American Association of Oral and Maxillofacial Surgeons' Position Paper on Medication-Related Osteonecrosis of the Jaws-2022 Update

Rebound hypercalcaemia timing is associated with cumulative weight-based denosumab dose for central giant cell granuloma treatment in children despite a dose weaning regimen

Central giant cell granulomas (CGCG) are locally destructive, non-neoplastic lesions that express receptor activator of nuclear factor-κB (RANK) and RANK ligand. Denosumab, a monoclonal antibody against RANK ligand, is licensed in skeletally mature patients, with less experience in children who are at risk of rebound hypercalcaemia. We describe the response to denosumab in five skeletally immature children with CGCG. Denosumab was started aged 2.1 to 11.6 years, for 8 to 22 months, with a cumulative dose of 9.6 to 58.8 mg/kg. Three patients followed a weaning protocol (using reducing dose frequency and zoledronic acid). Denosumab ossified all lesions. Three patients had subsequent surgery, and one had recurrence. All had rebound hypercalcaemia, 8.9-47 weeks (median 23.3 weeks) after the last treatment dose. Four presented with symptomatic hypercalcaemia and acute kidney injury. Cumulative denosumab treatment dose/kg positively correlated with (1) time to rebound after the last treatment dose (r2 = 0.94, p = 0.006); and (2) length of admission for hypercalcaemia treatment (r2 = 0.87, p = 0.02). All patients had increased bone mineral density and metaphyseal sclerosis that improved after stopping denosumab. One had a clavicular fracture at the intersection of normal and high-density bone. We propose that rebound hypercalcaemia should be an anticipated consequence of stopping denosumab in skeletally immature patients and exists on a spectrum. A higher cumulative denosumab dose/kg increases the time to rebound hypercalcaemia and its severity. Further work is needed to establish the lowest dose and the shortest treatment duration to balance effective treatment with minimising side effects.

Preventive effect of platelet-rich plasma/Bio-Oss granules composite on medication-related osteonecrosis of the jaw in a rat model

OBJECTIVE

This study aimed to investigate the preventive effects of the platelet-rich plasma (PRP)/Bio-Oss granules composite on medication-related osteonecrosis of the jaw (MRONJ).

MATERIAL AND METHODS

An MRONJ rat model was established by intraperitoneal injections of zoledronic acid (0.1 mg/kg/dose) thrice a week for 12 weeks. At 4 weeks post-injection, 18 bisphosphonates (BPs)-treated rats underwent bone defect preparations at mandibular molar extraction sites and were then randomly divided into 3 groups (n = 6). In the model control group, the bone defect sites were unfilled. In the Bio-Oss granules group and the composite group, the bone defect sites were filled with Bio-Oss granules and PRP/Bio-Oss granules composites, respectively. Euthanasia was performed at 8 weeks post-surgery. Macroscopic observation, Micro-CT, and histological analysis were performed to analyze bone exposure rate, bone mineral density (BMD), bone volume fraction (BV/TV), and percentage of empty osteocyte lacunae at bone defect sites.

RESULTS

The bone exposure rate in the model control group, Bio-Oss granules group, and composite group was 83.33 %, 66.67 %, and 0 %, respectively. The composite group demonstrated superior mucosal healing, higher BMD, BV/TV, and a lower percentage of empty osteocyte lacunae compared with the other 2 groups (P < 0.001).

CONCLUSION

Applying Bio-Oss granules alone cannot halt the progression of MRONJ, whereas PRP/Bio-Oss granules composite was effective in preventing MRONJ in BPs-treated rats.

CLINICAL RELEVANCE

The PRP/Bio-Oss granules composite may serve as a potential treatment option for both MRONJ prevention and management of established cases with extensive osteonecrosis.

Do infectious disease consultations improve outcomes of surgical management of MRONJ?

OBJECTIVES

The aim of this study is to evaluate the effect of infectious disease (ID) consultations on outcomes of patients with surgically managed medication-related osteonecrosis of the jaw (MRONJ).

STUDY DESIGN

We utilized a retrospective cohort study of patients managed surgically for MRONJ at an academic center. The primary predictor was presence vs absence of ID consult. The primary outcome was the surgical outcome, and the secondary outcomes were length of hospital stay and continuous postoperative antibiotic duration in days. Descriptive and multivariate statistics were computed.

RESULTS

The study included 146 surgically managed patients with MRONJ (mean age = 68.7 years), with 101 women (69%). Rates of improvement in MRONJ were similar among both groups (no ID consult = 86.0% and ID consult = 80.4%, P = .39). ID consult was associated with a greater length of hospital stay (ID consult = 3.17 days [1.95-4.40 days]) vs no consult = 1.25 days [0.895-1.61 days], P < .05) and longer duration of postoperative antibiotics (ID consult = 51.4 days [37.1-65.8 days] vs no consult = 26.1 days [22.3-29.9 days], P < .05).

CONCLUSIONS

The outcomes of surgically managed MRONJ did not differ between patients who had ID consultations vs those who did not. In a subset of patients with a complex disease course based on the clinical and microbiologic findings, ID consultations may be beneficial.

Indications and Regenerative Techniques for Lateral Window Sinus Floor Elevation With Ridge Augmentation

Maxillary sinus elevation is a critical procedure in dental implantology, often necessary to address bone deficiencies in the posterior maxilla. However, various medical conditions, local factors, and surgical complexities can significantly influence the outcomes. This article delves into the implications of systemic conditions such as smoking, diabetes, osteoporosis, antiresorptive and antiangiogenic medications, radiotherapy, immunocompromised states, cardiovascular diseases, chronic alcoholism, and oxidative stress on sinus floor elevation and associated dental implant placements. Each condition presents unique challenges and necessitates tailored clinical considerations to mitigate risks and enhance surgical success. A comprehensive pre-operative assessment is essential, including detailed patient history and radiographic evaluation. Local conditions affecting the maxillary sinus, such as sinusitis, require careful examination and possible otolaryngologist consultation. The article discusses a standardized Digital Surgical Planning (DSP) protocol involving CBCT imaging, intraoral scans, virtual diagnostic wax-ups, and guided implant placement to optimize surgical planning and outcomes. Surgical techniques for lateral window antrostomy are examined, including flap design, window size and location, and piezoelectric and rotary instrumentation. Subsequent regenerative procedures involve meticulous membrane elevation and particulate graft placement, with considerations for graft material and technique to ensure stability and volume retention. Post-operative care, encompassing antibiotic prophylaxis, corticosteroid use, and decongestants, is outlined to prevent infections and manage edema. Conclusively, the article stresses the necessity for implantologists to be proficient in various techniques and make evidence-based decisions tailored to individual patient needs, ensuring optimal implant therapy outcomes. The lateral window approach remains a cornerstone of regenerative dental procedures, maintaining its significance through evolving methodologies and clinical advances. The lateral window sinus elevation procedure has demonstrated consistent success as a pre-prosthetic surgical intervention for over four decades, supported by multiple reviews. Initially a hospital-based procedure requiring autogenous bone harvesting, it has evolved into a minimally invasive, office-based procedure without the need for donor bone. Smaller access windows and flaps have further reduced morbidity. Despite the emergence of less invasive techniques such as the transcrestal approach and the use of tilted or short implants, the lateral window procedure remains relevant due to its unique advantages: Provides greater access to overcome obstacles like septa. Facilitates single-surgery management of multiple implant sites. Remains applicable regardless of residual crestal bone height. Allows intraoperative management of complications such as membrane perforations.

International Expert-Based Consensus Definition, Classification Criteria, and Minimum Data Elements for Osteoradionecrosis of the Jaw: An Interdisciplinary Modified Delphi Study

PURPOSE

Osteoradionecrosis of the jaw (ORNJ) is a severe iatrogenic disease characterized by bone death after radiation therapy to the head and neck. With >9 published definitions and at least 16 classification systems, the true incidence and severity of ORNJ are obscured by lack of a standard for disease definition and severity assessment, leading to inaccurate estimation of incidence, reporting ambiguity, and likely underdiagnosis worldwide. This study aimed to achieve consensus on an explicit definition and phenotype of ORNJ and related precursor states through data standardization to facilitate effective diagnosis, monitoring, and multidisciplinary management of ORNJ.

METHODS AND MATERIALS

The Orodental Radiotherapy-Associated Late-Effects Consortium comprised 69 international experts, including representatives from medical, surgical, radiation oncology, and oral/dental disciplines. Using a web-based modified Delphi technique, panelists classified descriptive cases using existing classification systems, reviewed systems for feature extraction and specification, and iteratively classified cases based on clinical/imaging feature combinations.

RESULTS

The Consortium ORNJ definition was developed in alignment with Systematized Nomenclature of Medicine - Clinical Terms (SNOMED-CT) terminology and recent International Society of Oral Oncology-Multinational Association for Supportive Care in Cancer and the American Society of Clinical Oncology (ISOO-MASCC-ASCO) guideline recommendations. Case review using existing ORNJ classification systems showed high rates of inability to classify (up to 76%). Ten consensus statements and 9 minimum data elements (MDEs) were outlined for prospective collection and classification of precursor/ORNJ disease states.

CONCLUSIONS

This study provides an international, consensus-based definition and MDE foundation for standardized ORNJ reporting in cancer survivors treated with radiation therapy. Head and neck surgeons, radiation, surgical, medical oncologists, and dental specialists should adopt MDEs to enable scalable health information exchange and analytics. Work is underway to develop both a human- and machine-readable knowledge representation for ORNJ (ie, ontology) and multidisciplinary resources for dissemination to improve ORNJ reporting in academic and community practice settings.

Bone Health in Women

Osteoporosis is a significant chronic condition worldwide, causing morbidity and mortality that may be prevented with mitigation of risk factors, screening, and treatment of low bone density to prevent fractures. Adequate intake of calcium and vitamin D as well as regular weight-bearing exercise are integral for optimal bone health. Decreased bone density on dual-energy x-ray absorptiometry screening or evidence of fragility fractures are qualifiers for treatment. Treatment options beyond the first-line treatment of oral bisphosphonates exist for those who do not tolerate these medications or for those who require intensified regimens due to very high risk of fracture.

Mild antiresorptive activity of an anti-vascular endothelial growth factor A antibody and sunitinib in a rat model of bone resorption

Medication-Related-Osteonecrosis-of-the-Jaw (MRONJ) is an adverse event linked to antiresorptives such as bisphosphonates and denosumab. While MRONJ predominantly affects cancer patients treated with these agents, it has been less frequently reported in cancer patients receiving angiogenesis inhibitors (AgIs) like bevacizumab and sunitinib, even without concurrent use of antiresorptives. We hypothesized that certain AgIs exhibit antiresorptive activity in addition to their antiangiogenic effects, potentially influencing the pathophysiology of MRONJ. 52 five-week-old SD rats were randomized to receive vehicle (VEH), an oncologic dose of zoledronic acid (ZOL), or low (LD) and high doses (HD) of either an anti-VEGFA antibody or sunitinib (SU) for 10 days. We used the Schenk assay to assess the in vivo antiresorptive properties of these drugs/agents. We evaluated serum biomarkers of bone resorption (TRACP 5b) and formation (P1NP), pQCT variables of the femurs/tibias, and bone resorption/formation variables by bone histomorphometry at the distal femur metaphysis. ZOL reduced TRACP-5b levels, osteoclast number, and BFR while increasing vBMD, mineralized tissue volume, calcified cartilage volume, and bone volume. Both anti-VEGFA and SU decreased osteoclast number and increased calcified cartilage volume relative to total mineralized tissue volume, though to a lesser extent than ZOL. Anti-VEGFA (HD) also reduced TRACP-5b levels. Furthermore, both AgIs decreased P1NP levels, MAR, and bone elongation rate but increased growth cartilage thickness and induced physeal dysplasia. In conclusion, AgIs, particularly anti-VEGFA, exhibit significant yet milder antiresorptive activity compared to ZOL. They also affect bone formation, suggesting a complex mechanism that may play a role in the pathophysiology of MRONJ.

Diagnostic value of 99mTc-MDP single-photon emission computed tomography/computed tomography in medication-related osteonecrosis of the jaw: A single-center retrospective study of 39 patients

OBJECTIVE

The focus of this study was to assess the diagnostic effectiveness of 99mTc-MDP single-photon emission computed tomography/computed tomography (SPECT/CT) in pinpointing medication-related osteonecrosis of the jaw (MRONJ).

METHODS

We gathered a total of 39 patients who were suspected of having MRONJ and displayed radionuclide concentration in the jaws on whole-body bone scans. These patients were subjected to simultaneous SPECT/CT fusion imaging of the jaws during delayed imaging. A consistent team of nuclear medicine physicians and oral and maxillofacial surgeons carried out diagnostic evaluations using SPECT/CT image analysis and dental specialist examinations, and the diagnoses were documented.

RESULTS

Based on the SPECT/CT image analysis and dental specialist examination outcomes, we calculated the sensitivity, specificity, accuracy, positive predictive value, and negative predictive value of 99mTc-MDP SPECT/CT in diagnosing suspected MRONJ. Further, we enumerated the number and proportion of patients at each stage.

CONCLUSION

Our findings suggest that 99mTc-MDP SPECT/CT demonstrates high diagnostic precision in patients suspected of MRONJ who display radionuclide concentration in the jaw on whole-body bone scans. Moreover, it proves beneficial in identifying the early stages of MRONJ.

Bisphosphonates with high bone-resorption-capacity promote osteonecrosis of the jaw development after tooth extraction in mice

INTRODUCTION

Medication-Related Osteonecrosis of the Jaw (MRONJ) is a condition marked by osteonecrosis of the jaw bone and other symptoms seen following invasive surgical procedures in patients administered bone-modifying agents. Once disease develops, a patient's ADL levels are significantly compromised. However, the pathogenesis of this disease is not clearly understood. Bisphosphonates (BPs) are bone resorption inhibitors commonly used to treat osteoporosis. Although not confirmed, it is generally believed that MRONJ risk is higher in the presence of injectable rather than oral formulations. Here, we assessed risk of developing ONJ in mice in the presence of 3 different BPs-zoledronate, ibandronate, or alendronate-that are administered clinically intravenously or via infusion.

MATERIALS AND METHODS

Eight-week-old wild-type mice were administered zoledronate, alendronate, ibandronate or PBS vehicle subcutaneously once a week for 2 weeks. Then the right first molars in the mandible were extracted. Six-weeks later, osteonecrosis development was analyzed by histochemistry.

RESULTS

Among mice administered BPs, mice treated with zoledronate exhibited the highest frequency of osteocytes exhibiting osteonecrosis. Bone mineral density was higher in mice receiving zoledronate, alendronate, or ibandronate than in PBS control mice, but effects of the 3 drugs were comparable. Moreover, formation of multi-nuclear osteoclasts in vitro was most strongly inhibited by zoledronate, followed by alendronate and ibandronate.

CONCLUSION

Administration of BPs with high osteoclastogenesis inhibitory potential, such as zoledronate, increases risk of ONJ development after tooth extraction more than treatment with other agents tested, even at equivalent dosage.

Clinical outcomes and bone marker changes in postmenopausal women with dental implants: a one-year prospective study

OBJECTIVES

The feasibility of dental implants in patients with osteoporosis remains controversial, with limited prospective studies on quantitative changes in bone mineral density (BMD) and bone turnover markers (BTMs). This study assessed implant survival and clinical outcomes while evaluating systemic changes during 1 year of implant treatment.

MATERIALS AND METHODS

Postmenopausal women requiring dental implants were enrolled at the Yonsei University Dental Hospital. BMD and BTMs were evaluated in collaboration with the endocrinology department. Participants were divided into two groups: Group A (T-score ≥ -2) and Group B (T-score < -2). All implants used in the study were surface-treated with hydroxyethyl piperazine ethane sulfonic acid (HEPES), and clinical, radiographic, and systemic parameters were monitored for over 1 year.

RESULTS

Between April 2022 and May 2024, 45 implants were placed in 36 patients (mean age: 68 years). Group A included 17 patients with 21 implants (mean age: 66 years), and Group B included 19 patients with 24 implants (mean age: 70 years). The cumulative survival rate was 100%. Resonance frequency analysis at 12 months revealed a mean implant stability tester value of 71.4 ± 5.52, indicating excellent osseointegration. Peri-implant bone loss averaged 0.54 ± 0.35 mm. No implant failures occurred, with stable plaque scores, probing depths, and bleeding upon probing. BMD and BTMs changes were minimal.

CONCLUSIONS

Both groups achieved high implant survival and stable clinical outcomes. Systemic evaluations confirmed only minor changes in BMD and BTMs over 1 year. Larger multicenter studies are required to confirm the systemic safety of dental implants in patients with osteoporosis.

CLINICAL RELEVANCE

Dental implants show excellent survival and stability in postmenopausal women with osteoporosis, with minimal impact on bone density and turnover-supporting their safe use in this population.

CLINICAL TRIAL REGISTRATION

This study was prospectively registered at the Clinical Research Information Service of the National Research Institute of Health, Republic of Korea (KCT0007100). The registration details can be accessed at https://cris.nih.go.kr .

Iatrogenic Head and Neck Necrosis of Bone and Soft Tissue in Cancer Patients

BACKGROUND

Cancer patients are at risk of developing a wide range of treatment-related toxicities that may affect the head and neck region. Iatrogenic necrosis of bone and soft tissue in this area represents a distinct clinical entity characterized by significant complexities and challenges, arising as a consequence of radiotherapy (osteoradionecrosis) or the administration of bone-modifying and/or antiangiogenic therapies (medication-related osteonecrosis of the jaw).

OBJECTIVE

This review provides a comprehensive understanding of this potentially highly impactful complication of cancer therapy and antiresorptive therapy by examining its pathophysiology, risk factors, clinical presentation, and management strategies.

RESULTS

Risk factors associated with these conditions include radiotherapy-related variables, medication-related factors, and local predisposing conditions.

CONCLUSION

This review highlights the importance of preventive strategies, including comprehensive dental evaluations and the development of personalized treatment plans before, during, and after cancer therapy, as well as when patients are undergoing or are expected to undergo treatment with bone-modifying medications. By addressing these critical aspects, clinicians can better manage and mitigate the impact of this challenging complication on the quality of life and morbidity outcomes.

Multimorbidity patterns and prevalence among geriatric patients in Japanese hospital dentistry

BACKGROUND

This study aimed to determine the prevalence of multimorbidity of a hospital dental patients with high rates of aging in Japan and to identify multimorbidity patterns in older patients (aged 65 years and older) through cluster analysis. As the population ages, the number of patients with multimorbidity is rising, highlighting the need for efficient allocation of dental resources and collaboration with other healthcare professionals. However, the prevalence and patterns of multimorbidity in older dental patients have not yet been reported. Such data could support standardized approaches to systematizing dental care.

METHODS

A retrospective survey was conducted on 1,011 patients in the Dental and Oral Surgery Department of Acute Care Hospital from April to October 2022, examining 17 types of chronic diseases per patient. For patients aged 65 years and older, cluster analysis using the non-hierarchical k-means method was applied to identify multimorbidity patterns.

RESULTS

The prevalence of multimorbidity was 61.4% among all patients and 86.5% among those aged 65 years and older. Cluster analysis revealed five distinct multimorbidity patterns in patients aged 65 and older, each defined by specific combinations of chronic diseases. Additionally, low independence in daily activities and high nursing care needs were associated with two particular multimorbidity patterns: a combination of stroke, digestive disease, hypertension, neurological disease, and a combination of cardiovascular disease, digestive disease, and metabolic disease.

CONCLUSIONS

This study identified the prevalence and specific patterns of multimorbidity among older hospital dental patients, providing essential insights for dental professionals to enhance service provision and manage complex multimorbidity cases.

Systemic Ozone Therapy Improves Oral Hard and Soft Tissue Healing in Medication-Related Osteonecrosis of the Jaw (MRONJ): A Study in Senescent Female Rats

Background/Objectives: Medication-related osteonecrosis of the jaw (MRONJ) is a challenging condition often associated with bisphosphonate use, leading to impaired bone healing and difficult clinical management. Given the lack of predictable therapeutic options, this study investigated the effects of systemic ozone therapy on MRONJ healing. This study aimed to analyze the effects of systemic ozone therapy on oral hard and soft tissue healing in senescent rats with medication-related osteonecrosis of the jaw (MRONJ) induced by antiresorptive therapy. Methods: Twenty-eight senescent Wistar rats, aged eighteen months and weighing ~350 g, were used for this study. The animals were divided into four groups. The negative control (SAL) group received saline applications, while the control-treated (SAL+OZ) group received saline applications and ozone therapy (0.7 mg/kg). The MRONJ (ZOL) group received Zoledronate, an intravenous antiresorptive drug (100 μg/kg), and the MRONJ-treated (ZOL+OZ) group received zoledronate application and was treated with systemic ozone therapy (0.7 mg/kg). All rats underwent molar extraction in the third week of the experiment and were euthanized in the seventh week of the experiment. The mandibles were resected, reduced, and prepared for microtomographic analysis, histopathological/histometric analysis, and immunohistochemistry. Results: The ZOL group presented characteristics of vitreous, non-vital, and dense bone, poor vascularization, and high values of inflammation markers compatible with MRONJ. In contrast, the ZOL+OZ group exhibited improvement in alveolar bone and soft tissue healing, a decrease in nonvital bone area, and modulation of local inflammation. Conclusions: It can be concluded that Ozone therapy improved oral hard and soft tissue healing of MRONJ in senescent female rats subjected to antiresorptive drugs and might be considered for future clinical applications.

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.

Intraoperative ICG NIF Imaging Defines Surgical Margin in MRONJ: A Prospective Observational Study

BACKGROUND

This study explored the feasibility and effectiveness of indocyanine green (ICG)-based near-infrared fluorescence (NIF) imaging for localizing bone lesions associated with medication-related osteonecrosis of the jaw (MRONJ) during surgical intervention.

METHODS

A prospective observational study was conducted on 68 patients who underwent surgical treatment for MRONJ at a single institution between January 2021 and April 2024. Among them, 14 patients received surgery guided by NIF imaging, while the remaining patients underwent surgery without NIF guidance. Postoperative follow-up was performed to assess clinical outcomes.

RESULTS

There were no significant differences between the two groups regarding age, medication type and duration, underlying disease, lesion location, clinical stage, concomitant symptoms, or surgical approach. NIF imaging remained stable in 14 patients who underwent MRONJ fluorescence surgery. The recurrence rate was lower in the NIF group (14.29%) than in the non-NIF group (27.78%). The difference in the recurrence-free survival curves between the two groups was statistically significant (p = 0.043).

CONCLUSION

ICG-mediated NIF imaging provides a reliable method for identifying MRONJ-related bone lesions and offers valuable intraoperative guidance, potentially improving surgical outcomes.

One-Year Follow-Up of Non-Healing Socket in Hodgkin's Lymphoma Patient: Case Report and Literature Review on Management Strategies

Background and Clinical Significance: Sodium hypochlorite (NaOCl) is widely used in root canal treatment for its potent antiseptic and antibacterial effects. However, its cytotoxicity-particularly at higher concentrations and in patients with low immune status-has been associated with serious postoperative complications. This case report describes the risks associated with NaOCl exposure in a medically compromised patient and reviews the relevant literature on NaOCl-related injuries, offering insights into potential current management strategies. Case Presentation: This case report describes a challenging scenario of a 25-year-old male with a history of Hodgkin's lymphoma who developed a non-healing bone in the lower right first molar (LR6) region after NaOCl exposure. Several months after undergoing root canal treatment and an extraction of the LR6, the patient presented with exposed necrotic bone in the region. The case's complexity was heightened by the patient's medical and dental history, which included chemotherapy and NaOCl exposure. Following a detailed clinical, radiographic examination and biopsy, the patient was diagnosed with bone necrosis due to NaOCl exposure. The treatment involved the extraction of the LR6, the debridement of the necrotic bone, and long-term follow-up with antimicrobial therapy. Despite efforts to manage the complication, the healing process was prolonged, potentially due to the patient's immunocompromised state from chemotherapy. The patient's condition remained unresolved after nearly a year, and ongoing management, including regular follow-up, was necessary to monitor healing and prevent further complications. This case highlights the challenges of treating dental complications in immunocompromised patients, particularly those with Hodgkin's lymphoma, where delayed healing is a problem that might occur. Conclusions: Given the complexity of this case, different adjunctive treatment options, such as leukocyte-platelet-rich fibrin (L-PRF), pentoxifylline and tocopherol (PENTO), and hyperbaric oxygen therapy (HBOT), were discussed as potential treatments to help manage non-healing sockets in patients with similar conditions.

Time since last intravenous bisphosphonate and risk of osteonecrosis of the jaw in osteoporotic patients

Medication-related osteonecrosis of the jaw is a rare but serious condition in which the jawbone fails to heal and becomes necrotic, typically after dental surgery in patients treated with bisphosphonates. However, clear evidence guiding how long bisphosphonate treatment should be paused before dental surgery remains limited. Here we show that a longer time since the last dose of intravenous bisphosphonate is associated with a reduced risk of jawbone necrosis. Using a nationwide retrospective cohort of 152,299 older adults diagnosed with osteoporosis, we analyze the relationship between the duration of bisphosphonate discontinuation prior to dental extraction and the occurrence of osteonecrosis of the jaw. We find that the risk is substantially lower when treatment is paused for more than 90 days, and lowest when the pause exceeds one year. The risk reduction appears more consistent with ibandronate, whereas with zoledronate, only pauses longer than one year show a meaningful association. These findings underscore the potential value of personalized prevention strategies based on bisphosphonate type.

Supra-Physiological Levels of Magnesium Counteract the Inhibitory Effect of Zoledronate on RANKL-Dependent Osteoclastogenesis

Bisphosphonates (BPs) are drugs used to cure metabolic diseases like osteoporosis and oncological conditions, such as multiple myeloma and bone metastases. The pharmacological activity of these compounds is mediated by their capacity to induce a systemic osteoclast depletion, finally resulting in reduced bone resorption. In spite of their efficacy, the clinical application of BPs is sometimes associated with a frightening side effect known as osteonecrosis of the jaw (ONJ). In principle, a therapeutic approach able to elicit the local re-activation of osteoclast production could counteract the onset of ONJ and promote the healing of its lesions. Using a vitamin D3-dependent model of osteoclast differentiation, it has been previously demonstrated that when used at supra-physiological concentrations, magnesium strongly favors the process under consideration, and its effect is furtherly enhanced by the presence of a BP called zoledronate. Here, we show that similar results can be obtained in a RANKL-dependent model of osteoclast differentiation, suggesting that a topical therapy based on magnesium may be also suitable for ONJ determined by denosumab in light of the ability of this monoclonal antibody to target RANKL.

Analysis of prosthetic risk factors for peri-implant medication-related osteonecrosis of the jaw: an observational study

The study aimed to evaluate clinical characteristics of peri-implant medication-related osteonecrosis of the jaw (PI-MRONJ) and to identify prosthetic risk factors for PI-MRONJ. Demographic and pharmacological data were collected from 32 patients. Radiographic assessments were performed to evaluate potential risk factors related to prosthetic elements, including prosthesis margin, embrasure space, emergence profile and angle, span of prostheses, and cantilever extensions. 24 patients were classified as having implant presence-triggered PI-MRONJ, while 8 were categorized as having implant surgery-triggered PI-MRONJ. Even in well-functioning implants, MRONJ developed after an average of 48.3 months following the initiation of anti-resorptive drug (ARD) therapy. Similarly, in implants placed during ARD therapy and showing successful osseointegration, MRONJ occurred after an average of 23.3 months of implant placement. Comparing prostheses in MRONJ-affected areas to those in unaffected areas, the presence of cantilever extensions showed the only significant difference (p = 0.002). Regression analysis revealed that cantilever extensions (p = 0.001), sex (p = 0.009), duration of ARD (p = 0.042), and age (p = 0.046) were significantly associated with PI-MRONJ. These findings suggest that non-axial loading may be a risk factor for PI-MRONJ. Proper prosthetic design and load management, along with long-term monitoring, are crucial for preventing PI-MRONJ.

Management of Medication-Related Osteonecrosis of the Jaw in Multiple Myeloma Patients With Pentoxifylline and Tocopherol: Case Reports

Medication-related osteonecrosis of the jaw (MRONJ) is a well-known side effect of bone-modifying agents such as antiresorptive medications including pamidronic and zoledronic acids (intravenous bisphosphonates) and denosumab (anti-RANK ligand humanized monoclonal antibody). The major risk factor for the precipitation of MRONJ in a patient taking antiresorptive medication is dentoalveolar trauma such as dental extractions. Management of MRONJ in oncology patients is exceptionally challenging. In this report, two multiple myeloma patients with longstanding advanced-stage MRONJ were successfully managed with combined pentoxifylline-tocopherol treatment pre- and postextraction/sequestrectomy. In conclusion, based on this report and other published reports, it appears that the use of combined pentoxifylline-tocopherol protocol in the management of MRONJ is effective.

Dental Complications and Reasons for Delayed Clearance Before Hematopoietic Stem Cell Transplant

AIM

Dental evaluation before hematological stem-cell transplant (HSCT) is considered a standard of care. Data on the complications of dental treatment before HSCT are scarce. The aim was to analyze the data on dental treatment in patients undergoing HSCT with an emphasis on complications and reasons for delayed dental clearance.

MATERIALS AND METHODS

Retrospective chart review of 125 patients referred for dental evaluation before HSCT was performed. Demographic, medical, dental data, and complications were registered. Number of appointments and days required to obtain a dental clearance for HSCT were registered, as well as reasons for delayed (i.e., > 21 days) dental clearance.

RESULTS

The most common procedure was tooth extraction, performed in 48 (38.4%) patients. Complications, that is, local infection and delayed healing, occurred in 2 (1.6%) patients. Most patients (104; 83.2%) obtained dental clearance for HSCT in 1-2 appointments (median 1 day). No patient experienced dental complications during the early (≤ 30 days) post-transplant period. Seven (5.6%) patients had their dental clearance delayed for more than 21 days due to increased treatment needs and complex medical conditions.

CONCLUSIONS

Dental treatment before HSCT can be performed with an acceptable safety rate. Delayed dental clearance occurs in complex, high-risk patients with significantly increased treatment needs.

Identifying a predictive level of serum C-terminal telopeptide associated with a low risk of medication-related osteonecrosis of the jaw secondary to oral surgery: A systematic review and meta-analysis

OBJECTIVE

Our aim was to determine serum C-terminal telopeptide of type I collagen (sCTX) thresholds for predicting the minimal risk of medication-related osteonecrosis of the jaw (MRONJ) in patients undergoing anti-resorptive therapy prior to oral surgery.

METHODS

A systematic literature search was conducted in MEDLINE, EMBase, and the Cochrane Library up to September 2023 for case-control, prospective and retrospective studies that assessed sCTX levels in patients exposed to anti-resorptive drugs who underwent oral surgery. We extracted data using a predetermined form. We performed an original percentile meta-analysis method, following PRISMA-DTA guidelines and descriptive analysis to identify the threshold associated with the lowest risk while assessing the overall result of the 95th, 97.5th and 99th percentiles with a random-effect model with weighting by DerSimonian and Laird (RStudio software [v. 4.2.0]).

RESULTS

Seven studies involving 1281 patients were included. Most patients (96%) were treated for osteoporosis, predominantly with oral bisphosphonates (94.5%). Individual data were available for 58 patients. In the entire population of patients who experienced MRONJ after oral surgery (n = 113), the 95th, 97.5th and 99th percentiles of sCTX were 338.0 pg/mL [95%CI: 190,3; 485,7], 401.9 pg/mL [95%CI: 191,3; 612,6], and 458.0 pg/mL [95%CI: 190,4; 725,6], respectively. Among those treated with oral bisphosphonates for osteoporosis (n = 38), the sCTX 95th, 97.5th and 99th percentiles were 185.3 pg/mL [95%CI: 131,3; 239,3] 187.4 pg/mL [95%CI: 133,9; 240,8] and 188.6 pg/mL [95%CI: 135,4; 241,9], respectively. The determination of these same percentiles with individual data analysis yielded similar results, i.e., 202.0, 257.0 and 260.0 pg/mL.

CONCLUSION

This pioneering meta-analysis assesses the risk of MRONJ by analyzing sCTX levels in patients undergoing oral surgery while exposed to antiresorptive drugs. Among patients receiving oral bisphosphonate therapy for osteoporosis, a sCTX threshold of 260 pg/mL is linked to an extremely low risk of MRONJ occurrence, surpassing the 99th percentile. Conversely, for patients undergoing treatment for cancer-related conditions, sCTX levels do not reliably serve as a biomarker for identifying this risk.

Navigating skeletal wellness after breast cancer

Breast cancer is the leading cause of death in the female population. Hormone receptor-positive cancers are usually treated with surgery in combination with endocrine therapy. The latter is known to lower estrogen levels, contributing, therefore, to loss of bone density (BMD) and higher risk of fracture. Bone-modifying agents (BMAs) can regulate the bone-related adverse effects of cancer treatment. In premenopausal women, intravenous zoledronate effectively prevents bone loss. However, the evidence regarding its ability to reduce disease recurrence remains inconclusive. In postmenopausal women, denosumab demonstrates the most substantial evidence for fracture prevention, supported by one well-powered randomized controlled trial, but has not been shown to confer anticancer benefits. While bisphosphonates effectively prevent and reduce clinical vertebra fractures, their impact on overall fracture risk is unclear. In clinical practice, management of bone health in this group of patients starts with stratification for the risk of fracture. This can be done using the FRAX algorithm; measurements of bone mineral density can help to optimize stratification for individuals at higher fracture risk. Caution is advised when interpreting the results, as the FRAX algorithm has been considered to underestimate the true fracture risk in this population, given that the algorithm has not been adjusted for the effect of anti-cancer agents. Nowadays, clodronate, ibandronate, and zoledronic acid are recommended for bone protection in this group of patients, while denosumab is not. Further research is required to highlight the optimal BMA according to patient characteristics.

An assessment of the oral health status and dental care treatment needs of oncology patients receiving bone modifying agents

OBJECTIVE

The objective of this study was to assess the oral health status and dental care treatment need of oncology patients receiving bone modifying agents (BMAs).

STUDY DESIGN

This was a cross-sectional study conducted in oncology patients. Their oral health status was assessed and dental care treatment needs were completed prior to commencing a BMA. Statistical analysis was conducted to identify certain characteristics which may highlight risk factors for dental disease and dental treatment needs.

RESULTS

A total of 150 patients were assessed, with a mean age of 61.5 years (standard deviation [SD] = 11.75 years). Breast cancer was the most common cancer (n = 96). Sixty-five patients (43.3%) did not have a dentist. The mean Decayed, Missing, and Filled Teeth (DMFT) index was 17.68 (SD = 7.85) and 145 patients (97%) had periodontal disease. Eighty-six restorations were placed and 188 teeth were extracted. One hundred forty-seven patients (98%) achieved dental fitness. Statistical analysis found a significant result for a periodontal extraction and increasing age, which increased by 21.2% every 10 years (P = .0239). Patients who did not have a dentist required 67.5% more restorations and a current smoker was 3.4 times as likely to require an extraction due to periodontal disease (P < .001).

CONCLUSIONS

Our study highlights the vulnerability of this cohort due to their dental treatment needs. (Oral Surg Oral Med Oral Pathol Oral Radiol YEAR;VOL:page range).

Monoclonal Antibodies and Small-Molecule Inhibitors Associated Osteonecrosis of Jaw: A Retrospective Pharmacovigilance Study

BACKGROUND

Osteonecrosis of the jaw (ONJ) is an adverse effect associated with medications such as monoclonal antibodies and small-molecule inhibitors.

PURPOSE

This study assesses the association between monoclonal antibodies and small-molecule inhibitors with ONJ.

STUDY DESIGN, SETTING, SAMPLE

The study design was a retrospective pharmacovigilance case series. The sample was derived from the United States Food and Drug Administration Adverse Event Reporting System database reporting ONJ from March 2004 to March 2024. The inclusion criteria were the reports relating ONJ occurrence with exposure to monoclonal antibodies (trastuzumab, bevacizumab, denosumab, elotuzumab, isatuximab, pertuzumab, ramucirumab, romosozumab, and ado-trastuzumab emtansine) and small-molecule inhibitors (abemaciclib, alpelisib, axitinib, cabozantinib, lapatinib, lenvatinib, palbociclib, ribociclib, and sunitinib). The exclusion criteria were the reports associating the role of monoclonal antibodies and small molecule inhibitors to ONJ with roles other than primary suspicion.

PREDICTOR VARIABLE

Not applicable.

MAIN OUTCOME VARIABLE

The outcome variable is the case status divided into case and noncase. Cases were defined as reports with ONJ associated with monoclonal antibodies or small-molecule inhibitors while noncases were the reports with other adverse events. Secondary outcome variables were death, hospitalization, and disability observed with monoclonal antibodies/small-molecule inhibitors-associated ONJ.

COVARIATES

Age and gender were the covariates included in this study.

ANALYSES

The case-noncase approach was applied for signal detection, using frequentist (reporting odds ratio [ROR] and proportional reporting ratio [PRR]) and Bayesian methods (lower limit of 95% CI of Information component [IC025]). The ROR is determined by comparing the odds of ONJ being reported for a given drug to the odds of the same event being reported for all other drugs and PRR is estimated by the ratio of proportion of reports for a specific drug with ONJ over the proportion of reports with ONJ for all other drugs. The information component is defined as defined as the logarithmic ratio of the observed ONJ with the primary suspected drug relative to the expected frequency of the drug-ONJ pair based on overall reporting rates in the database. Outcomes were analyzed with statistical comparisons using χ2 tests (χ2) at P ≤ .05.

RESULTS

A total of 7,402 reports were included with median age ranging between 61 and 76 years with female preponderance. Denosumab (ROR: 64.7 [62.5, 67]; PRR: 61.9 [59.9, 64.1]; P < .05; and IC025: 5.1), romosozumab (ROR 4.2 [3, 6]; PRR: 4.2 [3, 6]; P < .05; and IC025: 1.5), and lenvatinib (ROR: 3.1 [2.3, 4.2]; PRR: 3.1 [2.3, 4.1]; P < .05; and IC025: 1.2) showed positive signals for ONJ compared to all other drugs in the database by both frequentist and Bayesian analyses indicating a potential association. Sixty-two point eight percent cases resulted in hospitalization and was no significant differences were observed in the distribution of outcomes between the monoclonal antibodies and small molecule inhibitors (χ2: 12; df: 14; P = .6). The risk was mainly observed in elderly and female patients.

CONCLUSION AND RELEVANCE

Denosumab, romosozumab, and lenvatinib are significantly associated with ONJ, particularly in older and female patients. Further research is needed to understand the mechanisms and improve risk management strategies.

Antiresorptive Therapy to Reduce Fracture Risk and Effects on Dental Implant Outcomes in Patients With Osteoporosis: A Systematic Review and Osteonecrosis of the Jaw Taskforce Consensus Statement

OBJECTIVE

Placement of a dental implant in a patient on antiresorptive therapy has been hypothesized to increase the risk of medication-related osteonecrosis of the jaw (MRONJ) and/or impact implant survival. In patients with osteoporosis, the risk of MRONJ with antiresorptive therapy is only marginally higher than observed in the general population.

METHODS

The International ONJ Taskforce conducted a systematic review of the literature and evaluated the outcomes of implant placement in individuals with osteoporosis receiving antiresorptive therapy.

RESULTS

The data were reviewed by the International Taskforce, and consensus was achieved on the following GRADEd recommendation. In patients with osteoporosis on antiresorptive therapy, the Taskforce suggests that antiresorptive therapy does not need to be stopped prior to proceeding with dental implant (weak recommendation, very low-quality evidence). Long-term bisphosphonate use maybe associated with a small increase in the risk of MRONJ (3 cases per 1000 patients; adjusted hazard ratio: 4.09, 95% CI: 2.75-6.09, P < .001, moderate certainty).

CONCLUSION

Current evidence does not suggest an association between antiresorptive therapy in patients with osteoporosis and dental implant failure. Implants may be safely placed in the presence of concomitant use of bisphosphonates or denosumab in patients with osteoporosis with no evidence of an increased risk of implant failure/compromise.

The efficacy of different local flaps for wound closure of defects after removal of necrotic bone in advanced medication-related osteonecrosis of the jaw: A single-center cohort study

For this study, the surgical outcomes of patients with advanced medication-related osteonecrosis of the jaw (MRONJ), treated with different local flaps for soft-tissue closure, were evaluated. Cases of stage 2 and 3 MRONJ patients (n = 96) with a 12-month minimum follow-up were retrospectively analyzed. All patients underwent surgical treatment and soft-tissue closure with local flaps, including buccal fat flap (BFF), nasolabial flap (NLF), facial artery musculomucosal flap (FAMM-F), and submental island flap (SIF), based on the size and location of the defects. The occurrence of side effects was also evaluated. At the time of the last follow-up, 97.7% (42 of 43) of the patients in the BFF group, 90.3% (28 of 31) of the NLF patients, 100% (8 of 8) of the FAMM-F patients, and 92.9% (13 of 14) of the SIF patients showed mucosal integrity. No serious complications were observed. Five cases with relapsed MRONJ were in cancer patients who continued both chemotherapy and antiresorptive therapy. Different local flaps for soft-tissue closure after bone surgery in advanced MRONJ patients could provide a mechanically stable and well-vascularized covering of the exposed bone, leading to good healing.

Prevalence of Bisphosphonate and Denosumab Use in Elderly Care Facilities: Implications for the Management of Medication-Related Osteonecrosis of the Jaw

OBJECTIVE

Our group is investigating the contribution of pharmacists in reducing medication-related osteonecrosis of the jaw (MRONJ) associated with bisphosphonates (BPs) and denosumab (Dmab). Recently, our group encountered a case of MRONJ occurring in an elderly care setting. The aim of this study was therefore to investigate the actual use of BP and Dmab and the incidence of MRONJ in elderly care facilities. We also discussed measures for the prevention and early detection of MRONJ by dentists and pharmacists associated with these facilities.

MATERIALS AND METHODS

A cross-sectional survey across four elderly care facilities (including the one where the case occurred) was conducted to determine the prevalence of BP and Dmab use and related factors, as well as the incidence of MRONJ.

RESULTS

Among 327 residents, 9.8% (32) were receiving BP or Dmab therapy (84.4% oral, 15.6% injectable). The encountered MRONJ case was the only one identified, occurring in a resident using injectable BP.

CONCLUSION

In these elderly facilities, 9.8% of residents used BPs or Dmab, with 15.6% receiving injectable formulations. One MRONJ case occurred with injectable BP use, suggesting the potential for sporadic MRONJ in elderly care. As BP/Dmab use is likely to increase, pharmacist intervention for prescription review and training for visiting dentists are considered effective strategies for MRONJ prevention and early detection.

The Role of Dental Oncology in Cancer Care: a Critical Component of Comprehensive Treatment, Education, and Interdisciplinary Collaboration- a Narrative Review

Dental oncology, a vital branch of special care dentistry, addresses the oral health needs of patients undergoing cancer treatment. This narrative review explores the critical role of dentists specializing in cancer care, known as "onco-dentists," in managing the unique oral complications caused by cancer therapies, including chemotherapy, radiation therapy, and surgery. These treatments often lead to a range of oral health issues, such as mucositis, xerostomia, dental caries, periodontal disease, and trismus, significantly impacting a patient's quality of life and potentially disrupting cancer care. By providing tailored preventive and therapeutic interventions, onco-dentists enhance treatment outcomes and improve overall patient well-being. Furthermore, their collaboration with oncologists and other healthcare professionals promotes integrated care plans that address both cancer treatment and oral health management, emphasizing the importance of a holistic approach to patient care. This review aims to highlight the multifaceted role of onco-dentists, the significance of interdisciplinary collaboration, and the necessity of proactive oral health management in comprehensive cancer care. Moreover, the review underscores the importance of education at multiple levels-integrating dental oncology into medical and dental curricula, raising public awareness, and providing patient education to empower individuals in managing their oral health during cancer treatment.

Surgical extraction with photobiomodulation as an adjunctive modality in patients at-risk for medication-related osteonecrosis of the jaw: retrospective study

AIM

The study aims to retrospectively assess and share the experience of the use of photobiomodulation (PBM) as an adjunctive to surgical extraction in patients at-risk for medication-related osteonecrosis of the jaw (MRONJ) due to a treatment history with bone-modifying agents.

METHODS

The department database and medical records were examined in the period between 2016 and 2023. The inclusion criteria were; at-risk patients for MRONJ with current or previous treatment with bone-modifying agents, with or without a history of antiangiogenic agents administration, who underwent single or multiple dental extractions, subjected to PBM preventive protocol, and without a diagnosis or history of MRONJ development. The PBM protocol consisted of four sessions, two sessions before the intervention and two sessions after the intervention. The PBM parameters (per session) were; total power of 0.6 W, time of 15 min, frequency of 30 kHz, and total energy of 577.4 J.

RESULTS

A total of 62 patients (58 females and 4 males) fulfilled the inclusion criteria with a mean age of 67.5 years. Complete healing without the development of MRONJ was shown in 50 (80.65%) patients, and the development of MRONJ was shown in 12 (19.35%) patients. The statistical analysis revealed a higher risk of MRONJ in patients with a history of administration of zoledronic acid (p = 0.029) and in patients undergoing corticosteroid therapy (p = 0.039). While a lower risk was observed in patients in treatment for thyroid pathology (p = 0.055).

CONCLUSIONS

The majority of the included at-risk MRONJ patients showed complete healing after surgical extraction with the use of PBM as an adjunctive modality. Corticosteroid treatment as a systemic risk factor and zoledronic acid as a drug-related risk factor show significant associations with the development of MRONJ.

Autofluorescence-Guided Surgery in the Management of Osteonecrosis of the Jaw: Correlation Between Bone Autofluorescence and Histopathological Findings in 56 Samples

(1) Background: Osteonecrosis of the jaw (ONJ) remains a challenging condition without a universally accepted treatment protocol. Surgical therapy, particularly Er:YAG laser-assisted surgery, has shown more predictable long-term results compared with non-surgical options. However, the identification of resection margins in ONJ surgery is complex and currently relies on the surgeon's intraoperative assessment, without standardization. Bone autofluorescence (AF) has been proposed as an intraoperative diagnostic tool for visualizing necrotic bone; under VELscope (LED Medical Diagnostics Inc., Barnaby, BC, Canada) illumination, healthy bone exhibits hyperfluorescence, while pathological bone appears dark brown/black (loss of autofluorescence, LAF). (2) Methods: 22 patients with ONJ requiring surgical therapy were included. After bone exposure, VELscope system was used to induce and visualize bone AF. Areas exhibiting absent or pale AF were identified as necrotic and removed; additional samples were collected from adjacent hyperfluorescent regions. (3) Results: Histopathologic evaluation of 56 specimens were conducted; 35 hypofluorescent samples were found to be necrotic bone tissue; in the 21 hyperfluorescent samples, 86% demonstrated normal, vital bone. The correlation between fluorescence and bone vitality was highly significant (p < 0.0000001). (4) Conclusions: Our data show that AF-guided surgical resection, combined with Er:YAG laser-assisted surgery, may improve clinical outcomes.

Prevalence of MRONJ in patients treated with antiresorptive agents for glucocorticoid-induced osteoporosis

PURPOSE

In this study, we aimed to investigate the incidence of medication-related osteonecrosis of the jaw (MRONJ) in patients with glucocorticoid-induced osteoporosis (GIOP) and to examine risk factors for MRONJ development, as well as the preventive effect of tooth extraction before antiresorptive agent (ARA) administration.

METHODS

This retrospective study included patients who received ARA to prevent fragility fractures due to GIOP. The cumulative incidence of MRONJ in patients with GIOP was calculated using the Kaplan-Meier method. Univariate and multivariate Cox regression analyses were used to analyze risk factors for MRONJ occurrence.

RESULTS

The study included 327 individuals. Six patients developed MRONJ; the crude incidence of MRONJ was 1.8%, and the cumulative incidence at 1, 2, 3, 4, and 5 years was 0.32%, 0.97%, 1.35%, 1.85%, and 2.56%, respectively. In this study, 159 teeth were extracted during dental intervention before ARA administration in 58 patients; however, no MRONJ development was observed at the extraction site. Tooth extraction, diabetes mellitus, and duration of ARA administration were not identified as risk factors in this study.

CONCLUSIONS

The incidence of MRONJ in patients with GIOP was higher than the previously reported incidence in patients with age-related osteoporosis but lower than the incidence in patients using high-dose ARA. The results support the effectiveness of prophylactic procedures to remove the infected lesions as much as possible from the jawbone and periodontal tissue before ARA administration.

CLINICAL TRIAL NUMBER

Not applicable.

Recent Stem-Cell-Based and Stem-Cell-Free Possibilities for the Therapeutic Management of the Osteonecrosis of the Jaw

Osteonecrosis of the jaw (ONJ), including the maxilla and mandible, is considered a challenging therapeutic problem, mainly due to the lack of understanding of its pathogenesis. It is well known that ONJ is a severe side effect caused by certain medications used to treat bone metastasis and osteoporosis, such as bisphosphonates, which inhibit bone resorption. Other therapeutics with similar side effects are, for instance, receptor activators of nuclear factor kappa-B ligand (RANK-L) inhibitor (denosumab), tyrosine kinase inhibitors (sunitinib), and antiangiogenics (bevacizumab). The conservative or surgical treatment of these medication-related osteonecroses of the jaw (MRONJs) is generally effortful and still not entirely effective. Therefore, the research seeks alternative treatment options like tissue engineering and stem cell therapy, which predominantly represent mesenchymal stem cells (MSCs) and their derivatives, such as extracellular vesicles. Moreover, it was published that novel stem cell therapy could even prevent the onset of MRONJ. On the other hand, the administration of stem cells may also be accompanied by some other health risks, such as an increased chance of cancer metastasis occurrence in cancer patients. The current review paper summarizes the most recent progress in stem-cell-based and stem-cell-free treatment options for the ONJ. Similarly, we discuss this novel approach's future perspectives and possible obstacles.

Potential of zoledronate for treating diffuse sclerosing osteomyelitis of the mandible in adult patients

INTRODUCTION

Diffuse sclerosing osteomyelitis (DSO) is a rare nonbacterial bone disease associated with recurrent pain and swelling, and its pathogenesis remains unknown. Despite the absence of an established treatment for DSO, bisphosphonates have recently been considered effective in managing this condition. However, the use of zoledronate is off-label, with limited reported cases. Therefore, this study aimed to investigate the effects of zoledronate on pain suppression in DSO.

METHODS

This single-arm retrospective study evaluated adult patients diagnosed with mandibular DSO and treated with zoledronate. Patient demographics, pain suppression effect, recurrence, number of zoledronate administration, adverse reactions to zoledronate, and imaging findings were investigated.

RESULTS

The study included 18 patients (median age of 59.5 years). Zoledronate effectively suppressed pain in all patients, with a median duration of effect onset of 1 day. Symptom recurrence was observed in 66.7% of patients, with a median time of 29 months from the first zoledronate administration to recurrence. Zoledronate was administered multiple times to 44.7% of patients. The median duration of response was 80 months for patients who experienced relief after a single administration of zoledronate compared to 32 months for those who received multiple administrations (p < 0.001). Adverse reactions, including flu-like symptoms, were observed in 72.2% of the patients, and no medication-related osteonecrosis of the jaw was observed during the follow-up period.

CONCLUSIONS

Zoledronate is a relatively safe and effective treatment option for DSO of the mandible. Key Points • Zoledronate effectively suppresses pain in mandibular diffuse sclerosing osteomyelitis. • All condylar lesions recurred after zoledronate administration. • Patients with mandibular canal enlargement required multiple doses of zoledronate. • Adverse reactions to zoledronate administration were minor.

Molecular targeted drugs affect the development of antiresorptive-related osteonecrosis of the jaw in patients with lung and kidney cancers

The use of antiresorptive agents in patients with cancer is strongly associated with the development of medication-related osteonecrosis of the jaw, with an incidence of ≥10%. Despite the presence of clinical position papers on this issue, the incidence of medication-related osteonecrosis of the jaw has not decreased. Therefore, we believe there are some unknown underlying factors, so we focused on the use of anticancer agents, especially molecular targeted drugs, in this study. We retrospectively evaluated the data of 366 patients who received antiresorptive agents for metastatic cancer treatment. All patients received proper oral care before antiresorptive agent initiation. Of the 366 patients, 48 (13.1%) developed medication-related osteonecrosis of the jaw. Medication-related osteonecrosis of the jaw developed in 18/55 (32.7%) patients who received molecular targeted drugs and in 30/311 (9.6%) patients who did not (p < 0.001). Among patients with lung cancer, 10/29 (34.5%) patients who received molecular targeted drugs and 5/96 (5.2%) who did not (p < 0.001) developed medication-related osteonecrosis of the jaw. In patients with kidney cancer, medication-related osteonecrosis of the jaw developed in 5/11 patients (45.5%) who received molecular targeted drugs and not in any of the 13 patients who did not (p < 0.01). Molecular targeted drugs significantly affect the development of medication-related osteonecrosis of the jaw. Therefore, in cancer treatment, close attention should be paid to antiresorptive agent use and to the details of anticancer therapies for managing medication-related osteonecrosis of the jaw.

Peri-implant inflammation increases the risk of osteonecrosis in mice treated with bisphosphonate

BACKGROUND

Bisphosphonates (BPs) are effective in managing bone diseases due to their anti-resorptive properties but are linked to medication-related osteonecrosis of the jaw (MRONJ), particularly concerning dental implants. This study explored the combined impact of ligature-induced peri-implant inflammation and zoledronic acid (ZA), a BP, using a murine model.

METHODS

Twenty-four mice underwent bilateral maxillary molar extractions and implant placements, with ZA or vehicle treatment and ligature placement on the left side. Two groups were defined: group 1 (vehicle-treated) with control (Veh-C) and ligature (Veh-L) implants, and group 2 (ZA-treated) with control (ZA-C) and ligature (ZA-L) implants. Clinical, micro-CT, histological, and immunohistochemical analyses were performed. We hypothesized that peri-implant inflammation elevates MRONJ risk with BP treatment.

RESULTS

Ligature groups showed increased soft tissue edema compared to controls, without differences between vehicle and ZA treatments. The Veh-L group exhibited significantly greater bone loss than other groups. Histology showed higher inflammatory infiltrate in ligature groups. Osteocyte empty lacunae and osteonecrosis were significantly greater in ZA-L. Picrosirius red staining revealed disorganized collagen fibers and separation in ZA-L. Immunohistochemistry showed increased neutrophils (NIMP-R14+) and monocytes/macrophages (CD11b+) in the ligature groups, with no significant differences between Veh-C and ZA-C.

CONCLUSION

Ligature treatment enhances peri-implant inflammation, with ZA heightening the risk of MRONJ. These findings highlight the critical importance of early detection and management of peri-implant inflammation in patients undergoing BP therapy, particularly those at high risk of MRONJ. Clinicians should emphasize preventive measures, such as regular monitoring of peri-implant health and reducing local inflammatory triggers, to mitigate the adverse effects of BPs on peri-implant bone health.

PLAIN LANGUAGE SUMMARY

Dental implants are a reliable solution to replace missing teeth. However, like natural teeth, implants can develop inflammation around them-peri-implantitis. Our study found that, when this inflammation occurs in patients taking BPs (a medication commonly used to treat osteoporosis and other bone diseases), the risk of developing a serious jaw condition called osteonecrosis (ONJ) increases significantly. ONJ prevents the jawbone from healing properly, leading to pain, infection, and even exposed bone. These findings highlight the importance of preventing and managing inflammation around dental implants to reduce the risk of complications, especially in patients taking BPs. Our research suggests regular dental check-ups and proper oral hygiene can help maintain implant health and prevent severe bone-related conditions. Patients and healthcare providers can take proactive steps to improve long-term oral health outcomes by understanding these risks.

Clinical effectiveness of 3D SPECT/CT imaging in determining osteotomy range for surgical treatment of medication-related osteonecrosis of the jaw: a retrospective study

OBJECTIVE

This study aims to evaluate the clinical effectiveness of 3D SPECT/CT imaging in determining the osteotomy range during surgical treatment of Medication-Related Osteonecrosis of the Jaw (MRONJ) when combined with composite tissue flap techniques.

METHODS

A retrospective analysis was conducted involving 12 patients diagnosed with MRONJ. Each patient underwent a 3D SPECT/CT examination prior to surgery, where the region of interest (ROI) was outlined in the 3D images. During surgery, the affected bone was excised 0.5 cm beyond the delineated ROI. Various types of composite tissue flaps were utilized to close the defects based on their size and location.

RESULTS

Patients were followed for an average of 7.9 months (range: 6-12 months), with all 12 achieving successful outcomes devoid of complications such as pyorrhea.

CONCLUSION

The utilization of 3D SPECT/CT enhances the precision of determining the osteotomy range in MRONJ surgeries. Coupled with composite tissue flap techniques for defect closure, this approach yields favorable clinical outcomes.

Radioactivity levels in the saliva of patients undergoing targeted radioligand therapy with [177Lu]Lu-PSMA-I&T and [177Lu]Lu-DOTA-TOC

OBJECTIVES

The number of patients receiving radioligand therapy (RLT) has risen sharply in recent years. This raises concerns about possible risks to dental healthcare workers due to their exposure to the patients and their saliva. We therefore set about to measure the salivary radioactivity in patients undergoing 177Lu-RLT.

MATERIALS AND METHODS

We recruited in-house RLT patients receiving [177Lu]Lu -DOTA-TOC (n = 6) or [177Lu]Lu-PSMA-I&T (n = 14). We measured the radioactivity concentrations in 1 ml saliva samples collected before and 0.5, 2, 4, 21, 27, and 45 h post application of the radioligands, with additional samples collected at 51 and 69 h for [177Lu]Lu-PSMA-I&T patients. The biological half-life (BHL) and area under the curve (AUC) were calculated for the radioactivity of the saliva for both cohorts.

RESULTS

Both cohorts exhibited increases in salivary radioactivity, attaining peaks at 2 h p.i. of [177Lu]Lu-DOTA-TOC and 4 h p.i. of [177Lu]Lu-PSMA-I&T, and presenting with a significant decrease until the patients discharge. The median peak concentration for [177Lu]Lu-PSMA-I&T was four-fold higher than for the [177Lu]Lu-DOTA-TOC group. For PSMA-patients, the BHL was 14 h and the mean AUC was 895 kBqh/ml. For DOTA-TOC patients, these values were 8.5 h and 96 kBqh/ml, respectively.

CONCLUSION

Salivary radioactivity peaks earlier and at lower levels in [177Lu]Lu-DOTA-TOC patients compared to [177Lu]Lu-PSMA-I&T, which shows longer retention and ten times higher radioactivity turnover in saliva. However, radiation exposure to medical staff by the patents saliva can be considered minimal.

CLINICAL RELEVANCE

Salivary radioactivity of patients undergoing 177Lu-RLT poses minimal risk to oral healthcare workers.

Treatment period and changes in bone markers according to the application of teriparatide in treating medication-related osteonecrosis of the jaw

BACKGROUND

This study aimed to explore the effects of teriparatide (TPTD) on treatment duration, surgical procedures, and bone turnover markers in medication-related osteonecrosis of the jaw (MRONJ).

METHODS

We analyzed 76 patients with MRONJ post-treatment and divided them into conservative/surgical and TPTD/non-TPTD groups. Key assessments included treatment duration, surgery count, and changes in bone markers (serum C-terminal telopeptide of type 1 collagen [CTX], osteocalcin [OC], procollagen type 1 N-terminal propeptide [P1NP], parathyroid hormone [PTH], 25-OH-vitamin D [25(OH)D], calcium, and inorganic phosphorus) measured at the initial and post-treatment stages.

RESULTS

TPTD-treated surgical patients experienced shorter treatment periods and underwent fewer surgeries than did non-TPTD counterparts. Post-treatment, both groups showed significant increases in CTX, OC, and 25(OH)D levels. P1NP elevation was significant only in the non-TPTD group. Although the PTH levels decreased in both groups, the difference was not statistically significant. Calcium and phosphorus levels increased in both groups, but only calcium levels increased significantly in the TPTD group. Additionally, TPTD-treated patients showed significant improvements in T-scores, particularly in the lumbar spine and femur neck, compared to the non-TPTD group.

CONCLUSIONS

TPTD administration during MRONJ treatment potentially reduces the need for surgical intervention and accelerates recovery, significantly affecting bone metabolism. These findings highlight TPTD's role in enhancing the efficacy of MRONJ treatment. TPTD could potentially offer the dual benefit of promoting bone healing and reducing the need for surgical intervention, thus improving overall outcomes for patients with MRONJ.

Teriparatide as an adjuvant therapy in the management of advanced-stage medication-related osteonecrosis of the jaw

Teriparatide, recombinant human parathyroid hormone, is a US Food and Drug Administration (FDA)-approved drug used for the treatment of osteoporosis in men and postmenopausal women. Recent studies have shown that it may promote bone healing in medication-related osteonecrosis of the jaw (MRONJ). We describe a case of successful management of advanced-stage MRONJ with teriparatide therapy that was initially prescribed for osteoporosis. This case demonstrates that in patients with progressive MRONJ with significant pain and frequent flares of acute infection, teriparatide may be a viable adjunct in treating MRONJ, as well as helping alleviate symptoms and improve quality of life. (Oral Surg Oral Med Oral Pathol Oral Radiol YEAR;VOL:page range).

The usefulness of different imaging modalities in mandibular osteonecrosis and osteomyelitis diagnosis

To examine the CT-imaging features of subjects with bacterial osteomyelitis (OM), osteoradionecrosis (ORN), and medication-related osteonecrosis of the jaw (MRONJ) with histopathological confirmation, and to examine the diagnostic efficacy of panoramic radiography and MRI in detecting these disease features. 150 cases with preoperative CT data were selected: 61 bacterial OM, 19 ORN, and 70 MRONJ. 143 cases underwent panoramic X-ray examination, and 47 underwent MRI. The assessment criteria for imaging findings included: (1) bone resorption, (2) osteosclerosis, (3) clarity of the mandibular canal, (4) periosteal reactions, (5) cortical bone perforation, (6) sequestrum, and (7) pathological fractures. CT was considered the gold standard for assessing these features. Compared with CT, all panoramic radiographs were detectable for diagnostic features of the disease. Bone resorption was detected in 123 cases (sensitivity 91.1%), and osteosclerosis was detected in 131 cases (sensitivity 98.5%). With panoramic radiography, most changes to clarity of the mandibular canal and pathological fractures were detected (sensitivities of 87.8% and 68.8%, respectively). However, the sensitivities for detection of periosteal reactions, cortical bone perforation and sequestration were low (19.6%, 17.8% and 19.4%, respectively). Sensitivity of MRI for detecting periosteal reactions, cortical bone perforation, sequestration, and pathological fractures (27.3%, 73.5%, 35.7%, and 60.0%, respectively) was equivalent or superior to panoramic imaging. MR-specific characteristics of bone marrow edema were depicted on almost all examinations. Panoramic radiography may be adequate for identifying bone resorption and osteosclerosis. However, MRI provides more value than panoramic radiography in detecting periosteal reactions, cortical bone perforation, sequestration, and bone marrow edema.

The proteome of osteoblasts in a 3D culture perfusion bioreactor model compared with static conditions

Bone disorders represent a significant global burden. Currently, animal models are used to develop and screen novel treatments. However, interspecies variations and ethical concerns highlight the need for a more complex 3D bone model. In this study, we developed a simplified in vitro bone-like model using a U-CUP perfusion-based bioreactor system, designed to provide continuous nutrient flow and mechanostimulation through 3D cultures. An immortalized human fetal osteoblastic cell line was seeded on collagen scaffolds and cultured for 21 days in both a perfusion bioreactor system and in static cultures. PrestoBlue™ assay, scanning electron microscopy, and proteomics allowed monitoring of metabolic activity and compared morphological and proteome differences between both conditions. Results indicated an altered cellular morphology in the bioreactor compared to the static cultures and identified a total of 3494 proteins. Of these, 105 proteins exhibited significant upregulation in the static culture, while 86 proteins displayed significant downregulation. Enrichment analyses of these proteins revealed ten significant pathways including epithelial-mesenchymal transition, TNF-alpha signaling via NF-kB, and KRAS pathway. The current data indicated of osteogenic differentiation enhancement within the bioreactor on day 21 compared to static cultures. In conclusion, the U-CUP perfusion bioreactor is beneficial for facilitating osteogenic differentiation in 3D cultures.

Exposed Necrotic Bone in a Head and Neck Cancer Patient: Report of a Diagnostic Challenge

Background and Clinical Significance: The current study aims to show the diagnostic challenge of mandibular exposed necrotic bone in a patient with locally aggressive cutaneous squamous cell carcinoma of the lower lip and carrying risk factors for osteoradionecrosis and medication-related osteonecrosis of the jaws. Case Presentation: In March 2023, an 80-year-old ex-farmer male patient complaining of feeding difficulty showed a 3 cm area of exposed bone in the left region of the mandible. In July 2020, the patient underwent an incisional biopsy of a lower labial cutaneous keratinizing squamous cell carcinoma, which developed within actinic cheilitis. The cancer was unresectable due to the extent of the local invasion; thus, the patient underwent radiotherapy. In February 2022, the cancer reached the left mandibular canal by completely infiltrating the homolateral canal of the mental nerve. Therefore, the oncologist prescribed cemiplimab and denosumab as palliative immunotherapy. The differential diagnosis included osteoradionecrosis, stage-III medication-related osteonecrosis of the jaws, and intraoral localization of the cutaneous squamous cell carcinoma. The oral surgeon performed a sequestrectomy under local anesthesia and antibiotic prophylaxis; a histological examination confirmed the hypothesis of medication-related osteonecrosis. The patient currently undergoes follow-up visits monthly; the combination of photobiomodulation therapy and cycles of antibiotics keeps the necrotic lesion steady, and the oncological therapy prevents the growth of the cutaneous squamous cell cancer. Conclusions: The current case supports the need for histological examination to resolve the diagnostic challenge of mandibular exposed necrotic bone and to differentiate among osteoradionecrosis, stage-III medication-related osteonecrosis of the jaws, and intraoral localization of cutaneous squamous cell carcinoma.

The Application and Validity of a New Composite Radiographic Index for Patients with Osteonecrosis of the Jaws

Background/Objectives: This study aims to determine the validity of a recently developed and published index (the modified Composite Radiographic Index-CRIm) as an indicator of disease gravity and progression in the CBCT scans of patients with medication-related osteonecrosis of the jaw (MRONJ) and to detect possible correlations between the radiologic findings and clinical staging of the disease. Methods: This study included 43 MRONJ patients with CBCT scans from the School of Dentistry of National and Kapodistrian University of Athens, approved by the Research Ethics Committee. Clinical staging (0-3) was provided based on AAOMS 2022 guidelines. A total of 52 CBCT scans were analyzed, with maxillae and mandibles evaluated separately when both were involved. Two independent observers assessed eight radiologic features, including lytic changes, sclerosis, periosteal reaction, sequestration, non-healing extraction sockets, and other findings (sinus involvement, inferior alveolar canal involvement, and jaw fracture). The CRIm was applied to quantify osseous changes, scoring each feature (0 (absent), 1 (localized/single), 2 (extensive/multiple)), yielding a range of 0-12. For the statistical analysis, Fisher's exact test and Spearman's correlation coefficient were used. Results: Clinical Stage 1 consisted of 19 jaws, Stage 2 consisted of 16 jaws, and Stage 3 consisted of 17 jaws. No affected jaws were recorded with Stage 0. A statistically significant correlation between the clinical stage and lytic changes, sequestration, and inferior alveolar canal involvement was found (p-value < 0.05). Extensive lytic changes, sclerosis, sequestration, periosteal bone formation, and inferior alveolar canal involvement were mostly observed in clinical Stage 3. Furthermore, a statistically significant correlation between clinical stage and CRIm classification was found (rho = 0.446; p-value < 0.001). Conclusions: The CRIm tends to increase as the clinical stages of MRONJ advance, suggesting a correlation between them.

Effect of anti-resorptive therapy on implant failure: a systematic review and meta-analysis

PURPOSE

This review was conducted to systematically assess the impact of bisphosphonates (BPs) and denosumab, used as anti-resorptive therapies, on the incidence of dental implant failure.

METHODS

Electronic and manual searches were performed in accordance with the described search protocol. Only articles that met the inclusion criteria were selected. The primary outcome was implant failure, while secondary outcomes included biological complications and comorbidities. Following data extraction, a quality assessment and meta-analysis were conducted.

RESULTS

Fourteen eligible studies were included in the analysis following a qualitative evaluation. BP administration, regardless of the timing of anti-resorptive therapy, did not significantly increase the risk of implant failure (odds ratio [OR], 1.40; 95% confidence interval, 0.83-2.34). Subgroup analysis revealed a slightly higher, although statistically insignificant, risk of failure in patients with a follow-up period of 3 years or more compared to those with a follow-up duration of less than 3 years (with ORs of 2.82 and 1.53, respectively). Due to a lack of eligible studies, a meta-analysis for denosumab could not be conducted.

CONCLUSIONS

Our findings suggest that BP treatment does not compromise the survival of dental implants. Specifically, in patients with osteoporosis, implant failure rates were not significantly influenced by the administration of BPs before the placement of dental implants, suggesting that low-dose BP therapy may not contraindicate implant placement. Nevertheless, regular check-ups and maintenance periodontal treatment must not be neglected, and concomitant biological factors should be considered to ensure the long-term success of implant rehabilitation.

Metastatic neuroendocrine carcinoma of the small intestine presenting as temporomandibular disorder

BACKGROUND

Neuroendocrine carcinomas (NECs) are rare tumors from hormone-secreting neuroendocrine cells, often within the gastrointestinal tract. The authors report what is, to their best knowledge, the first case of a small intestine NEC metastasizing to the temporomandibular joint (TMJ).

CASE DESCRIPTION

A 60-year-old man came to the oral medicine, oncology, and orofacial pain clinic with a chief concern of left-sided jaw pain. Clinical examination revealed left TMJ arthralgia and deep masseter myalgia, and results of imaging showed both osteoblastic and osteolytic changes in the left TMJ. A comprehensive diagnostic approach, including detailed history, clinical evaluation, and advanced imaging techniques, such as positron emission tomography computed tomography, was used to establish an accurate diagnosis.

PRACTICAL IMPLICATIONS

This case highlights the importance of considering metastasis in differential diagnosis of TMJ pain in patients with NEC, underscoring collaboration between oncology and orofacial pain specialists for accurate diagnosis and effective management.

Mechanisms Underlying Medication-Related Osteonecrosis of the Jaw

OBJECTIVE

Medication-related osteonecrosis of the jaw (MRONJ) is a rare but debilitating disease characterized by a progressive necrosis of jaw bones in patients who have received anti-resorptive or anti-angiogenic therapies. Unfortunately, we still have no validated preventive or pharmaceutical interventions to help these patients, primarily due to our limited understanding of MRONJ pathogenesis. Here, we offer an extensive review of recent studies relevant to MRONJ pathogenesis. We present a hypothesis regarding the coupling of bone resorption and angiogenesis that relies on osteoblast-derived, matrix-bound vascular endothelial growth factors to explain why ONJ is associated with both anti-resorptive and anti-angiogenic agents.

METHODS

A narrative review was conducted by searching databases, including PubMed, Scopus, Google Scholar, and Web of Science, to retrieve relevant reports.

RESULTS

Reduced bone resorption leads to reduced angiogenesis, and vice versa, creating a vicious cycle that ultimately results in ischemic necrosis of the jaw. Additionally, we suggest that reduced angiogenesis, induced by anti-resorptive or anti-angiogenic agents, aggravates bacterial infection-induced bone necrosis, explaining why the jaw bone is particularly susceptible to necrosis.

CONCLUSION

Our novel hypothesis will facilitate the advancement of future research and the development of more targeted approaches to managing MRONJ.

Risk assessment and drug interruption guidelines for dentoalveolar surgery in patients with osteoporosis receiving anti-resorptive therapy

Medication-related osteonecrosis of the jaw (MRONJ) is a rare and challenging complication of anti-resorptive therapy. This review addresses the critical issue of risk management in patients with osteoporosis who require dentoalveolar surgery while undergoing anti-resorptive therapy. Dental practitioners should be aware of these risks; however, they should not refuse treatment based solely on them. This review discusses the risks through five major factors: invasive dentoalveolar surgeries, concomitant oral infection, type of medication, duration of medication, and preoperative drug discontinuation. Additionally, we discussed the local factors associated with dental practices. Our review underscored the importance of personalized risk assessment, considering each patient's unique drug history and oral condition. Based on a comprehensive literature review and clinical evidence, we proposed specific guidelines for preoperative drug interruption tailored to different anti-resorptive agents. These recommendations aimed to balance osteoporosis management by minimizing the risk of MRONJ during oral surgical interventions and bridging the knowledge gap in managing patients with osteoporosis requiring dental care. This review will allow clinicians to improve their practice and optimize patient outcomes by providing evidence-based strategies.

Next-generation sequencing analysis of bacterial species present in the sequestrum of medication-related osteonecrosis of the jaw patients

OBJECTIVE

Antiresorptives cases of adverse reactions to highly effective drugs used to treat skeletal-related events that occur during treatment of osteoporosis or malignancy have been reported in the jaw. To date, there is no clear pathophysiology for medication-related osteonecrosis of the jaw (MRONJ), but the role of inflammation or infection has been proposed as one of several possible pathogenesis theories. This study was designed to investigate the role of infection in the pathogenesis of MRONJ by analyzing the microbial communities observed in the bone samples from MRONJ patients.

DESIGN

Oral microbial samples were collected from 39 MRONJ patients and 45 healthy patients and subjected to next generation sequencing analysis. Alpha diversity, beta diversity, linear discriminant analysis and effect size, and network analysis were applied to compare the microbiome features.

RESULTS

The 10 predominant microbial strains observed in MRONJ patients were Streptococcus spp. S. constellatus, Tannerella forsythia, Parvimonas micra, Granulicatella adiacens, Bacteroidaceae G-1 bacterium HMT 272, Treponema socranskii, T. maltophilum, Pyramidobacter piscolens, and Fretibacterium fastidiosum. Network analysis revealed a significant correlation between T. forsythia and P. gingivalis. T. socranskii was closely related to T. maltophilum, Fretibacterium fastidiosum, and Peptostreptococcaceae nodatum. G. adiacens was closely related to Streptococcus parasanguinis, S. sanguinis, and Prevotella buccae.

CONCLUSIONS

In conclusion, this study sheds light on the potential role of infection in the pathogenesis of MRONJ. A distinct microbial profile was identified in MRONJ patients, with notable predominance of S. constellatus, T. forsythia, P. micra and G. adiacens among others. Network analysis further revealed significant correlations between certain microbial strains, suggesting possible synergistic interactions in MRONJ pathogenesis. These findings contribute to a deeper understanding of the complex microbial dynamics underlying MRONJ and may inform future therapeutic strategies aimed at targeting specific bacterial species implicated in this condition.

Non-surgical endodontic management for the medically complex - hints and tips for the general dental practitioner

The management of patients with additional medical complexities is challenging and can cause apprehension when considering if dental treatment is able to be provided in primary care. Non-surgical endodontic treatment is generally a low-risk procedure for many patient cohorts. This paper describes commonly seen medical conditions, the impact on bleeding and infection, and where extraction would preferably be avoided. It explores the risk assessment of these conditions and provides 'hints and tips' for the provision of endodontic treatment, allowing for the safe and effective provision of dental care, in the appropriate setting, by the appropriate specialty.