Intravenous bisphosphonate-related osteonecrosis of the jaw: long-term follow-up of 109 patients

Risk comparison of osteonecrosis of the jaw in osteoporotic patients treated with bisphosphonates vs. denosumab: a multi-institutional retrospective cohort study in Taiwan

In this multi-institutional retrospective cohort study, we compared the long-term risk of osteonecrosis of the jaw following the use of denosumab vs. bisphosphonates in osteoporotic patients. After 2-year use, the likelihood of osteonecrosis of the jaw is lower with denosumab compared to bisphosphonates, and the difference increases with time.

PURPOSE

To compare the long-term risk of osteonecrosis of the jaw (ONJ) between osteoporotic patients treated with bisphosphonates (BPs) and denosumab.

METHODS

This multi-institutional retrospective cohort study included patients aged > 40 years with osteoporosis between January 2010 and December 2018. Patients who met the eligibility criteria were divided into BPs and denosumab groups by propensity score matching (PSM). The risk of ONJ of denosumab vs. BPs was estimated using a Cox proportional hazards model and was described by the cumulative incidence rate using the Kaplan-Meier method.

RESULTS

A total of 84,102 patients with osteoporosis were enrolled, among whom, 8962 were eligible for inclusion based on their first-line drug use (denosumab, n = 3,823; BPs, n = 5,139). Following PCM matching (1:1), the BPs and denosumab groups included 3665 patients each. The incidence density of ONJ in the denosumab and BPs matching groups was 1.47 vs. 2.49 events (per 1000 person-years), respectively. The hazard ratio of ONJ in the denosumab vs. BPs group was estimated as 0.581 (95% confidence interval: 0.33-1.04, p = 0.07). The cumulative incidence rates of ONJ in both groups were similar for the first and second years of drug use (p = 0.062), but significantly different from the third year onwards (p = 0.022). The severity of ONJ was not significantly different between the two groups.

CONCLUSION

In osteoporotic patients, after 2 years of use, the likelihood of ONJ being induced by denosumab is lower than that of BPs, and the difference increases with time.

Post biphosphonate mandible osteonecrosis: A case study and literature review

Purpose

Bisphosphonates have proven effective in reducing pain and skeletal events in bone metastases treatment. However, there is a long-term complication called osteonecrosis of the jaw, which has been reported for more than a decade. Despite various professional recommendations, there is no international consensus on the best therapeutic strategy. Prevention is crucial, and a multidisciplinary approach must be tailored to each stage of the condition.

Design

We present a case of osteonecrosis of the jaw in a patient with metastatic breast cancer who was receiving 4 mg injectable zoledronic acid.

Result

The patient stopped treatment with zoledronic acid and received systemic treatment (analgesics, antibiotics), with the resolution of symptoms.

Conclusion

ONJ is a serious condition associated with taking BP that can impact oral health and quality of life. Our study highlights the effectiveness of systematic treatment in managing ONJ with BP-related alterations. Preventative measures, such as regular dental consultations, play a vital role in reducing the risk of ONJ. Multidisciplinary management is essential to addressing the different stages of the condition.

Prevalence of dental alterations in patients under bisphosphonates therapy: a systematic review

This systematic review aimed to estimate the prevalence and describe dentoalveolar lesions associated with bisphosphonates therapy. A systematic review of the literature was conducted using the following databases: PubMed, Embase, Cochrane, CINAHL, Scopus, Web of Science, Lilacs, SciElo, and Grey Literature. Quality of individual studies analysis was performed by using Newcastle-Ottawa Scale. Certainty of cumulative evidence was achieved by applying Grading of Recommendations Assessment, Development, and Evaluation (GRADE) criteria. The software R Statistics version 4.0.5 (The R Foundation) was used for proportion estimations per study and corresponding confidence intervals were estimated through the Clopper-Pearson method. Four articles were included for the qualitative synthesis. Two studies were considered of good quality, one of fair, and one of poor quality. A total of 231 patients were encompassed. Widening of the periodontal ligament space (22.2-39.7%), periradicular radiolucencies (20-22.9%), and pulp calcifications (33.3-69.2%) were the most frequent alterations. Certainty of evidence was rated as very low. Based on limited evidence, this systematic review reports a variety of dentoalveolar alterations in patients under bisphosphonate therapy. These features might impact on dental clinical practice. However, the level of evidence is considered very low due to important limitations.

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

Strategies for management of patients with, or at risk for, medication-related osteonecrosis of the jaws (MRONJ) - formerly referred to as bisphosphonate-related osteonecrosis of the jaws (BRONJ)-were set forth in the American Association of Oral and Maxillofacial Surgeons (AAOMS) position papers in 2007, 2009 and 2014. The position papers were developed by a committee appointed by the AAOMS Board of Trustees and comprising clinicians with extensive experience in caring for these patients, as well as clinical and basic science researchers. The knowledge base and experience in addressing MRONJ continues to evolve and expand, necessitating modifications and refinements to the previous position papers. Three members of the AAOMS Committee on Oral, Head, and Neck Oncologic and Reconstructive Surgery (COHNORS) and three authors of the 2014 position paper were appointed to serve as a working group to analyze the current literature and revise the guidance as indicated to reflect current knowledge in this field. This update contains revisions to diagnosis and management strategies and highlights the current research status. AAOMS maintains that it is vitally important for this information to be disseminated to other relevant healthcare professionals and organizations.

CD34 and CD105 Microvessels in Resected Bone Specimen May Implicate Wound Healing in MRONJ

Clinical treatment outcome of MRONJ (medication-related osteonecrosis of the jaw) surgery despite radical osseous removal and primary closure healing still shows differences in terms of outcome and disease recurrence. The study aims to assess the rate of angiogenesis of MRONJ lesions in order to understand the impact of angiogenesis and neoangiogenesis status on MRONJ surgical treatment outcome. This is the first study correlating microvessel density with prognosis in MRONJ surgically-treated patients. The immunohistochemical expression of CD34 and CD105 in MRONJ specimens obtained from surgically-treated patients was evaluated. The most vascularized areas detected by CD34 and CD105 were selected and the microvessel density value of the samples was registered. Samples were retrospectively divided according to the clinical outcome of MRONJ surgical treatment, dividing patients into two groups, “healed” and “not healed”. Statistical analysis was performed to assess if neovessels could influence treatment outcome in patients undergoing radical surgery. In the examined cohort, this value was highly predictive of better treatment outcome after radical surgery of MRONJ. Understanding of angiogenesis-dependent factors deserves further attention as a future target for MRONJ prevention and therapies.

Diabetic wound healing in soft and hard oral tissues

There is significant interest in understanding the cellular mechanisms responsible for expedited healing response in various oral tissues and how they are impacted by systemic diseases. Depending upon the types of oral tissue, wound healing may occur by predominantly re-eptihelialization, by re-epithelialization with substantial new connective tissue formation, or by a a combination of both plus new bone formation. As a result, the cells involved differ and are impacted by systemic diaseses in various ways. Diabetes mellitus is a prevalent metabolic disorder that impairs barrier function and healing responses throughout the human body. In the oral cavity, diabetes is a known risk factor for exacerbated periodontal disease and delayed wound healing, which includes both soft and hard tissue components. Here, we review the mechanisms of diabetic oral wound healing, particularly on impaired keratinocyte proliferation and migration, altered level of inflammation, and reduced formation of new connective tissue and bone. In particular, diabetes inhibits the expression of mitogenic growth factors whereas that of pro-inflammatory cytokines is elevated through epigenetic mechanisms. Moreover, hyperglycemia and oxidative stress induced by diabetes prevents the expansion of mesengenic cells that are involved in both soft and hard tissue oral wounds. A better understanding of how diabetes influences the healing processes is crucial for the prevention and treatment of diabetes-associated oral complications.

Oral health condition in cancer patients under bisphosphonate therapy

OBJECTIVES

To investigate the association of oral health condition with the occurrence of medication-related osteonecrosis of the jaw (MRONJ) in a cancer population.

METHODS

A multicenter cross-sectional study was conducted with cancer patients exposed to bisphosphonates for at least 7 months. Dental and periodontal conditions were assessed by epidemiological indices.

RESULTS

The sample consisted of 80 patients under bisphosphonate therapy, nine of which were allocated to group 1 (with MRONJ) and 71 to group 2 (without MRONJ). Osteonecrosis cases presented 19 decayed, missing, and filled teeth on average. Moderate gingival inflammation was noted in both groups and together with severe inflammation exceeded 50% of the groups. The presence of dental calculus was detected in about half of the individuals in both groups. Shallow periodontal pockets were detected in about 25% of both groups. Deep periodontal pockets were more prevalent among patients with osteonecrosis. Regular oral hygiene was detected in approximately 25% of individuals in both groups. There was a strong positive correlation between the clinical staging of osteonecrosis and decayed, missing, and filled teeth index (DMFTI).

CONCLUSIONS

Patients had a poor oral health condition. All but one osteonecrosis case had no previous history of tooth extraction; oral infections seemed to play a major role in the development of bone necrosis. Advanced osteonecrosis stages were associated with a higher DMFTI.

The role of antiresorptive drugs and medication-related osteonecrosis of the jaw in nononcologic immunosuppressed patients: A systematic review

Medication related osteonecrosis of the jaw (MRONJ) is a severe condition affecting the jaws of patients exposed to specific drugs, and is primarily described in patients receiving bisphosphonate (BP) therapy. However, more recently it has been observed in patients taking other medications, such as the RANK ligand inhibitor (denosumab) and antiangiogenic drugs. It has been proposed that the existence of other concomitant medical conditions may increase the incidence of MRONJ. The primary aim of this research was to analyze all available evidence and evaluate the reported outcomes of osteonecrosis of the jaws (ONJ) due to antiresorptive drugs in immunosuppressed patients. A multi-database (PubMed, MEDLINE, EMBASE and CINAHL) systematic search was performed. The search generated twenty-seven studies eligible for the analysis. The total number of patients included in the analysis was two hundred and six. All patients were deemed to have some form of immunosuppression, with some patients having more than one disorder contributing to their immunosuppression. Within this cohort the commonest trigger for MRONJ was a dental extraction (n=197). MRONJ complications and recurrence after treatment was sparsely reported in the literature, however a total of fourteen cases were observed. The data reviewed have confirmed that an invasive procedure is the commonest trigger of MRONJ with relatively high frequency of post-operative complications or recurrence following management. However, due to low-quality research available in the literature it is difficult to draw a definitive conclusion on the outcomes analysed in this systematic review.

Smoking and alcohol consumption as risk factors in 112 oncology patients diagnosed with bisphosphonate-associated osteonecrosis of the jaw

Background: Bisphosphonate-associated osteonecrosis of the jaws (BAONJ) is a complication of great medical importance. Some of the most discussed and controversial aspects are the risk factors, some of which are related to patients' smoking and alcohol consumption. The Aim: To study cancer patients with BAONJ and determine their participation in the mentioned above risky health-related habits. Material and methods: A prospective epidemiological study of 112 patients diagnosed with bisphosphonate-associated osteonecrosis of the jaw in 2016 and 2017 was conducted at the Clinic of Maxillofacial surgery of University hospital "St. George", Plovdiv, Bulgaria, based on anamnesis, clinical examination, and hospital documentation. SPSS Statistics v.24 was used for statistical analysis, at a significance level p<0.05. Results: Over 2/3 of the patients were smokers (40.18%) or ex-smokers (25.00%), which linked them with the risk factor of smoking. At the time of the study, patients smoking between 1 and 9 and between 10 and 19 cigarettes a day had equal relative shares of 44.22%. More than half of the patients smoked from the age of 20-39, which we explain by the high average age. The majority of patients studied consumed alcohol, most often once a week or on weekends (28.57%) or only on occasions (26.79%), followed by 24.11% who used alcohol several times per week. Nearly 2/3 drink drinks with both low and high alcohol content. Conclusion: The highest proportion of patients are smokers / ex-smokers and consume alcoholic beverages occasionally, which links them to these risk potential factors.

Application of pamidronate disodium for the treatment of diffuse sclerosing osteomyelitis of the mandible: A clinical study

OBJECTIVE

This study aimed to assess the clinical effectiveness of using pamidronate disodium to treat patients with diffuse sclerosing osteomyelitis of the mandible (DSOM ).

STUDY DESIGN

Patients with DSOM who were hospitalized in the Department of Oral and Maxillofacial Surgery, Peking University Hospital of Stomatology (Beijing, China), between March 2018 and March 2019 were included. All patients were treated with intravenous administration of pamidronate disodium for 3 days. Pain intensity, mouth opening, blood workup findings, imaging examination findings, and incidence of complications before and after treatment and during the follow-up period, were recorded and compared.

RESULTS

Forty-three patients were treated with pamidronate disodium. Adverse reactions, including fever, hypocalcemia, hypokalemia, and diarrhea, were observed during treatment. Fourteen patients had moderate to severe pain before treatment, and the pain was markedly alleviated after days 2 and 3 of treatment. Pain and swelling were found to have disappeared at the 6-month follow-up in 39 patients (90.7%). Mean mouth opening increased from 28.5 mm to 38.1 mm. Imaging examinations showed that the bone mass in the affected area had markedly improved in 32 patients (74.4%).

CONCLUSIONS

Pamidronate disodium alleviated pain and swelling and improved mouth opening in patients with DSOM. Follow-up after 6 to 18 months demonstrated stable treatment effectiveness.

Clinical profile of individuals with bisphosphonate-related osteonecrosis of the jaw: an integrative review

BACKGROUND

Bisphosphonate-related osteonecrosis of the jaw (BRONJ) is still the most prevalent type of osteonecrosis with clinical relevance. In Brazil, bisphosphonate use is high but there is a lack of epidemiological studies on BRONJ.

OBJECTIVE

To determine the clinical profile of BRONJ in a Brazilian population through an integrative review.

DESIGN AND SETTING

Integrative review of BRONJ in a Brazilian population.

METHODS

Cases and clinical research on Brazilians with BRONJ between 2010 and 2019, indexed in PubMed/MEDLINE, Scopus, Web of Science and LILACS were reviewed. Age, sex, type and time of bisphosphonate intake, administration route, related diseases, region of the BRONJ, diagnostic criteria, staging, triggering factor and type of treatment were analyzed.

RESULTS

Fifteen articles on 128 subjects were included. Most patients were women (82.03%); the mean age was 63 years. Intravenous zoledronic acid was mostly used (62.50%), for breast cancer treatment (46.87%). The main localization of BRONJ was the mandible (54.68%), associated mainly with tooth extractions (45.98%). The diagnostic criteria were clinical (100%) and radiographic (89.06%), mostly in stage II (68.08%). The surgical treatments were sequestrectomy (37.50%) and platelet-rich plasma (PRP) (36.71%). Microbial control was done using chlorhexidine (93.75%) and infection control using clindamycin (53.90%).

CONCLUSIONS

BRONJ had higher prevalence in Brazilian women receiving treatment for breast cancer and osteoporosis. The mandible was the region most affected with a moderate stage of BRONJ, particularly when there were histories of tooth extraction and peri-implant surgery. Sequestrectomy with additional drugs and surgical therapy was the treatment most accomplished.

Oral Surgical Management of Bone and Soft Tissues in MRONJ Treatment: A Decisional Tree

Background: The aim of the present work was to analyze a 10-year retrospective series of surgically treated medication-related osteonecrosis of the jaws (MRONJ) cases, reporting the clinical outcome and success rate for each adopted procedure in order to draw a treatment algorithm that is able to standardize clinical decision making and maximize the success of oral surgical treatment of MRONJ. Methods: Different surgical approaches were categorized taking into consideration two variables (a) hard tissue management (defined as debridement, saucerization or marginal resective surgery of maxillary necrotic bone) and (b) soft tissue management (defined as type of flap design and related modality of wound-healing). Results: For the retrospective cohort study, 103 MRONJ patients were enrolled and a total of 128 surgical procedures were performed. The role of radical-intended surgery using local flaps in MRONJ treatment was investigated, as well as palliative treatments. All stage I–II patients completely healed when a combination of radical necrotic bone surgery associated with a first intention healing of soft tissues was obtained. In stage III, when a patient was not eligible for maxillo-facial surgery, the use of palliative surgical strategies was effective in symptom relief in order to maintain a better quality of life for the duration of the patient’s life. Conclusions: Oral surgery with radical intent associated with a flap design able to ensure first intention healing might represent a valid option for the majority of MRONJ patients. The designed decision tree allows clinicians to assess individual surgical approaches for MRONJ treatment in accordance with patient-centered outcomes and surgical skills.

Bisphosphonate-Related Osteonecrosis of the Jaw: An Enigma among Medical Practitioners

Context: Owing to the increasing number of cancer cases, and introduction of newer drugs like bisphosphonates (BP) for the management of metastatic bone disease, complications such as bisphosphonate-related osteonecrosis of the jaw (BRONJ) have come into light. However, several of the treating physicians are not fully aware of this adverse effect. Aim: This study aimed to assess the knowledge and awareness of physicians regarding BRONJ and practices related to bisphosphonate use. Settings and Design: A cross-sectional study conducted among health-care professionals in various medical institutions in Mangalore. Subjects and Methods: A questionnaire was developed to assess the knowledge and awareness of physicians about osteonecrosis of the jaw and practices related to bisphosphonate use, consisting of 21 questions, 12 – knowledge based and 9 – practice based. The questionnaire was validated and distributed among 113 doctors; their responses assigned scores, tabulated and assessed. Statistical Analysis: One-way analysis of variance and Tukey test. Results: More than 50% of the medical professionals had a score <40%, which shows a lack of knowledge about BP and BRONJ. About 45% of the medical professionals in the study group failed to identify the clinical features of BRONJ, and 67.26% were unaware of the risk associated with tooth extractions and oral surgical procedures in the development of the condition. Conclusion: Bisphosphonate-related osteonecrosis is almost exclusively seen in the jaws and hence, the diagnosis usually made by a dental practitioner. Lack of awareness of jaw osteonecrosis among the medical practitioners can result in delay in providing the right treatment.

Medication-Related Osteonecrosis of the Jaws: Two Center Retrospective Cohort Studies

This retrospective cohort study aims to describe characteristics of patients with MRONJ, to identify factors associated with MRONJ development, and to examine variables associated with favourable outcome. Totally 32 patients were followed and observed: 21 females and 11 males, in the age range 35-84 in the period from 2009 to 2018. Clinical, radiological examination (Orthopantomograph and CBCT) and biopsy were performed in order to achieve diagnosis. Demographic and clinical variables were taken into consideration: sex, age, primary disease, medication type, mode of delivery, anatomic location, drug treatment duration, timing of tooth extraction, chemotherapy, presence of bone metastasis, aetiology of MRONJ, disease stage, and treatment modality. MRONJ developed under osteoporosis and malignant disease in 11 and 21 patients, respectively. MRONJ development was triggered by tooth extraction or trauma in 30 out of 32 cases, whereas the two patients developed MRONJ spontaneously. Stages I, II, and III were confirmed in 5 (16%), 18 (58%), and 9 (28%) patients, respectively. Mandible was affected in 23 (72%) patients. MRONJ was treated in our department by conservative and surgical modality. In this study we found that 65% of all patients were classified in the cured/improvement group and 35% in the stable/progression group. The female gender, osteoporosis as primary disease, oral regime intake, shorter period on BPs, earlier stage of disease, and specific anatomic localisation (frontal and premolar maxilla) were factors associated with better response to therapy and favourable clinical outcome. Comprehensive treatment protocol and further randomized studies are necessary for further improvements.

Fluorescence and Near-Infrared Light Transillumination

This article describes the current applications of various technologies based on either autofluorescence or near-infrared light illumination, tailored to aid practitioners in detecting and quantitatively monitoring oral diseases such as dental caries and oral cancer at the earliest stage of their formation, or in the conservative surgical excision of necrotic bones in diseases such as chronic osteomyelitis, osteoradionecrosis, and medication-related osteonecrosis of the jaw. The data discussed are primarily based on published scientific studies and reviews from case reports, clinical trials, and in vitro and in vivo studies. References have been traced manually, by MEDLINE, or through manufacturer's websites.

Treatment of Medication-Related Osteonecrosis of the Jaw and its Impact on a Patient's Quality of Life: A Single-Center, 10-Year Experience from Southern Italy

INTRODUCTION

No official guidelines are available for the management of medication-related osteonecrosis of the jaw (MR-ONJ). The additional benefit of surgery after pharmacological treatment is debated by both clinicians and patients.

OBJECTIVE

The aim of this study was to evaluate the changes in patients' MR-ONJ-related quality of life (QoL) after pharmacological treatment with or without surgery in a large cohort affected by MR-ONJ.

METHODS

Anonymized data on patients diagnosed with MR-ONJ were extracted from the database of the Osteonecrosis of the Jaw Treatment Center (University of Messina, Italy) in the years 2005-2015. QoL was evaluated at the moment of MR-ONJ diagnoses (T0), after pharmacological treatment with or without surgery (T1 and T2, respectively), based on scores from the European Organisation for Research and Treatment of Cancer (EORTC) QOL Module for Head and Neck Cancer (global oral health status [GOHS]) and a visual analog scale (VAS), stratified by indication for use.

RESULTS

Among 100 patients, 36% were affected by osteoporosis (OSTEO group) and 64% were affected by cancer (ONC group). Considering T0, QoL scores were higher in the OSTEO group then in the ONC group. At T1, GOHS and VAS increased in both groups (OSTEO group: +9.9% and +39.9%; ONC group: +35.4 and +97.2%, respectively). Pharmacological treatment was effective in reducing pain (OSTEO group: -22.0%; ONC group: -44.8%), and social contact troubles (OSTEO group: -40.3%; ONC group: -26.7%). At T2, GOHS and VAS further increased. Scores related to 'pain' and the troubles related to the 'social dimension' also decreased (OSTEO group: -91.3% and -72.0%; ONC group: 50.8% and -16.4%, respectively).

CONCLUSIONS

MR-ONJ-related QoL increased after pharmacological treatment and, more notably, after surgery, which may offer benefits to selected patients. QoL data may help clinicians in promoting tailored management of MR-ONJ.

Prognostic factors for outcome of surgical treatment in medication-related osteonecrosis of the jaw

OBJECTIVES

The number of patients with medication-related osteonecrosis of the jaw (MRONJ) is increasing, but treatment remains controversial. Published papers and systematic reviews have suggested that surgical treatment is effective in patients with MRONJ. The purpose of this study was to determine whether preoperative University of Connecticut Osteonecrosis Numerical Scale (UCONNS), other serologic biomarkers, and size of necrosis are prognostic factors for outcome of surgical treatment in MRONJ.

MATERIALS AND METHODS

From January 2008 to December 2016, 65 patients diagnosed with MRONJ at the Department of Oral and Maxillofacial Surgery in College of Dentistry, Dankook University who required hospitalization and surgical treatment were investigated. Patient information, systemic factors, and UCONNS were investigated. In addition, several serologic values were examined through blood tests one week before surgery. The size of osteolysis was measured by panoramic view and cone-beam computed tomography in all patients. With this information, multivariate logistic regression analysis with backward elimination was used to examine factors affecting postoperative outcome.

RESULTS

In multivariate logistic analysis, higher UCONNS, higher C-reactive protein (CRP), larger size of osteolysis, and lower serum alkaline phosphate were associated with higher incidence of incomplete recovery after operation. This shows that UCONNS, CRP, serum alkaline phosphate, and size of osteolysis were statistically significant as factors for predicting postoperative prognosis.

CONCLUSION

This study demonstrated that CRP, UCONNS, serum alkaline phosphate, and size of osteolysis were statistically significant factors in predicting the prognosis of surgical outcome of MRONJ. Among these factors, UCONNS can predict the prognosis of MRONJ surgery as a scale that includes various influencing factors, and UCONNS should be used first as a predictor. More aggressive surgical treatment and more definite surgical margins are needed when the prognosis is poor.

Oral-Health-Related Quality of Life After Surgical Treatment of Osteonecrosis of the Jaws

The aim of this study is to analyze the clinical outcome and the change in oral-health-related quality of life (QoL) of osteoporotic patients affected by medication-related osteonecrosis of the jaws (MRONJ). Forty-one patients, consecutively treated for a 10-year period, were retrospectively analyzed. All the patients underwent a marginal osseous resective jaw surgery. A clinical 12 months postoperative evaluation has been performed and the complete mucosal healing, the absence of swelling and suppuration, and no signs of disease recurrence were defined like success parameters. Quality-of-life surveys tests like EORTC QQ-C30 and QLQ-HN35 appendices in conjunction with a perceived oral health visual analog scale (VAS) were administered before (time of diagnosis of MRONJ) and after surgery (at least 6 months) in order to record the different oral health status of the treated patients. The majority of MRONJ-diagnosed patients complained symptoms like pain, eating discomfort, and sense problems, with occasional involvement of the social dimension. There was a prevalence of troubles with social eating and social contact.The complete mucosal healing was achieved in 100% of the patients and the administered survey tests reported a significant improvement in all the investigated spheres. Similarly, an increased mean score of perceived oral health VAS was reported.Marginal-resective surgery of the necrotic jaw bone can be an effective treatment of osteoporotic patients affected by localized MRONJ. Quality-of-life parameters are demonstrated to be useful for recording the patient-centered outcome of MRONJ treatment.

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

OBJECTIVE

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

STUDY DESIGN

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

RESULTS

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

CONCLUSIONS

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

Bisphosphonates in multiple myeloma: an updated network meta-analysis

BACKGROUND

Bisphosphonates are specific inhibitors of osteoclastic activity and are used in the treatment of patients with multiple myeloma (MM). While bisphosphonates are shown to be effective in reducing vertebral fractures and pain, their role in improving overall survival (OS) remains unclear. This is an update of a Cochrane review first published in 2002 and previously updated in 2010 and 2012.

OBJECTIVES

To assess the evidence related to benefits and harms associated with use of various types of bisphosphonates (aminobisphosphonates versus non-aminobisphosphonates) in the management of patients with MM. Our primary objective was to determine whether adding bisphosphonates to standard therapy in MM improves OS and progression-free survival (PFS), and decreases skeletal-related morbidity. Our secondary objectives were to determine the effects of bisphosphonates on pain, quality of life, incidence of hypercalcemia, incidence of bisphosphonate-related gastrointestinal toxicities, osteonecrosis of jaw (ONJ) and hypocalcemia.

SEARCH METHODS

We searched MEDLINE, Embase (September 2011 to July 2017) and the CENTRAL (2017, Issue 7) to identify all randomized controlled trial (RCT) in MM up to July 2017 using a combination of text and MeSH terms.

SELECTION CRITERIA

Any randomized controlled trial (RCT) comparing bisphosphonates versus placebo/no treatment/bisphosphonates and observational studies or case reports examining bisphosphonate-related ONJ in patients with MM were eligible for inclusion.

DATA COLLECTION AND ANALYSIS

Two review authors extracted the data. Data were pooled and reported as hazard ratio (HR) or risk ratio (RR) using a random-effects model. We used meta-regression to explore statistical heterogeneity. Network meta-analysis using Bayesian approach was conducted.

MAIN RESULTS

In this update, we included four new studies (601 participants), resulting in a total of 24 included studies.Twenty RCTs compared bisphosphonates with either placebo or no treatment and four RCTs involved another bisphosphonate as a comparator. The 24 included RCTs enrolled 7293 participants. Pooled results showed that there was moderate-quality evidence of a reduction in mortality with on OS from 41% to 31%, but the confidence interval is consistent with a larger reduction and small increase in mortality compared with placebo or no treatment (HR 0.90, 95% CI 0.76 to 1.07; 14 studies; 2706 participants). There was substantial heterogeneity among the included RCTs (I² = 65%) for OS. To explain this heterogeneity we performed a meta-regression assessing the relationship between bisphosphonate potency and improvement in OS, which found an OS benefit with zoledronate but limited evidence of an effect on PFS. This provided a further rationale for performing a network meta-analyses of the various types of bisphosphonates that were not compared head-to-head in RCTs. Results from network meta-analyses showed evidence of a benefit for OS with zoledronate compared with etidronate (HR 0.56, 95% CI 0.29 to 0.87) and placebo (HR 0.67, 95% CI 0.46 to 0.91). However, there was no evidence for a difference between zoledronate and other bisphosphonates.The effect of bisphosphonates on disease progression (PFS) is uncertain. Based on the HR of 0.75 (95% CI 0.57 to 1.00; seven studies; 908 participants), 47% participants would experience disease progression without treatment compared with between 30% and 47% with bisphosphonates (low-quality evidence). There is probably a similar risk of non-vertebral fractures between treatment groups (RR 1.03, 95% CI 0.68 to 1.56; six studies; 1389 participants; moderate-quality evidence). Pooled analysis demonstrated evidence for a difference favoring bisphosphonates compared with placebo or no treatment on prevention of pathological vertebral fractures (RR 0.74, 95% CI 0.62 to 0.89; seven studies; 1116 participants; moderate-quality evidence) and skeletal-related events (SREs) (RR 0.74, 95% CI 0.63 to 0.88; 10 studies; 2141 participants; moderate-quality evidence). The evidence for less pain with bisphosphonates was of very low quality (RR 0.75, 95% CI 0.60 to 0.95; eight studies; 1281 participants).Bisphosphonates may increase ONJ compared with placebo but the confidence interval is very wide (RR 4.61, 95% CI 0.99 to 21.35; P = 0.05; six studies; 1284 participants; low-quality evidence). The results from the network meta-analysis did not show any evidence for a difference in the incidence of ONJ (eight RCTs, 3746 participants) between bisphosphonates. Data from nine observational studies (1400 participants) reported an incidence of 5% to 51% with combination of pamidronate and zoledronate, 3% to 11% with zoledronate alone, and 0% to 18% with pamidronate alone.The pooled results showed no evidence for a difference in increase in frequency of gastrointestinal symptoms with the use of bisphosphonates compared with placebo or no treatment (RR 1.23, 95% CI 0.95 to 1.59; seven studies; 1829 participants; low-quality evidence).The pooled results showed no evidence for a difference in increase in frequency of hypocalcemia with the use of bisphosphonates compared with placebo or no treatment (RR 2.19, 95% CI 0.49 to 9.74; three studies; 1090 participants; low-quality evidence). The results from network meta-analysis did not show any evidence for differences in the incidence of hypocalcemia, renal dysfunction and gastrointestinal toxicity between the bisphosphonates used.

AUTHORS' CONCLUSIONS

Use of bisphosphonates in participants with MM reduces pathological vertebral fractures, SREs and pain. Bisphosphonates were associated with an increased risk of developing ONJ. For every 1000 participants treated with bisphosphonates, about one patient will suffer from the ONJ. We found no evidence of superiority of any specific aminobisphosphonate (zoledronate, pamidronate or ibandronate) or non-aminobisphosphonate (etidronate or clodronate) for any outcome. However, zoledronate was found to be better than placebo and first-generation bisposphonate (etidronate) in pooled direct and indirect analyses for improving OS and other outcomes such as vertebral fractures. Direct head-to-head trials of the second-generation bisphosphonates are needed to settle the issue if zoledronate is truly the most efficacious bisphosphonate currently used in practice.

Evaluation of the Treatment Strategies for Medication-Related Osteonecrosis of the Jaws (MRONJ) and the Factors Affecting Treatment Outcome: A Multicenter Retrospective Study with Propensity Score Matching Analysis

Medication-related osteonecrosis of the jaw (MRONJ) is an adverse event that may inhibit the treatment of primary disease and remarkably influence the patient's quality of life. The treatment methods for MRONJ, nonsurgical and surgical, are controversial, with no agreement as to which method provides the best outcome and should therefore be recommended. This multicenter retrospective study aimed to investigate the treatment methods and outcome in a large number of patients with MRONJ in Japan, utilizing propensity score matching analysis. A total of 361 patients with MRONJ, at eight hospitals, were registered in this study retrospectively. Various demographic and treatment-related variables were examined and analyzed to determine their correlation with the treatment outcome. After propensity score matching for treatment methods (nonsurgical versus surgical treatment), 176 patients were analyzed by logistic regression. It was shown that those with low-dose administration of an antiresorptive agent and surgical treatment had better outcomes. Furthermore, in 159 patients who underwent surgical treatment, those who underwent extensive surgery experienced significantly better treatment outcomes than those who underwent conservative surgery. This is the first study to compare treatment methods for MRONJ using propensity score matching analysis. The results indicated that extensive surgical treatment should be performed as first-choice therapy for patients with MRONJ. © 2017 American Society for Bone and Mineral Research.

Time to onset of bisphosphonate-related osteonecrosis of the jaws: a multicentre retrospective cohort study

OBJECTIVES

Osteonecrosis of the jaw (ONJ) is a potentially severe adverse effect of bisphosphonates (BP). Although the risk of ONJ increases with increasing duration of BP treatment, there are currently no reliable estimates of the ONJ time to onset (TTO). The objective of this study was to estimate the TTO and associated risk factors in BP-treated patients.

SUBJECTS AND METHODS

Retrospective analysis of data from 22 secondary care centres in seven countries relevant to 349 patients who developed BP-related ONJ between 2004 and 2012.

RESULTS

The median (95%CI) TTO was 6.0 years in patients treated with alendronate (n = 88) and 2.2 years in those treated with zoledronate (n = 218). Multivariable Cox regression showed that dentoalveolar surgery was inversely associated, and the use of antiangiogenics directly associated, with the TTO in patients with cancer treated with zoledronate.

CONCLUSIONS

The incidence of ONJ increases with the duration of BP therapy, with notable differences observed with respect to BP type and potency, route of administration and underlying disease. When data are stratified by BP type, a time of 6.0 and 2.2 years of oral alendronate and intravenous zoledronate therapy, respectively, is required for 50% of patients to develop ONJ. After stratification by disease, a time of 5.3 and 2.2 years of BP therapy is required for 50% of patients with osteoporosis and cancer, respectively, to develop ONJ. These findings have significant implications for the design of future clinical studies and the development of risk-reduction strategies aimed at either assessing or modulating the risk of ONJ associated with BP.

Extensive Surgical Procedures Result in Better Treatment Outcomes for Bisphosphonate-Related Osteonecrosis of the Jaw in Patients With Osteoporosis

PURPOSE

To identify the risk factors associated with relapse or treatment failure after surgery for bisphosphonate-related osteonecrosis of the jaw (BRONJ) in patients with osteoporosis.

PATIENTS AND METHODS

We performed a retrospective cohort study of BRONJ in patients with osteoporosis who had undergone surgical procedures from 2004 to 2016 at the Department of Oral and Maxillofacial Surgery, Seoul National University Dental Hospital. The predictor variables were a set of heterogeneous variables, including demographic (age, gender), anatomic (maxilla or mandible, or both, affected location), clinical (disease stage, etiology, comorbidities, history of intravenous bisphosphonate intake), time (conservative treatment before surgery, bisphosphonate treatment before the development of BRONJ, discontinuation of the drug before surgery, interval to final follow-up, interval to reoperation in the case of relapse or treatment failure), and perioperative variables (type of anesthesia, type of surgical procedures). The primary outcome variable was relapse after surgery that required reoperation (yes vs no). The descriptive and bivariate statistics were computed to assess the relationships between the study variables and the outcome. To determine the risk factors, we conducted a survival analysis using the Cox model.

RESULTS

The final sample included 325 subjects with a median age of 75 years, and 97% were women. After surgery, 30% of patients did not completely recuperate and underwent repeat surgery. The interval from the first surgery to reoperation ranged from 10 days to 5.6 years. Relapse or treatment failure most often occurred immediately after surgery. The type of surgical procedure and mode of anesthesia were the most important factors in the treatment outcome. A drug holiday did not appear to influence the likelihood of relapse after surgery.

CONCLUSIONS

Treatment of BRONJ in patients with osteoporosis might benefit from more careful and extensive surgical procedures rather than curettage performed with the patient under local anesthesia.

Osteonecrosis of the jaw associated with everolimus: A case report

Everolimus, a mammalian target of rapamycin inhibitor, has recently been approved for the treatment of metastatic estrogen receptor-positive breast cancer, at a daily dose of 10 mg in combination with exemestane. Osteonecrosis of the jaw (ONJ) is a rare but severe condition, characterized by exposed necrotic bone, and is associated with various drugs that are often used to treat advanced malignancies. We herein report the case of a patient with breast cancer who developed ONJ during treatment with everolimus, which improved after discontinuation of the drug. To the best of our knowledge, this is the first reported case of everolimus-associated ONJ in a patient receiving everolimus for metastatic breast cancer. In 2014, an 80-year-old woman was started on treatment with everolimus and exemestane for stage IIB estrogen receptor-positive breast cancer. Within 2 months, the left side of her face became edematous, with localized heat and tenderness of the left mandibular region and a 3-mm round area of exposed bone. There was purulent discharge and the surrounding gingiva was edematous and erythematous. The left mandible exhibited a low signal intensity area on T1-weighted magnetic resonance imaging. Treatment was discontinued and ONJ showed improvement after 2 months. Therefore, when prescribing everolimus for metastatic breast cancer, oncologists should be aware of the possibility of ONJ as a complication.

Identifying MRONJ-affected bone with digital fusion of functional imaging (FI) and cone-beam computed tomography (CBCT): case reports and hypothesis

Surgical debridement of medication-related osteonecrosis of the jaw (MRONJ) lesions is far less predictable than lesion resection. Margins for surgical debridement are guided by surrogate markers of bone viability, such as bleeding and bone fluorescence, which limit debridement to visibly necrotic bone. In contrast, surgical resection is extensive, including a substantial portion of surrounding bone. The concept that the MRONJ lesion is a composite of affected but viable ("compromised") and necrotic bone is supported by histopathological data. Hence, removing only the necrotic bone during lesion debridement could inadvertently leave behind residual compromised bone in the lesion, subsequently contributing to persistence or reestablishment of the lesion. Using 2 case reports, this manuscript illustrates a novel assessment of the MRONJ lesion to enable demarcation of both the compromised and necrotic portions of the lesion. This assessment uses tumor-surveillance functional bone imaging data that may already be available for cancer patients with MRONJ and fuses these data digitally with computed tomography/cone-beam computed tomography imaging of the jaw obtained during MRONJ assessment. If validated, preoperative functional imaging-based assessment of the MRONJ lesion could enable surgeons to eliminate both the compromised and nonviable portions of the lesion precisely with conservative debridement, matching surgical resection in outcome.

Evaluation of the predisposing factors and involved outcome of surgical treatment in bisphosphonate-related osteonecrosis of the jaw cases including bone biopsies

Objectives

This study examined the statistical relevance of whether the systemic predisposing factors affect the prognosis of surgical treatment of bisphosphonate-related osteonecrosis of the jaw (BRONJ). All cases had undergone bone biopsies to determine the characteristics of the mechanisms of BRONJ by optical microscopy.

Materials and Methods

The data included 54 BRONJ cases who underwent surgery and in whom bone biopsies were performed. The results of surgery were evaluated and the results were classified into 3 categories: normal recovery, delayed recovery, and recurrence after surgery. The medical history, such as diabetes mellitus, medication of steroids, malignancies on other sites was investigated for an evaluation of the systemic predisposing factors in relation to the prognosis. The three factors involved with the medication of bisphosphonate (BP) were the medication route, medication period, and drug holiday of BP before surgery. The serum C-terminal cross-linking telopeptide (CTX) value and presence of microorganism colony in bone biopsy specimens were also checked. Statistical analysis was then carried out to determine the relationship between these factors and the results of surgery.

Results

The group of patients suffering from diabetes and on steroids tended to show poorer results after surgery. Parenteral medication of BP made the patients have a poorer prognosis after surgery than oral medication. In contrast, the medication period and drug holiday of BP before surgery did not have significance with the results of surgery nor did the serum CTX value and presence of microorganism colony. Necrotic bone specimens in this study typically showed disappearing new bone formation around the osteocytic lacunae and destroyed Howship's lacunae.

Conclusion

Although many variables exist, this study could in part, predict the prognosis of surgical treatment of BRONJ by taking the patient's medical history.

Advantages and Disadvantages of Bone Protective Agents in Metastatic Prostate Cancer: Lessons Learned

Nine out of ten metastatic prostate cancer (PCa) patients will develop osseous metastases. Of these, every second will suffer from skeletal-related events (SRE). SRE are associated with an increased risk for death, which is markedly increased in the presence of pathological fracture. Moreover, health insurance costs nearly double in the presence of SRE. Zoledronic acid and denosumab are both approved drugs for the prevention or delay of SRE in castration-resistant prostate cancer (CRPC) patients with osseous metastases. However, long-term treatment with one of these two drugs is associated with the development of medication-related osteonecrosis of the jaw (MRONJ). Routine inspections of the oral cavity before and during treatment are mandatory in these patients. Regarding imaging techniques, bone scintigraphy seems to be a promising tool to detect early stage MRONJ. Zoledronic acid does not reduce the incidence of SRE in hormone-sensitive PCa. First data shows 3-monthly application of zoledronic acid to be equi-effective to monthly application.

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

OBJECTIVE

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

STUDY DESIGN

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

RESULTS

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

CONCLUSIONS

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

Diabetes Mellitus and Its Association to the Occurrence of Medication-Related Osteonecrosis of the Jaw

To date there is no consensus on the role of diabetes in the development of medication-related osteonecrosis of the jaws (MR-ONJ). Therefore, this study aimed to investigate the prevalence of diabetes and pathological glucose metabolism in patients with MR-ONJ compared to the general population. All maxillofacial surgery inpatients in one year at our department were investigated regarding diagnosis, anamnesis, medication, and blood glucose readings. 1374 records were analyzed. 35 patients with MR-ONJ were identified. Diabetics accounted for 14.3%. No significant difference in the prevalence of known diabetes was found, except for pathological glucose metabolism in patients with MR-ONJ (p < 0.001). Diabetes does not necessarily promote the onset of MR-ONJ. Therefore, diabetes should not be considered as a standalone risk factor. On the contrary, hyperglycemia as a possible indicator for poorly managed or yet undetected diabetes is associated with MR-ONJ.

Fluorescence-guided surgery for the treatment of medication-related osteonecrosis of the jaw: A prospective cohort study

INTRODUCTION

The delineation of the necrotic bone is a crucial step in the surgical treatment of medication-related osteonecrosis of the jaw (MRONJ). Several different approaches have been described including the innovative technique of fluorescence-guided surgery. However, until now there is a lack of data regarding the outcome. Therefore, the aim of the present study is to investigate the long-term success rates of fluorescence-guided surgery in the treatment of MRONJ.

PATIENTS AND METHODS

54 Patients were prospectively assigned for surgical treatment of medication-related osteonecrosis of the jaw using fluorescence-guided surgery. Patients received doxycycline 100 mg twice a day for at least seven days preoperatively. Surgical treatment of MRONJ included complete removal of necrotic bone, which was monitored using the visual enhanced lesion scope (Velscope), followed by smoothening sharp bony edges and meticulous wound closure. Procedure success was assessed as postoperative maintenance of full mucosal coverage without pain, infection or bone exposure during regular follow-up.

RESULTS

The study included a total of 54 patients (32 female and 22 male, mean age 71.4 ± 9.2 years). In the last follow-up an intact mucosa and absence of exposed bone, pain or signs of infection was identified in 47 of 54 patients (87%) and 56 of 65 lesions (86.2%) after first surgery using fluorescence-guidance. In 4 patients with 6 lesions a second fluorescence-guided surgery was necessary to achieve complete mucosal closure. Respectively, including the case with second surgical attempt 51 of 54 patients (94.4%) and 62 of 65 lesions (95.4%) showed complete mucosal healing.

CONCLUSION

The study shows that fluorescence-guided surgery is a safe and successful treatment option which can be considered for all stages of MRONJ. The technique seems also promising for MRONJ cases under denosumab.

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

This case series describes the course of osteonecrosis of the jaw (ONJ) in thirteen patients with metastatic bone tumors treated solely with denosumab. Patients on denosumab may be more prone to developing ONJ even without a risk/precipitating factor and they may develop ONJ early in their denosumab therapy. The outcomes of ONJ in ten patients following a period of denosumab discontinuation after the onset of ONJ were: 3 had complete resolution of symptoms, 4 patients' ONJ progressed, 2 patients' ONJ was unchanged and in 1 patient there was partial ONJ resolution. The role of drug discontinuation prior to an invasive dental procedure or after the onset of ONJ still remains debatable.

Bone scintigraphy predicts bisphosphonate-induced osteonecrosis of the jaw (BRONJ) in patients with metastatic castration-resistant prostate cancer (mCRPC)

OBJECTIVES

The aim of this study was to evaluate the role of bone scintigraphy (BS) in early prediction of clinically asymptomatic bisphosphonate (BP)-related osteonecrosis of the jaws (BRONJ) in patients with metastatic castration-resistant prostate cancer (mCRPC).

MATERIAL AND METHODS

BS of mCRPC patients treated with BP was evaluated for pathologic tracer uptake of the jaws in BS suspicious for BRONJ. Results were compared to development of clinically evident BRONJ. Sensitivity, specificity and predictive values of BS for the detection of BRONJ as well as time from beginning of BP therapy to pathologic tracer uptake in BS and time from pathologic tracer uptake in BS to clinically evident BRONJ were determined.

RESULTS

Thirty BP-treated patients were included. Nine patients (30%) had pathologic BS lesions of the jaws. Six patients (20%) developed BRONJ. Sensitivity and specificity of BS for BRONJ prediction were 67 and 79%. Median time from the start of BP treatment to pathologic tracer uptake in BS was 28 months (range 10-33) and from pathologic tracer uptake in BS to clinically evident BRONJ 6.5 months (range 2-19). Pathologic tracer uptake in BS was significantly more often observed in patients who developed BRONJ compared to patients who did not (p = 0.049; OR 7.6).

CONCLUSIONS

Patients with pathologic tracer uptake in the jaws in BS significantly more often develop BRONJ. An unsuspicious BS is predictive for absence of BRONJ in the future.

CLINICAL RELEVANCE

We conclude that when BS has been performed, it should not only be used to assess tumour stage and treatment response but also to check for pathologic tracer uptake in the jaws in BS to detect BRONJ at an early stage in mCRPC patients receiving bisphosphonates.

"Phossy Jaw" and "Bis-phossy Jaw" of the 19th and the 21st Centuries: The Diuturnity of John Walker and the Friction Match

Some 200 years ago, workers developed gingivitis, periodontal disease, alveolar crest bone sequestra, and draining fistulae after exposure to phosphorous fumes and phosphorous paste in the manufacture of the friction match. Many also suffered loss of teeth and pathologic fracture of the mandible. Known as "phossy jaw," the constellation rather abruptly vanished following the International Berne Convention of 1906. Today, "bis-phossy jaw" (bisphosphonate-induced osteonecrosis of the jaw) has surfaced with pathologic fractures and other features common to its predecessor, "phossy jaw." This modern equivalent is reported with ever-increasing frequency and is presented here in the format of a brief historical review and a case report that includes segmental en bloc extirpation of necrotic mandible and pain-free salvage. Computerized imagery and three-dimensional printing technology were successfully chosen to create and apply a custom titanium bone plate, without free-tissue transfer.

Diabetes as a risk factor for medication-related osteonecrosis of the jaw

Medication-related osteonecrosis of the jaw (MRONJ) is a severe devastating complication for which the exact pathogenesis is not completely understood. Multiple systemic and local factors may contribute to the development of MRONJ. A growing body of evidence supports diabetes mellitus (DM) as an important risk factor for this complication; however, the exact mechanism by which DM may promote MRONJ has yet to be determined. The current review elucidates the role of DM in the pathogenesis of MRONJ and the mechanisms by which DM may increase the risk for MRONJ. Factors related to DM pathogenesis and treatment may contribute to poor bone quality through multiple damaged pathways, including microvascular ischemia, endothelial cell dysfunction, reduced remodeling of bone, and increased apoptosis of osteoblasts and osteocytes. In addition, DM induces changes in immune cell function and promotes inflammation. This increases the risk for chronic infection in the settings of cancer and its treatment, as well as antiresorptive medication exposure, thus raising the risk of developing MRONJ. A genetic predisposition for MRONJ, coupled with CYP 450 gene alterations, has been suggested to affect the degradation of medications for DM such as thiazolidinediones and may further increase the risk for MRONJ.

Bisphosphonate-Related Osteonecrosis of the Jaws and Its Array of Manifestations

PURPOSE

Bisphosphonate (BP) therapy in the treatment of bone diseases and malignancy may induce a major side effect known as bisphosphonate-related osteonecrosis of the jaws (BRONJ). A particular view of this condition is reported in this case series investigating eight patients. The aim of the study was to evaluate the BRONJ lesions concerning their aspects and progression. Also, identify if it is possible to predict the degree of severity in these cases.

METHODS

Patients were evaluated by their condition and systemic health. The lesions were evaluated in clinical and radiographic aspects. The patients were followed-up for 2 years.

RESULTS

The patients presented with specific peculiarities, and the BRONJ lesions varied in several characteristics. The BRONJ lesions ranged from simple to severe conditions, and the complicated cases presented with major pain, swelling, secondary infection and an extensive necrotic area, classified with high grade of severity.

CONCLUSIONS

The patients presented here confirm the existence of a relation between multiple features and BRONJ and to understand the whole process of aggravation, all systemic and local information have to be taken into account, together with all data related to the BP utilized. Regardless of the low incidence of this side effect in relation to osteoporosis treatment, in some cases, the BRONJ may become a severe condition and compromise the patient's quality of life.

Clinical aspects, imaging features, and considerations on bisphosphonate-related osteonecrosis risk in a pediatric patient with osteogenesis imperfecta

Osteogenesis imperfecta (OI) is a rare hereditary condition caused by changes in collagen metabolism. It is classified into four types according to clinical, genetic, and radiological criteria. Clinically, bone fragility, short stature, blue sclerae, and locomotion difficulties may be observed in this disease. OI is often associated to severe dental problems, such as dentinogenesis imperfecta (DI) and malocclusions. Radiographically, affected teeth may have crowns with bulbous appearance, accentuated constriction in the cementoenamel junction, narrowed roots, large root canals due to defective dentin formation, and taurodontism (enlarged pulp chambers). There is no definitive cure, but bisphosphonate therapy is reported to improve bone quality; however, there is a potential risk of bisphosphonate-related osteonecrosis of the jaw. In this study we report a case of OI in a male pediatric patient with no family history of OI who was receiving ongoing treatment with intravenous perfusion of bisphosphonate and who required dental surgery. In addition, we discussed the clinical and imaging findings and briefly reviewed the literature.

Three-phase bone scintigraphy for imaging osteoradionecrosis of the jaw

This study evaluates the diagnostic utility of 3-phase bone scintigraphy for diagnosing osteoradionecrosis of the jaw (ORNJ).

METHODS

Thirty-two consecutive patients with a history of radiation to the head and neck region (range, 62-70 Gy; mean, 68 Gy; median, 69 Gy) due to squamous cell cancer and suspected ORNJ underwent 3-phase bone scans after injection of 520 to 750 MBq of Tc-MPD. In addition to planar scans, tomographic images (SPECT) were acquired in the second phase and SPECT/CT images during the third phase. Histopathologic findings (n = 18) and clinical follow-up (n = 14) served as reference standard for osteoradionecrosis.

RESULTS

The first, second, and third phases of planar images were rated positive in 18/32 patients (56.3%), 25/32 (78.1%), and 27/32 patients (84.4%), respectively. The late SPECT was positive in all patients (32/32, 100%), respectively. Histopathologic findings available in 18/32 patients (56.3%) confirmed ORNJ in all subjects. Acute inflammation was histologically proven in 18/18 specimens (100%) and additional chronic inflammation in 12/18 (66.7%). In 13/18 (72.2%) specimens, superinfection was evident histopathologically. A photopenic defect with surrounding hypermetabolism, a reported hallmark of ORJN, was found in less than 5%.

CONCLUSIONS

The predominant scintigraphic pattern of osteoradionecrosis includes increased bone mineralization phase in all patients. Central photopenia, reportedly a typical bone scan finding in bisphosphonate-induced osteonecrosis, was not characteristic for ORNJ. A differentiation of acute from chronic inflammatory processes was not possible.

Pamidronate disodium for palliative therapy of feline bone-invasive tumors

This study sought to quantify in vitro antiproliferative effects of pamidronate in feline cancer cells and assess feasibility of use of pamidronate in cats by assessing short-term toxicity and dosing schedule in cats with bone-invasive cancer. A retrospective pilot study included eight cats with bone invasive cancer treated with intravenous pamidronate. In vitro, pamidronate reduced proliferation in feline cancer cells (P < 0.05). One cat treated with pamidronate in combination with chemotherapy and two cats treated with pamidronate as a single agent after failing prior therapy had subjective clinically stable disease; median progression free interval in these cats from initial pamidronate treatment was 81 days. Three cats developed azotemia while undergoing various treatment modalities including nonsteroidal anti-inflammatory drugs and pamidronate. Median overall survival was 116.5 days for all cats and 170 days for cats with oral squamous cell carcinoma. Median progression free survival was 55 days for all cats and 71 days for cats with oral squamous cell carcinoma. Pamidronate therapy appears feasible for administration in cancer bearing cats with aggressive bone lesions in the dose range of 1-2 mg/kg every 21–28 days for multiple treatments. No acute or short-term toxicity was directly attributable to pamidronate.

Anti-resorptive osteonecrosis of the jaws: facts forgotten, questions answered, lessons learned

Osteonecrosis of the jaws associated with bisphosphonate and other anti-resorptive medications (ARONJ) has historically been a poorly understood disease process in terms of its pathophysiology, prevention and treatment since it was originally described in 2003. In association with its original discovery 11 years ago, non-evidence based speculation of these issues have been published in the international literature and are currently being challenged. A critical analysis of cancer patients with ARONJ, for example, reveals that their osteonecrosis is nearly identical to that of cancer patients who are naive to anti-resorptive medications. In addition, osteonecrosis of the jaws is not unique to patients exposed to anti-resorptive medications, but is also seen in patients with osteomyelitis and other pathologic processes of the jaws. This article represents a review of facts forgotten, questions answered, and lessons learned in general regarding osteonecrosis of the jaws.