Bisphosphonate-associated osteonecrosis of the jaws: surgical treatment with ErCrYSGG-laser. Case report

Use of Phototherapy and Er-YAG Laser in the Management of Mandible Osteoradionecrosis: A Case Report

Introduction: Osteoradionecrosis (ORN) is a secondary complication from radiotherapy, which is difficult to manage and significantly reduces the life quality of the affected patients. Case Report: A 59-year-old female patient, diagnosed with infiltration by squamous cell carcinoma in the left cervical region, underwent adjuvant cervical-facial radiotherapy with a total dose of 66.6 Gy of radiation. Eight years after the diagnosis, the patient underwent multiple extractions and, subsequently, the installation of osseointegrated implants, evolving to extensive intraoral bone exposure associated with oral cutaneous fistula. The patient was initially exposed to photobiomodulation therapy (PBMT), with a low-power laser at wavelengths of 660 nm and 808 nm, and thereafter to antimicrobial photodynamic therapy (aPDT). After an improvement in the clinical condition and resolution of the oral cutaneous fistula, a surgical procedure with the Er: YAG laser was performed to remove the remaining necrotic bone. Once the ORN condition was completely treated, the patient's oral rehabilitation was implemented by the installation of an upper mucous-supported total prosthesis and a lower implant-supported prosthesis. Conclusion: The patient is in a clinical follow-up and has no signs of bone necrosis recurrence, suggesting that low and high-power laser treatment can be an effective therapeutic alternative to resolve this condition.

Beta tricalcium phosphate, either alone or in combination with antimicrobial photodynamic therapy or doxycycline, prevents medication-related osteonecrosis of the jaw

Surgical trauma in those under a prolonged use of bisphosphonates, can lead to mediation-related osteonecrosis of the jaw (MRONJ). This study aimed to evaluate the preventive therapies for MRONJ. Following four cycles of zoledronic acid administration, Wistar rats had their molar extracted, and were organized into nine treatment groups: negative control group (NCG), treated with saline solution and blood-clot in the alveolus; positive control group (PCG), with blood-clot in the alveolus; BG, β-tricalcium phosphate-based biomaterial; DG, 10% doxycycline gel; aG, antimicrobial photodynamic therapy; and DBG, aBG, aDG, and aDBG, using combination therapy. After 28 days, the lowest bone volume (BV/TV) was reported in PCG (42.17% ± 2.65), and the highest in aDBG (69.85% ± 6.25) (p < 0.05). The higher values of daily mineral apposition rate were recorded in aDBG (2.64 ± 0.48) and DBG (2.30 ± 0.37) (p < 0.001). Moreover, aDBG presented with the highest neoformed bone area (82.44% ± 2.69) (p < 0.05). Non-vital bone was reported only in the PCG (37.94 ± 18.70%). Owing to the key role of the biomaterial, the combination approach (aDBG) was the most effective in preventing MRONJ following tooth extraction.

Analysis of different therapeutic protocols for osteonecrosis of the jaw associated with oral and intravenous bisphosphonates

Introduction

Chemotherapy-associated osteonecrosis of the jaw caused by bisphosphonates is an exposure of necrotic bone with more than eight weeks of evolution that is attributable to bisphosphonates and no prior radiation therapy. Its etiopathogenesis remains unknown, although there are two hypotheses that may explain it: the drug’s mechanism of action, and the risk factors that can lead to osteonecrosis. There is a wide range of treatment options for managing chemotherapy-associated osteonecrosis of the jaw, from conservative treatments to surgical procedures of varying levels of invasiveness, which are sometimes supplemented with adjuvant therapies.

Objectives

The objective of this article is to group the therapeutic options for osteonecrosis of the jaw (ONJ) into seven different protocols and to evaluate their effectiveness in relation to stage of ONJ.

Material and Methods

A literature review was carried out in PubMed following the PRISMA criteria. A total of 47 were collected after compiling a series of variables that define ONJ, applied treatments, and the clinical results obtained.

Results and Discussion

The 47 articles selected have a low to average estimated risk of bias and are of moderate to good quality. According to the data obtained, Protocol 3 (conservative treatment, clinical and radiological follow-up, minimally invasive surgical treatment, and adjuvant therapies) is the most favorable approach for ONJ lesions caused by oral bisphosphonates. For lesions caused by intravenous bisphosphonates, Protocol 2 (conservative treatment, clinical and radiological follow-up, minimally invasive surgical treatment, and no adjuvant therapies) is the best approach. When comparing the different stages of ONJ, Protocol 1 (conservative treatment, clinical and radiological follow-up) promotes better healing of Stage 1 ONJ lesions caused by orally administered bisphosphonates, and Protocol 3 is recommended for Stage II. For ONJ lesions attributable to intravenous bisphosphonates, Protocol 7 (conservative treatment, clinical and radiological follow-up, and adjuvant therapies) provides the best results in Stage 0; in Stages I, II, and III, Protocol 1 gives better results.

Key words:Bisphosphonates, bronj, therapeutic protocol, clinical result.

Medication-Related Osteonecrosis of the Jaw: An Autofluorescence-Guided Surgical Approach Performed with Er:YAG Laser

OBJECTIVE

The aim of this study was to propose an autofluorescence (AF)-guided surgical approach performed with Er:YAG laser and Nd:YAG low-level laser therapy (LLLT).

BACKGROUND DATA

Medication-related osteonecrosis of the jaw (MRONJ) therapy remains an unresolved problem. The proposed conservative and surgical treatment regimens are associated with contradictory success rates. However, the increased experience with MRONJ management suggests that surgical therapy can halt disease progression, and can allow a histology-based diagnosis of osteonecrosis. Surgical approach with Er:YAG laser is associated with significantly better results compared with medical treatment and traditional surgical approaches. One of the difficulties encountered during surgical removal of a MRONJ is the precise individuation of necrotic bone margins.

PATIENT AND METHODS

A case of Stage III maxillary osteonecrosis treated with a new surgical approach is presented.

RESULTS

After 7 months of follow-up, complete mucosal healing was evident, and the patient was free of symptoms. Such a technique allowed a highly accurate and minimally invasive approach through the selective ablation of the non-/hypofluorescent areas.

CONCLUSIONS

Taking into account the advantages of laser therapy and the possible effectiveness of AF in highlighting surgical margins, this approach would probably achieve excellent outcomes.

Surgical management of bisphosphonate-related osteonecrosis of the jaws: literature review

PURPOSE

Surgical management of bisphosphonate-related osteonecrosis of the jaws (BRONJ) has been performed in an attempt to increase healing rates of the affected cases. This literature review aimed to identify clinical studies of surgical management of bisphosphonate-related osteonecrosis of the jaws (BRONJ) in order to assess their surgical treatment modalities, outcome and the follow-up.

METHODS

A search in the PubMed (Medline) database using specific terms and/or phrases as "bisphosphonate-related osteonecrosis" or "jaw osteonecrosis", and "surgical treatment" or "surgical management" was conducted in order to identify clinical trials and cases of surgical treatment of BRONJ. The review search covered the time period from 2004 to 2014. All studies identified in the search were selected according to the inclusion criteria. Relevant information was recorded according to the following items: author, year, number of patients, BRONJ clinical stage, surgical treatment modality, clinical success, and follow-up.

RESULTS

The initial database search yielded 345 titles. After filtering, 67 abstracts were selected culminating in 67 full text articles. A variety of surgical approach was found in this review: debridement, sequestrectomy bone resection, and bone reconstruction. Adjunctive therapies included hyperbaric oxygen, laser therapy, growth factors, and ozone.

CONCLUSION

Although there are many indexed studies about BRONJ, well-documented reports concerning surgical therapeutically techniques are scarce, resulting from a lack of well-established protocols. Considerable differences were found regarding sample size, surgical treatment modalities and outcomes. Clinical studies with larger number of patients and longer follow-up are required to provide best information for each surgical treatment modality and its outcomes.

Bisphosphonate-related osteonecrosis of the jaws: Report of a case using conservative protocol

Bisphosphonates have been the first-line treatment option for osteometabolic diseases, such as osteoporosis, hypercalcaemia in malignant bone diseases, and in bone metastasis. It is possible to observe a growing number of cases of osteonecrosis of the jaws in patients using this medication, called bisphosphonate-related osteonecrosis of the jaws. The purpose of this study was to report a conservative treatment for bisphosphonate-related osteonecrosis of the jaws--Stage 2, using antibacterial solution and low-level laser therapy. At the end of the treatment, the patient presented improvement of the lesion with the healing of the mucosa. The literature still lacks successful definite protocols, thus the present case may contribute with another option for conservative management for bisphosphonate-related osteonecrosis of the jaws. More research is necessary in order to develop a good protocol management for bisphosphonate-related osteonecrosis of the jaws.

Osteonecrosis of the jaws in 194 patients who have undergone intravenous bisphosphonate therapy in Spain

BACKGROUND

Osteonecrosis of the jaw (ONJ) is a destructive bone process in patients undergoing bisphosphonate therapy and it is modulated by local and systemic factors. The purpose of this article is to determine the prevalence of ONJ in patients who have undergone intravenous bisphosphonate therapy, and relate the risk factors described to establish a protocol to reduce the risk of developing ONJ.

MATERIAL AND METHODS

We performed a retrospective study on 194 patients treated with IV bisphosponates, analyzing clinical and pathological variables.

RESULTS

The prevalence of ONJ was 12.9 %. The most remarkable complication was pain, which was reported by 80% of patients. The average age of the patients undergoing bisphosphonate therapy was 68.91 years. Most of non-diabetic patients did not develop ONJ (92.3%) (p=0.048). During bisphosphonate therapy, 3.1% of patients underwent extractions in the same percentage in the maxilla and in the mandible; all of which, except for one patient, developed ONJ (p<0.001). In regards to the periodontal state, 94.3% of patients without periodontal problems did not develop ONJ (p=0.001). Almost 50% of the necrosis were located unifocally on the mandible (p<0.001). The number of affected patients and the aggressiveness of the disease increased significantly three years after starting treatment (p<0.001).

CONCLUSIONS

Etiology still is a controversial issue and we should focus on known risk factors, such as the development of surgical procedures in patients undergoing bisphosphonate therapy, especially in patients who have already started their treatment, a group in which ONJ prevalence increases. Moreover, a bad periodontal state in these patients is also an important risk factor, and the control of diabetes reduces it. Due to the above, all patients should be diagnosed and educated in oral hygiene prior to treatment, performing periodical maintenance, to detect possible traumatisms and periodontal infection as soon as possible.

Mandibular inferior cortical bone thickness on panoramic radiographs in patients using bisphosphonates

OBJECTIVE

The goal of this study was to detect dimensional changes in the mandibular cortical bone associated with bisphosphonate (BP) use and to correlate measurements of the cortical bone with the cumulative dose of BPs.

STUDY DESIGN

Mandibular inferior cortical bone thickness (MICBT) was measured under the mental foramen on panoramic radiographs of patients with and without bisphosphonate-related osteonecrosis of the jaws (BRONJ) taking BPs and controls.

RESULTS

Patients with BRONJ had the highest mean MICBT (6.81 ± 1.35 mm), compared with patients without BRONJ taking BPs (5.44 ± 1.09 mm) and controls (4.79 ± 0.85 mm) (P < .01). Mean MICBT of patients with BRONJ was significantly higher than that of patients without BRONJ taking BPs. There was a correlation between MICBT and cumulative dose of zolendronate.

CONCLUSIONS

Measurement of MICBT on panoramic radiographs is a potentially useful tool for the detection of dimensional changes associated with BP therapy.

Temporal correlation between bisphosphonate termination and symptom resolution in osteonecrosis of the jaw: a pooled case report analysis

PURPOSE

To investigate whether termination of bisphosphonates (BPs) affects resolution of bone exposure and symptomatic disease in patients with established medication-related osteonecrosis of the jaw (MRONJ).

PATIENTS AND METHODS

The studied population included 84 patients with established MRONJ who discontinued BP therapy before treatment (n = 21), at treatment initiation (n = 38), or later (or never) in the treatment course (n = 25). These 3 groups were compared using Kaplan-Meier curves and log-rank tests for differences in the respective times to resolution of 1) bone exposure for any treatment modality, 2) bone exposure not requiring radical surgery, and 3) disease symptoms.

RESULTS

Patients who continued BPs after the start of treatment exhibited significantly delayed resolution of symptoms (median 12 months; 95% confidence interval 8 to 15) compared with those who discontinued BPs before (3 months; 2 to 5) and at (6 months; 3 to 7) presentation (P < .005).

CONCLUSIONS

Independent of treatment modality and MRONJ stage at presentation, discontinuing BP before or at treatment initiation is associated with faster resolution of MRONJ symptoms compared with continuing the drug throughout jaw treatment. Patients should be counseled that continuing their BP medication after an established MRONJ diagnosis (compared to stopping the BP at diagnosis) may delay resolution of maxillofacial symptoms by approximately 6 months.

Conservative surgical management of stage I bisphosphonate-related osteonecrosis of the jaw

Purpose. To report the efficacy of conservative surgical treatment for stage I bisphosphonate-related osteonecrosis of the jaw (BRONJ). Materials and Methods. This study reports the clinical outcomes of 63 patients treated for BRONJ stage I (according to Ruggiero's staging system) at the Oral Pathology and Laser-Assisted Surgery Unit of the University of Parma between January 2004 and January 2011. Surgical interventions were performed, under local analgesia, in patients unresponsive for a period of six months to noninvasive treatments such as cycles of local or systemic antibacterial therapy combined or not to low level laser therapy, ozone therapy, or Hyperbaric Oxygen Therapy. All interventions were performed after the consultation of oncologist or physician. Results. In our experience, conservative surgical treatment is associated with the highest number of BRONJ healed sites in stage I disease. Complete healing was observed in 92.6% of sites surgically treated. Conclusions. This study confirms that treatment of patients affected by minimal bone exposition, (stage I of BRONJ), through conservative surgical strategies, possibly with laser, may result in a high control of the disease in the long term.

[Osteoporosis and oral diseases]

Osteoporosis is a major cause of fractures in elderly women. Bone densitometry is used in order to detect osteoporosis. It has been observed can also be analyzed in the jawbone. The osteoporosis may be associated with resorption of the residual ridge, periodontitis and tooth loss; also the same treatments can affect the jaws. A search was carried out in the Medline-Pubmed database in order to search the association between osteoporosis and oral diseases over the past 5 years. Forty-two articles were obtained after the selection process. The authors stated that: in reference to periodontal disease the results are conflicting, but there seems to be a higher prevalence of the disease and tooth loss and resorption of the crest. Oral bisphosphonates have little risk of causing osteonecrosis, and there is no relationship in the dental implant failure among patients taking bisphosphonates. There is no clear scientific evidence that could link osteoporosis and oral diseases.

Bisphosphonate related osteonecrosis of the jaws: a review

Bisphosphonate use has increased in veterinary medicine over the last decade. During this time, bisphosphonate related osteonecrosis of the jaws (BRONJ) in human patients has been identified. Only recently was a dog model for BRONJ developed for human oral surgery and medicine. Veterinary patients treated with bisphosphonates may be at an increased risk for BRONJ There has been little, to no, investigation of potential long term side-effects of bisphosphonate use in veterinary patients; potential sequelae are unknown. The history of bisphosphonates, their use, and BRONJ in veterinary patients are discussed.

Autologous bone marrow stem cell intralesional transplantation repairing bisphosphonate related osteonecrosis of the jaw

PURPOSE

Bisphosphonate - related osteonecrosis of the JAW (BRONJ) is a well known side effect of bisphosphonate therapies in oncologic and non oncologic patients. Since to date no definitive consensus has been reached on the treatment of BRONJ, novel strategies for the prevention, risk reduction and treatment need to be developed. We report a 75 year old woman with stage 3 BRONJ secondary to alendronate and pamidronate treatment of osteoporosis. The patient was unresponsive to recommended treatment of the disease, and her BRONJ was worsening. Since bone marrow stem cells are know as being multipotent and exhibit the potential for differentiation into different cells/tissue lineages, including cartilage, bone and other tissue, we performed autologous bone marrow stem cell transplantation into the BRONJ lesion of the patient.

METHODS

Under local anesthesia a volume of 75 ml of bone marrow were harvested from the posterior superior iliac crest by aspiration into heparinized siringes. The cell suspension was concentrated, using Ficoll - Hypaque® centrifugation procedures, in a final volume of 6 ml. Before the injection of stem cells into the osteonecrosis, the patient underwent surgical toilet, local anesthesia was done and spongostan was applied as a carrier of stem cells suspension in the bone cavity, then 4 ml of stem cells suspension and 1 ml of patient's activated platelet-rich plasma were injected in the lesion of BRONJ.

RESULTS

A week later the residual spongostan was removed and two weeks later resolution of symptoms was obtained. Then the lesion improved with progressive superficialization of the mucosal layer and CT scan, performed 15 months later, shows improvement also of bone via concentric ossification: so complete healing of BRONJ (stage 0) was obtained in our patient, and 30 months later the patient is well and without signs of BRONJ.

CONCLUSION

To our knowledge this is the first case of BRONJ successfully treated with autologous stem cells transplantation with a complete response.