The Effect of Platelet-Rich Fibrin Membrane in Surgical Therapy of Medication-Related Osteonecrosis of the Jaw

The effectiveness of autologous platelet concentrates in prevention and treatment of medication-related osteonecrosis of the jaws: A systematic review

The systematic review aims to answer the PICOS question: "Are the autologous platelet concentrates (APCs) an effective strategy in prevention and/or treatment of patients at risk of/affected by medication-related osteonecrosis of the jaws (MRONJ)?". A literature search was conducted via PubMed, MEDLINE, EMBASE, and CINAHL (January 2006 - September 2023). 30 articles were included, evaluating preventive (n = 8*) and treatment strategies (n = 23*). The risk of bias and quality of studies were assessed utilising ROB-2, ROBIN-1 and GRADE criteria. Meta-analysis was undertaken for eligible studies. The application of APCs demonstrated a statistically significant effectiveness in prevention of MRONJ in 86.13% (p < 0.001) but failed to achieve the same level of certainty in treatment of established MRONJ in 83.4% (p = 0.08). High levels of bias were identified; thus, the results should be interpreted with caution. More high quality prospective randomised controlled trials are needed to further evaluate the effectiveness of APCs in management of MRONJ.

Comparison of the Effectiveness of Conservative and Surgical Treatment of Medication-Related Osteonecrosis of the Jaw: a Systematic Review

Objectives

The objective of this systematic review is to evaluate the current knowledge on the effectiveness of conservative and surgical treatment of medication-related osteonecrosis of the jaw.

Material and Methods

MEDLINE (PubMed), ScienceDirect and Cochrane Library search in combination with hand-search of relevant journals was conducted including human studies published in English between January 2017 and February 2023. Studies assessing treatment strategies for medication-related osteonecrosis of the jaw (MRONJ) were included. Quality and risk-of-bias assessment were evaluated by Joanna Briggs Institute (JBI) Risk of Bias tool.

Results

A total of 4227 articles were screened from which 9 studies (7 cohort studies and 2 randomized controlled trials) met the inclusion criteria and were included in the final data synthesis. Two studies evaluate effectiveness of conservative approaches for treating MRONJ, 5 studies evaluate surgical approaches effectiveness, and 2 studies compare between those approaches. The follow-up period ranged from 6 months to 60 months. According to bias assessment, the mean JDI score of the included studies was > 9 ("low risk of bias"). The stage of the disease, the procedure performed on the patient and the results of the treatment were presented.

Conclusions

Surgical therapy seems to be superior to conservative therapy for the management of adverse stages medication-related osteonecrosis of the jaws, while conservative treatment appears to yield good outcomes at asymptomatic patients with early stages of the disease.

Efficacy of fibrin-rich platelets and leukocytes (L-PRF) in tissue repair in surgical oral procedures in patients using zoledronic acid-case-control study

INTRODUCTION

Medication-related osteonecrosis of the jaws (MRONJ) is a complication that develops in patients who use or have used antiresorptive or antiangiogenic medications for the treatment of bone metabolic disease and bone metastases. Clinically, MRONJ is characterized by the appearance of an inflammation in soft tissues and exposure of necrotic bone tissue in mandible or maxilla, for a period of 8 weeks, in patients with no history of head and neck radiotherapy that were being or are being treated with antiresorptive and/or antiangiogenic agents. The fibrin-rich platelets and leukocytes (L-PRF) membrane has been used as an alternative for MRONJ prevention. The aim of this study was to evaluate the use of L-PRF in prevention and treatment of bone necrosis.

MATERIAL AND METHODS

The patients included had MRONJ diagnosis confirmed after clinical and radiographic examination and patients whose only therapeutic option was dental extraction.

RESULTS

Twenty patients were included in the study and were divided in three groups. Two patients were removed from the study due to previous history of pentoxifylline and tocopherol use. The result of surgical treatment was successful in 57% in group 1 (control/MRONJ prevention), 100% in group 2 (MRONJ prevention), and 80% in group 3 (MRONJ treatment).

CONCLUSION

L-PRF is an autologous biomaterial that allows the release of growth factors for a prolonged time, resulting in a better healing, reducing the risk contamination, edema, and postoperative pain, being a great ally in the prevention and treatment of MRONJ because it returns to these patients, mainly quality of life, reducing pain, and recurrent infections commonly seen in the processes of bone necrosis of the jaws.

Use of Leukocyte-rich and Platelet-rich Fibrin (L-PRF) Adjunct to Surgical Debridement in the Treatment of Stage 2 and 3 Medication-Related Osteonecrosis of the Jaw

Medication-related osteonecrosis of the jaw (MRONJ) is characterized by exposed necrotic bone persisting for more than 8 weeks in the maxillofacial region in patients using antiresorptive or antiangiogenetic drugs for several treatment options like bone metastasis or osteoporosis. There are several treatment options studied in scientific literature, and one of them with promising results is using platelet concentrates adjunct to surgical therapy. The aim of this study is to examine the therapeutic effect of leukocyte and platelet-rich fibrin (L-PRF) on patients with MRONJ. This 2-centered study investigated patients referred to oral and maxillofacial surgery departments of 2 university clinics between the years 2014 and 2020 with the diagnosis of MRONJ. Demographic data, the indication of the drug usage, drug type, duration, administration route, and systemic comorbidities of the patients were recorded. L-PRF was applied to 20 osteonecrotic lesions of 19 patients following surgical debridement. The male/female ratio was 5/14. Except 1 of the patients, all of the indications of medication were neoplasia-related. The mean follow-up period of patients was 27.9±9.2 months. Most common antirezorptive drug was zoledronate (84.2%). Complete resolution was observed in 16 necrosis sites (80%). It could be concluded that the use of L-PRF may represent an important adjunct in the surgical management of MRONJ.

Effect on Cellular Vitality In Vitro of Novel APRF-Chlorhexidine Treated Membranes

INTRODUCTION

Chlorhexidine (CHX) has been used for some time in clinical practice as a local antiseptic agent with excellent efficacy. The combination of CHX with APRF (Advanced-platelet rich fibrin) membrane has the potential to stimulate tissue regeneration and to provide a bactericidal effect. We hypothesize that this may reduce the rate of infections development and protect cell viability.

AIM

The aim of this study was two-fold-to create a stable APRF membrane treated with different concentrations of CHX (0.01% and 0.02%) and to monitor its effect on the viability of PDL cells in vitro. This benefits the introduction of a new protocol for APRF membrane production -CHX-PRF and enriches the available evidence on the effect of this antiseptic agent on PDL (Periodontal ligament) cells.

MATERIALS AND METHODS

APRF membranes were prepared by the addition of two concentrations (0.01% and 0.02%) of CHX. Membranes without the antiseptic were also prepared and used as control samples. PDL cells were cultivated on the membranes for 72 h. Cell number and vitality were examined by fluorescent cell viability assays.

RESULTS

Our results demonstrated that a concentration of 0.01% CHX allowed the production of a stable APRF membrane. This concentration slightly reduced the viability of PDL cells to 96.7%, but significantly decreased the average number of cells attached to the membrane-149 ± 16.5 cells/field compared to controls -336 ± 26.9 cells/field. APRF-CHX 0.02% membranes were unstable, indicating a dose-dependent cytotoxic effect of CHX.

CONCLUSIONS

The introduced novel protocol leads to the production of a new type of APRF membrane-CHX-PRF. The incorporation of an antiseptic into the APRF membrane can improve its bactericidal activity and might serve as an important step for the prevention of postoperative infections.

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

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

Interventions for managing medication-related osteonecrosis of the jaw

BACKGROUND

Medication-related osteonecrosis of the jaw (MRONJ) is a severe adverse reaction experienced by some individuals to certain medicines commonly used in the treatment of cancer and osteoporosis (e.g. bisphosphonates, denosumab, and antiangiogenic agents), and involves the progressive destruction of bone in the mandible or maxilla. Depending on the drug, its dosage, and the duration of exposure, this adverse drug reaction may occur rarely (e.g. following the oral administration of bisphosphonate or denosumab treatments for osteoporosis, or antiangiogenic agent-targeted cancer treatment), or commonly (e.g. following intravenous bisphosphonate for cancer treatment). MRONJ is associated with significant morbidity, adversely affects quality of life (QoL), and is challenging to treat. This is an update of our review first published in 2017.

OBJECTIVES

To assess the effects of interventions versus no treatment, placebo, or an active control for the prophylaxis of MRONJ in people exposed to antiresorptive or antiangiogenic drugs. To assess the effects of non-surgical or surgical interventions (either singly or in combination) versus no treatment, placebo, or an active control for the treatment of people with manifest MRONJ.

SEARCH METHODS

Cochrane Oral Health's Information Specialist searched four bibliographic databases up to 16 June 2021 and used additional search methods to identify published, unpublished, and ongoing studies.  SELECTION CRITERIA: We included randomised controlled trials (RCTs) comparing one modality of intervention with another for the prevention or treatment of MRONJ. For 'prophylaxis of MRONJ', the primary outcome of interest was the incidence of MRONJ; secondary outcomes were QoL, time-to-event, and rate of complications and side effects of the intervention. For 'treatment of established MRONJ', the primary outcome of interest was healing of MRONJ; secondary outcomes were QoL, recurrence, and rate of complications and side effects of the intervention.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened the search results, extracted the data, and assessed the risk of bias in the included studies. For dichotomous outcomes, we reported the risk ratio (RR) (or rate ratio) and 95% confidence intervals (CIs).

MAIN RESULTS

We included 13 RCTs (1668 participants) in this updated review, of which eight were new additions. The studies were clinically diverse and examined very different interventions, so meta-analyses could not be performed. We have low or very low certainty about available evidence on interventions for the prophylaxis or treatment of MRONJ. Prophylaxis of MRONJ Five RCTs examined different interventions to prevent the occurrence of MRONJ. One RCT compared standard care with regular dental examinations at three-month intervals and preventive treatments (including antibiotics before dental extractions and the use of techniques for wound closure that avoid exposure and contamination of bone) in men with metastatic prostate cancer treated with zoledronic acid. The intervention seemed to lower the risk of MRONJ (RR 0.10, 95% CI 0.02 to 0.39, 253 participants). Secondary outcomes were not evaluated. Dentoalveolar surgery is considered a common predisposing event for developing MRONJ and five RCTs tested various preventive measures to reduce the risk of postoperative MRONJ. The studies evaluated plasma rich in growth factors inserted into the postextraction alveolus in addition to standardised medical and surgical care versus standardised medical and surgical care alone (RR 0.08, 95% CI 0.00 to 1.51, 176 participants); delicate surgery and closure by primary intention versus non-traumatic tooth avulsion and closure by secondary intention (no case of postoperative MRONJ in either group); primary closure of the extraction socket with a mucoperiosteal flap versus application of platelet-rich fibrin without primary wound closure (no case of postoperative MRONJ in either group); and subperiosteal wound closure versus epiperiosteal wound closure (RR 0.09, 95% CI 0.00 to 1.56, 132 participants).  Treatment of MRONJ Eight RCTs examined different interventions for the treatment of established MRONJ; that is, the effect on MRONJ cure rates.  One RCT analysed hyperbaric oxygen (HBO) treatment used in addition to standard care (antiseptic rinses, antibiotics, and surgery) compared with standard care alone (at last follow-up: RR 1.56, 95% CI 0.77 to 3.18, 46 participants).  Healing rates from MRONJ were not significantly different between autofluorescence-guided bone surgery and conventional bone surgery (RR 1.08, 95% CI 0.85 to 1.37, 30 participants). Another RCT that compared autofluorescence- with tetracycline fluorescence-guided sequestrectomy for the surgical treatment of MRONJ found no significant difference (at one-year follow-up: RR 1.05, 95% CI 0.86 to 1.30, 34 participants).  Three RCTs investigated the effect of growth factors and autologous platelet concentrates on healing rates of MRONJ: platelet-rich fibrin after bone surgery versus surgery alone (RR 1.05, 95% CI 0.90 to 1.22, 47 participants), bone morphogenetic protein-2 together with platelet-rich fibrin versus platelet-rich fibrin alone (RR 1.10, 95% CI 0.94 to 1.29, 55 participants), and concentrated growth factor and primary wound closure versus primary wound closure only (RR 1.38, 95% CI 0.81 to 2.34, 28 participants).   Two RCTs focused on pharmacological treatment with teriparatide: teriparatide 20 μg daily versus placebo in addition to standard care (RR 0.96, 95% CI 0.31 to 2.95, 33 participants) and teriparatide 56.5 μg weekly versus teriparatide 20 μg daily in addition to standard care (RR 1.60, 95% CI 0.25 to 1.44, 12 participants).

AUTHORS CONCLUSIONS

Prophylaxis of medication-related osteonecrosis of the jaw One open-label RCT provided some evidence that dental examinations at three-month intervals and preventive treatments may be more effective than standard care for reducing the incidence of medication-related osteonecrosis of the jaw (MRONJ) in individuals taking intravenous bisphosphonates for advanced cancer. We assessed the certainty of the evidence to be very low. There is insufficient evidence to either claim or refute a benefit of the interventions tested for prophylaxis of MRONJ in patients with antiresorptive therapy undergoing dentoalveolar surgery. Although some interventions suggested a potential large effect, the studies were underpowered to show statistical significance, and replication of the results in larger studies is pending. Treatment of medication-related osteonecrosis of the jaw The available evidence is insufficient to either claim or refute a benefit, in addition to standard care, of any of the interventions studied for the treatment of MRONJ.

Adjuvant therapies for MRONJ: A systematic review

OBJECTIVE

Medication-related osteonecrosis of the jaw (MRONJ) is a severe adverse reaction caused by the use of antiresorptive antiangiogenic medication. Treating MRONJ is difficult and besides standard treatments, which are conservative medical and surgical approaches, there are some adjuvant therapies that might further stimulate healing. The aim of this systematic review is to compare outcome and effectiveness of currently available adjuvant therapies for MRONJ.

METHODS

This systematic review was conducted following the PRISMA guidelines. Articles focusing on mucosal healing in patients treated with an adjuvant therapy for MRONJ were selected and analysed. Inclusion was not limited to randomized controlled trials to present a complete review of the current literature.

RESULTS

A search was performed in Pubmed, Embase, Web of Science and Cochrane Central Register of Controlled Trials. Thirty articles out of 3297 were included. Laser ablation had a success of 60-95% for complete healing. The controlled trials of leukocyte- and platelet-rich-fibrine (LPRF) showed 60-100% success for the same outcome. Fluorescence guided surgery had a complete healing percentage of 85-90%.

CONCLUSIONS

The results suggest that laser ablation, LPRF and fluorescence guided surgery might have a potential in improving the healing process. Interpreting the results should however be done with great care and a critical point of view, as most articles had a medium to high risk of bias. More randomized controlled trials are necessary to define the most beneficial therapy protocols.

CLINICAL RELEVANCE

It seems that adjuvant surgical therapies for treating MRONJ are beneficial for mucosal healing, but there is only low scientific evidence.

Osteonecrosis of the jaw associated with imatinib therapy in myeloproliferative neoplasm: a rare case report

Medication-related osteonecrosis of the jaw (MRONJ) is a relatively infrequent but very well-known adverse effect of bisphosphonates. This rare complication of bisphosphonates is rarest with the use of certain drugs. Tyrosine kinase inhibitors (TKIs), particularly used in renal cell carcinoma or gastrointestinal tumors as a chemotherapeutic agent, can precipitate this particular medical condition of bone when it is associated with either radiation or bisphosphonates, though, monodrug therapy with TKIs rarely causes MRONJ. This article describes a rare case of necrosis of the jawbone in a patient with a myeloproliferative neoplasm who was receiving the TKI imatinib and had no history of bisphosphonate or radiation therapy to head and neck region.