by Euler characteristic compared to AR-treated jaw bone. These samples may indicate extensive ossification and ineffective bone mass with superficially higher bone mass without existing or even reduced mechanical stability, indicated by connectivity loss. This result might also suggest a high risk to microcrack accumulation. At some point, possibly some kind of over-ossification could lead to under-nourishment and microarchitectural weakness, creating instability, subsequently increasing vulnerability to MRONJ.

Effect and timing of parathyroid hormone analog administration for preventing medication-related osteonecrosis of the jaws in a murine model

The aim of this study was to investigate the effect and timing of recombinant human parathyroid hormone analog (PTH) administration for preventing medication-related osteonecrosis of the jaws (MRONJ) using a murine model. After standardized MRONJ induction using zoledronic acid and dexamethasone injections, 48 female Sprague-Dawley rats were divided into four groups according to the timing of PTH administration before or after dental extraction. Rats were euthanized 3 weeks after dental extraction, followed by clinical and histologic analyses. No clinical improvements were observed in the preoperative and postoperative PTH groups, compared to controls (p = 0.638 and 0.496, respectively). However, on histological analysis, the number of empty lacunae reduced significantly, and the number of blood vessels increased in the preoperative PTH group (p = 0.004 and 0.002, respectively). The postoperative PTH group did not show significant differences for empty lacunae and blood vessels compared to controls (p = 0.075 and 0.194, respectively). The reduction in the empty lacunae and the increase in the blood vessels in the preoperative PTH group were significant compared to other groups, suggesting more viable bone tissue in this group. In perspective, preoperative PTH use may represent a better prophylactic regimen for preventing the occurrence of MRONJ after traumatic dental or surgical procedures, especially in patients with a history of long-term bisphosphonate administration or at high risk of developing MRONJ. However, the findings should be proven in further studies on other animals followed by clinical trials.

Bisphosphonate application and volumetric effects on MRONJ lesions

The purpose of this investigation was to analyze the volume of medication-related osteonecrosis of the jaw (MRONJ) lesions by semi-automatic segmentation of cone-beam computed tomography images, and correlate the results with the underlying diseases and applied medication. MRONJ lesions detected in cone-beam computed tomography images were assessed. The open-source software ITK-Snap enabled volumetric measurements of MRONJ lesions based on semi-automatic segmentation. Results were analyzed according to necrosis volume, localization, and gender. In addition, the underlying disease and the type of application of antiresorptive medication were investigated. Cone-beam computed tomography images of 66 patients were studied. 34 male and 32 female patients were included, with ages ranging from 50 to 93 years at the time of diagnosis. The mean volume was 993.24 ± 620.94 mm³: 484.73 ± 230.97 mm³ for the upper jaw and 1084.04 ± 625.74 mm³ for the lower jaw. The results indicated statistically significant differences between lesions of the upper and lower jaw, regardless of gender (p = 0.003). The analysis of differences between males and females did not show any significant results (p = 0.464), although males presented slightly larger lesions than females. With regard to the underlying disease, patients with osteoporosis presented larger volumes, whereas patients with malignant tumors presented smaller volumes. Nevertheless, no statistically significant differences according to the underlying disease (p = 0.313) were detected. However, patients with intravenous (iv) application showed statistically significantly larger lesions than patients who underwent oral or subcutaneous (s.c.) applications (p = 0.004). It seems that the osteonecrosis volume correlates with the applied antiresorptive agents. Larger MRONJ lesions should be expected in patients who receive intravenous antiresorptive therapy.

Clinical outcomes of open and closed management after surgical treatments in patients with medication-related osteonecrosis of the jaw

CONTEXT AND PURPOSE

To achieve success following surgical treatment of MRONJ, complete wound closure has been considered necessary; open wound management has not been generally recommended. Therefore, various closure techniques using local flaps have been reported. However, these techniques often increase surgical invasiveness, and there is minimal evidence regarding whether complete wound closure is preferable to open wound management following surgical treatment of MRONJ. The aim of this study was to clarify whether complete wound closure is necessary for successful healing following surgical treatment of MRONJ.

PROCEDURES

This retrospective study included 52 patients with stage 2 and 3 MRONJ who underwent surgical treatment. Twenty-seven of the 52 patients received open wound management, while the remaining 25 received complete wound closure management. The outcomes of both groups were evaluated at the 6-month follow-up visit; 'success' was defined as complete mucosal covering without symptoms and 'failure' was defined as the presence of residual bone exposure or progression of disease.

MAIN FINDINGS

In the open wound group, 23 patients (85.1%) exhibited 'success' and four patients (14.8%) exhibited 'failure'; in the closed wound group, 21 patients (84.0%) exhibited 'success' and four patients (16.0%) exhibited 'failure'. These outcomes were not significantly different between groups.

PRINCIPAL CONCLUSIONS

Although complete wound closure has many advantages with respect to the healing process, open wound management is also acceptable for patients with difficulty achieving complete wound closure, as well as for surgeons who wish to reduce surgical invasiveness.

Effectiveness of surgery and hyperbaric oxygen for antiresorptive agent-related osteonecrosis of the jaw: A subgroup analysis by disease stage

Antiresorptive agent-related osteonecrosis of the jaw (ARONJ) is an adverse event induced by antiresorptive agents (ARAs). The purpose of this study was to evaluate variables, mainly surgery and hyperbaric oxygen (HBO) therapy, associated with treatment outcomes in patients with a diagnosis of ARONJ at a single center. We enrolled consecutive patients who presented to our hospital for the management of stage 2 or 3 ARONJ between January 2003 and December 2019. The relationship between potentially predictive factors and outcome variables was examined using statistical analyses, along with a subgroup analysis based on disease stage. Of 252 patients included in this study, 206 had stage 2 ARONJ and 46 had stage 3 ARONJ. There were 119 patients with osteoporosis and 133 with malignant disease. In total, 139 patients were healed, and the healing rate of patients with stage 3 ARONJ was lower than that of patients with stage 2 ARONJ. With regard to the combination of surgery and HBO therapy, most patients underwent HBO before and after surgery. In the univariable analysis, surgery showed a therapeutic effect in both stage 2 and 3 ARONJ, whereas HBO showed a therapeutic effect in stage 2 ARONJ. In the multivariable analysis for stage 2 ARONJ, extensive surgery showed a stronger association with healing than conservative surgery, whereas ≥46 sessions of HBO therapy was less associated with healing than was non-HBO therapy. Our findings suggest that extensive surgery is highly effective against ARONJ regardless of disease stage if there is a sequestrum separation and systemic tolerance, whereas HBO therapy before and after surgical approach can be effective. Further studies are needed to identify treatment strategies for patients with treatment-refractory ARONJ who may be forced to undergo long-term HBO therapy with the expectation of sequestrum separation.

Successful Non-surgical Management of a Mandible Fracture Secondary to Medication-related Osteonecrosis of the Jaw: A Unique Case Report

Background:

Medication-related osteonecrosis of the jaw (MRONJ) may be a severe side effect of bone-modifying agents.

Objective:

Pathologic fractures treatment in patients with MRONJ remains challenging. The authors reported a unique case of successful non-surgical management of a mandible fracture secondary to MRONJ.

Methods:

A 78-year-old osteoporotic woman with a 4-year history of oral bisphosphonate therapy and a compromised dental condition developed an MRONJ-related right mandibular body fracture. Treatment consisted of systemic antibiotic administration (amoxiclav and metronidazole) and chlorhexidine mouthwash.

Results:

Follow-up visits revealed progressive healing of the mandibular fracture with bone callus formation and complete recovery of the ipsilateral lip and chin sensitivity after one year.

Conclusion:

Non-surgical management of pathological fractures related to MRONJ might be of interest in patients that refuse any type of surgery, but preventive measures, such as careful dental examination, should be taken before start antiresorptive therapy and during the treatment. The authors reported the first case in the literature of successful management of a mandibular fracture secondary to MRONJ with only antibiotics and mouthwashes.

Weak evidence for the management of medication-related osteonecrosis of the jaw: An overview of systematic reviews and meta-analyses

BACKGROUND

Although several therapies are proposed for medication-related osteonecrosis of the jaw (MRONJ), to date there is no consensus or treatment protocol for MRONJ. This overview aims to summarize the available evidence on the management and outcomes of MRONJ.

METHODS

An electronic search without language or date restrictions occurred in five databases and gray literature for articles published until March 2020. This overview was performed according to the PICO format. The eligibility criteria comprised systematic reviews (RS) with or without meta-analyses that analyzed treatments outcomes for MRONJ. The methodological quality of each SR was evaluated using AMSTAR 2.

RESULTS

Fifteen studies published between 2014 and 2020 were included in this overview. The summary of the evidence showed that conservative treatment and low level laser therapy can yield favorable results for early stages of MRONJ whereas surgical treatment seems to be better for advanced stages. However, qualitative assessment of the SRs highlighted a global low level of quality.

CONCLUSIONS

There is weak evidence to support treatment protocols for MRONJ. Because of the low quality of the SRs, highlighted by this overview, no insightful therapeutic recommendations can be issued for any intervention for MRONJ.