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Ferreira SS, do Amaral JB, Pacheco JJ, Salazar F, Monteiro L. Osteonecrosis of the Jaw Associated with Bisphosphonates Infusion for Treatment of Plasma Cell Myeloma-A Retrospective Observational Study of Northern Portuguese Population. J Clin Med 2024; 13:2679. [PMID: 38731207 PMCID: PMC11084472 DOI: 10.3390/jcm13092679] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2024] [Revised: 04/08/2024] [Accepted: 04/29/2024] [Indexed: 05/13/2024] Open
Abstract
Objectives: To verify medication-related osteonecrosis of the jaw (MRONJ) frequency among patients with plasma cell myeloma (PCM) that had been treated with bisphosphonates, to identify predisposing factors that could influence the development of osteonecrosis. Methods: This observational retrospective study was performed at the Department of Hematology of Hospital Center of Porto (CHUP), Portugal. Results: The study population (n = 112) had a 15.2% (n = 17) prevalence of osteonecrosis. Clinically, bone exposure was the most frequently observed sign, present in 100% (n = 17) of the patients, followed by inflammation in 82.4% (n = 14), orofacial pain in 70.6% (n = 12), suppuration in 47.1% (n = 8), and intra or extra-oral fistula in 17.6% (n = 3) of the cases. The most frequent triggering local factor was dental extraction (82.4%). There was a dependence between the presence of extractions and the development of MRONJ (p < 0.001) but not with the time elapsed from the initiation of infusions with BPs and dental extractions (p = 0.499). In the sample of patients with multiple myeloma (MM), 13.8% were found to be more likely to develop MRONJ after an extraction. Conclusions: The most common local predisposing factor was dental extraction. No dependence was observed between the development of osteonecrosis and the time elapsed from the beginning of treatment with bisphosphonates infusions to surgical procedures.
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Affiliation(s)
- Sara Sousa Ferreira
- UNIPRO, Unidade de Investigação de Patologia e Reabilitação Oral, Instituto Universitário de Ciências da Saúde do Norte (IUCS-CESPU), 4585-116 Gandra, Portugal; (J.J.P.); (F.S.); (L.M.)
- Oral Medicine and Oral Surgery Department, Instituto Universitário de Ciências da Saúde do Norte (IUCS-N), 4585-116 Gandra, Portugal;
| | - José Barbas do Amaral
- Oral Medicine and Oral Surgery Department, Instituto Universitário de Ciências da Saúde do Norte (IUCS-N), 4585-116 Gandra, Portugal;
| | - José Júlio Pacheco
- UNIPRO, Unidade de Investigação de Patologia e Reabilitação Oral, Instituto Universitário de Ciências da Saúde do Norte (IUCS-CESPU), 4585-116 Gandra, Portugal; (J.J.P.); (F.S.); (L.M.)
- Oral Medicine and Oral Surgery Department, Instituto Universitário de Ciências da Saúde do Norte (IUCS-N), 4585-116 Gandra, Portugal;
| | - Filomena Salazar
- UNIPRO, Unidade de Investigação de Patologia e Reabilitação Oral, Instituto Universitário de Ciências da Saúde do Norte (IUCS-CESPU), 4585-116 Gandra, Portugal; (J.J.P.); (F.S.); (L.M.)
- Oral Medicine and Oral Surgery Department, Instituto Universitário de Ciências da Saúde do Norte (IUCS-N), 4585-116 Gandra, Portugal;
| | - Luís Monteiro
- UNIPRO, Unidade de Investigação de Patologia e Reabilitação Oral, Instituto Universitário de Ciências da Saúde do Norte (IUCS-CESPU), 4585-116 Gandra, Portugal; (J.J.P.); (F.S.); (L.M.)
- Oral Medicine and Oral Surgery Department, Instituto Universitário de Ciências da Saúde do Norte (IUCS-N), 4585-116 Gandra, Portugal;
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Baek HJ, Lee H, Lee JR, Park JH, Kim KS, Kwoen MJ, Lee TY, Kim JW, Lee HJ. Pulp and periapical disease as a risk factor for osteonecrosis of the jaw: a national cohort-based study in Korea. J Periodontal Implant Sci 2024; 54:65-74. [PMID: 37524381 PMCID: PMC11065535 DOI: 10.5051/jpis.2300120006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Revised: 03/06/2023] [Accepted: 04/03/2023] [Indexed: 08/02/2023] Open
Abstract
PURPOSE This longitudinal cohort study aimed to evaluate the relationship between osteonecrosis of the jaw and pulp and periapical disease in patients who were administered bisphosphonates. METHODS Using data from a nationwide cohort, we examined the association among dental caries, pulp and periapical disease, and osteonecrosis of the jaw in women aged >50 years who received bisphosphonates for more than 1 year between 2002 and 2015. Because of ambiguities in the diagnosis of osteonecrosis of the jaw in population-based data, we operationally defined and categorized the condition into established and potential osteonecrosis of the jaw. RESULTS Pulp and periapical disease significantly increased the development of both established and potential osteonecrosis of the jaw (hazard ratio, 2.21; 95% confidence interval, 1.40-3.48; and hazard ratio, 2.22; 95% confidence interval, 1.65-2.98, respectively). Root canal treatment did not have any influence on the development of osteonecrosis of the jaw. CONCLUSIONS Pulp and periapical disease may be a major risk factor for osteonecrosis of the jaw. The study findings suggest that patients should undergo regular dental examinations to detect pulp and periapical disease before or during the administration of bisphosphonates and that root canal treatment should be considered to decrease the risk of osteonecrosis of the jaw.
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Affiliation(s)
- Hyeong-Jin Baek
- Department of Periodontology, Section of Dentistry, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Hyejin Lee
- Department of Family Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Jae-Ryun Lee
- Department of Family Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Jung-Hyun Park
- Department of Oral and Maxillofacial Surgery, Research Institute for Intractable Osteonecrosis of the Jaw, College of Medicine, Ewha Womans University, Seoul, Korea
| | - Keun-Suh Kim
- Department of Periodontology, Section of Dentistry, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Min-Jeong Kwoen
- Department of Periodontology, Section of Dentistry, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Tae-Yeon Lee
- Department of Conservative Dentistry, Yeouido St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Jin-Woo Kim
- Department of Oral and Maxillofacial Surgery, Research Institute for Intractable Osteonecrosis of the Jaw, College of Medicine, Ewha Womans University, Seoul, Korea.
| | - Hyo-Jung Lee
- Department of Periodontology, Section of Dentistry, Seoul National University Bundang Hospital, Seongnam, Korea.
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Bittrich M, Hetterich R, Solimando AG, Krebs M, Loda S, Danhof S, Anton S, Zhou X, Kerscher A, Beilhack A, Kortüm KM, Rasche L, Einsele H, Knop S, Hartmann S. Does medication-related osteonecrosis of the jaw affect survival of patients with Multiple Myeloma?: Exploring a large single center database using artificial intelligence. Clin Exp Med 2023; 23:5215-5226. [PMID: 37805620 PMCID: PMC10725344 DOI: 10.1007/s10238-023-01100-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Accepted: 05/23/2023] [Indexed: 10/09/2023]
Abstract
In addition to randomized clinical trials, consideration of Real-World Evidence is necessary for mirroring clinical reality. However, processing such evidence for large numbers of patients often requires considerable time and effort. This is particularly true for rare tumor diseases such as multiple myeloma (MM) or for adverse effects that occur even more rarely. In such cases, artificial intelligence is able to efficiently detect patients with rare conditions. One of these rare adverse events, and the most discussed, following bone protective treatment in MM is medication-related osteonecrosis of the jaw (MRONJ). The association of bone protective treatment to MM outcome has been intensively studied. However, the impact of MRONJ resulting from such treatment on MM prognosis and outcome is poorly understood. In this retrospective study, we therefore investigated the long-term effects of MRONJ. We used natural language processing (NLP) to screen individual data of 2389 MM patients to find 50 out of 52 patients with MRONJ matching our inclusion criteria. To further improve data quality, we then performed propensity score matching. In comparison to MM patients without MRONJ, we found a significantly longer overall survival (median 126 vs. 86 months) despite slightly worse clinical features.
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Affiliation(s)
- Max Bittrich
- Department of Internal Medicine II, University Hospital Würzburg, 97080, Würzburg, Germany.
| | - Regina Hetterich
- Department of Internal Medicine II, University Hospital Würzburg, 97080, Würzburg, Germany
| | - Antonio G Solimando
- Department of Biomedical Sciences and Human Oncology, Section of Internal Medicine 'G. Baccelli', University of Bari Medical School Bari, 70124, Bari, Italy
| | - Markus Krebs
- Comprehensive Cancer Center Mainfranken, 97080, Würzburg, Germany
| | - Sophia Loda
- Department of Internal Medicine II, University Hospital Würzburg, 97080, Würzburg, Germany
| | - Sophia Danhof
- Department of Internal Medicine II, University Hospital Würzburg, 97080, Würzburg, Germany
| | - Straub Anton
- Department of Oral and Maxillofacial Plastic Surgery, University Hospital Würzburg, 97070, Würzburg, Germany
| | - Xiang Zhou
- Department of Internal Medicine II, University Hospital Würzburg, 97080, Würzburg, Germany
| | | | - Andreas Beilhack
- Department of Internal Medicine II, University Hospital Würzburg, 97080, Würzburg, Germany
- Department of Biomedical Sciences and Human Oncology, Section of Internal Medicine 'G. Baccelli', University of Bari Medical School Bari, 70124, Bari, Italy
| | - K Martin Kortüm
- Department of Internal Medicine II, University Hospital Würzburg, 97080, Würzburg, Germany
| | - Leo Rasche
- Department of Internal Medicine II, University Hospital Würzburg, 97080, Würzburg, Germany
| | - Hermann Einsele
- Department of Internal Medicine II, University Hospital Würzburg, 97080, Würzburg, Germany
| | - Stefan Knop
- Department of Internal Medicine 5, Hematology and Oncology, University Hospital of Paracelsus Medical Private University, 90419, Nuremberg, Germany
| | - Stefan Hartmann
- Department of Oral and Maxillofacial Plastic Surgery, University Hospital Würzburg, 97070, Würzburg, Germany
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Nogueira D, Caldas IM, Dinis-Oliveira RJ. Bisphosphonates and osteonecrosis of the jaws: Clinical and forensic aspects. Arch Oral Biol 2023; 155:105792. [PMID: 37611492 DOI: 10.1016/j.archoralbio.2023.105792] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Revised: 07/30/2023] [Accepted: 08/14/2023] [Indexed: 08/25/2023]
Abstract
OBJECTIVE This manuscript aims to provide a comprehensive review of the current knowledge in the pathophysiology, diagnosis, prevention, and other relevant clinical and forensic aspects of a potentially severe complication known as medication-related osteonecrosis of the jaw (MRONJ) while synthesizing state-of-the-art information on bisphosphonates and introducing a possible differential diagnosis. DESIGN An extensive search was conducted in PubMed (U.S. National Library of Medicine) without a time or language constraint, focusing on the epidemiology, pathophysiology, risk factors, site specificity, signs and symptoms, differential diagnosis, prevention, and forensic aspects of MRONJ. All types of original articles, reviews, case reports, short communications, opinion articles, guidelines, and letters to editors were considered to produce a complete review on this subject. RESULTS MRONJ prevention relies on a multidisciplinary approach and is critical since truly effective treatments are lacking. This therapeutic challenge is partly due to uncertainty regarding this condition's pathophysiology. Differential diagnosis of osteonecrosis of the jaws associated with krokodil abuse, one of the most dangerous and homemade psychoactive illicit substances, should be considered. CONCLUSIONS Further research into the etiology and site specificity of MRONJ is encouraged, aiming to develop novel treatment prospects. Indeed, comprehending this would allow for increased efficacy and therapeutic options while emphasizing the importance of prevention. In addition, we advocate for greater consensus among the various societies regarding MRONJ's treatment and management.
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Affiliation(s)
- Diana Nogueira
- Department of Public Health and Forensic Sciences, and Medical Education, Faculty of Medicine, University of Porto, 4200-319 Porto, Portugal; Faculty of Dental Medicine, University of Porto, Rua Dr. Manuel Pereira da Silva, 4200-393 Porto, Portugal.
| | - Inês Morais Caldas
- Faculty of Dental Medicine, University of Porto, Rua Dr. Manuel Pereira da Silva, 4200-393 Porto, Portugal; 1H-TOXRUN, One Health Toxicology Research Unit, University Institute of Health Sciences, CESPU, CRL, 4585-116 Gandra, Portugal; Centre for Functional Ecology (CFE), Department of Life Sciences, University of Coimbra, Calçada Martim de Freitas, 3000-456 Coimbra, Portugal.
| | - Ricardo Jorge Dinis-Oliveira
- Department of Public Health and Forensic Sciences, and Medical Education, Faculty of Medicine, University of Porto, 4200-319 Porto, Portugal; 1H-TOXRUN, One Health Toxicology Research Unit, University Institute of Health Sciences, CESPU, CRL, 4585-116 Gandra, Portugal; UCIBIO/REQUIMTE, Laboratory of Toxicology, Faculty of Pharmacy, University of Porto, R. Jorge Viterbo Ferreira, No 228, 4050-313 Porto, Portugal.
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Kang JY, Kim SY, Lim JS, Kim JY, Jin GY, Lee YJ, Lee EY. Denosumab-associated jaw bone necrosis in cancer patients: retrospective descriptive case series study. Maxillofac Plast Reconstr Surg 2023; 45:23. [PMID: 37389685 DOI: 10.1186/s40902-023-00391-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Accepted: 06/20/2023] [Indexed: 07/01/2023] Open
Abstract
BACKGROUND Denosumab (DMB) is a bone antiresorptive agent used to treat osteoporosis or metastatic cancer of the bones. However, denosumab-associated osteonecrosis of the jaw (DRONJ) has become a common complication in cancer patients. The prevalence of osteonecrosis of the jaw (ONJ) in cancer patients is estimated to be similar for both bisphosphonate-related cases (1.1 to 1.4%) and denosumab-related cases (0.8 to 2%), with the addition of adjunctive therapy with anti-angiogenic agents reportedly increasing its prevalence to 3%. (Spec Care Dentist 36(4):231-236, 2016). The aim of this study is to report on DRONJ in cancer patients treated with DMB (Xgeva®, 120mg). CASE PRESENTATION In this study, we identified four cases of ONJ among 74 patients receiving DMB therapy for metastatic cancer. Of the four patients, three had prostate cancer and one had breast cancer. Preceding tooth extraction within 2 months of the last DMB injection was found to be a risk factor for DRONJ. Pathological examination revealed that three patients had acute and chronic inflammation, including actinomycosis colonies. Among the four patients with DRONJ referred to us, three were successfully treated without complications and had no recurrence following surgical treatment, while one did not follow up. After healing, one patient experienced a recurrence at a different site. Sequestrectomy in conjunction with antibiotic therapy and cessation of DMB use proved to be effective in managing the condition, and the ONJ site healed after an average 5-month follow-up period. CONCLUSION Conservative surgery, along with antibiotic therapy and discontinuation of DMB, was found to be effective in managing the condition. Additional studies are needed to investigate the contribution of steroids and anticancer drugs to jaw bone necrosis, the prevalence of multicenter cases, and whether there is any drug interaction with DMB.
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Affiliation(s)
- Ji-Yeon Kang
- Department of Oral & Maxillofacial Surgery, College of Medicine, Chungnam National University, Moonhwa-ro 282, Jung-Gu, Daejeon, 35015, Korea
| | - Sang-Yup Kim
- Department of Oral & Maxillofacial Surgery, College of Medicine and Medical Research Institute Chungbuk, National University, Chungdae-ro 1, Seowon-Gu, Cheongju, 28644, Chungbuk, Korea
- Department of Oral & Maxillofacial Surgery, Daejeon St. Mary's Hospital, Daeheung-ro 64, Jung-Gu, Daejeon, 34943, Korea
| | - Jae-Seok Lim
- Department of Oral & Maxillofacial Surgery, Chungbuk National University Hospital, Chungdae-ro 1, Seowon-Gu, Cheongju, 28644, Chungbuk, Korea
| | - Jwa-Young Kim
- Department of Oral & Maxillofacial Surgery, Hallym University Kangnam Sacred Heart Hospital, Singil-ro 1, Youngdeungpo-Gu, Seoul, 07441, Korea
| | - Ga-Youn Jin
- Department of Oral & Maxillofacial Surgery, Hankook General Hospital, Danjae-ro 106, Sangdang-Gu, Cheongju, 28713, Korea
| | - Yeon-Jung Lee
- Department of Oral & Maxillofacial Surgery, Hankook General Hospital, Danjae-ro 106, Sangdang-Gu, Cheongju, 28713, Korea
| | - Eun-Young Lee
- Department of Oral & Maxillofacial Surgery, College of Medicine and Medical Research Institute Chungbuk, National University, Chungdae-ro 1, Seowon-Gu, Cheongju, 28644, Chungbuk, Korea.
- Department of Oral & Maxillofacial Surgery, Chungbuk National University Hospital, Chungdae-ro 1, Seowon-Gu, Cheongju, 28644, Chungbuk, Korea.
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Bioinformatic Data Mining for Candidate Drugs Affecting Risk of Bisphosphonate-Related Osteonecrosis of the Jaw (BRONJ) in Cancer Patients. DISEASE MARKERS 2022; 2022:3348480. [PMID: 36157219 PMCID: PMC9492334 DOI: 10.1155/2022/3348480] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Accepted: 08/30/2022] [Indexed: 11/17/2022]
Abstract
Background. Bisphosphonate-related osteonecrosis of the jaw (BRONJ) leads to significant morbidity. Other coadministered drugs may modulate the risk for BRONJ. The present study aimed to leverage bioinformatic data mining to identify drugs that potentially modulate the risk of BRONJ in cancer. Methods. A GEO gene expression dataset of peripheral blood mononuclear cells related to BRONJ in multiple myeloma patients was downloaded, and differentially expressed genes (DEGs) in patients with BRONJ versus those without BRONJ were identified. A protein-protein interaction network of the DEGs was constructed using experimentally validated interactions in the STRING database. Overrepresented Gene Ontology (GO) molecular function terms and KEGG pathways in the network were analysed. Network topology was determined, and ‘hub genes’ with degree ≥2 in the network were identified. Known drug targets of the hub genes were mined from the ‘drug gene interaction database’ (DGIdb) and labelled as candidate drugs affecting the risk of BRONJ. Results. 751 annotated DEGs (
,
) were obtained from the microarray gene expression dataset GSE7116. A PPI network with 633 nodes and 168 edges was constructed. Data mining for drugs interacting with 49 gene nodes was performed. 37 drug interactions were found for 9 of the hub genes including TBP, TAF1, PPP2CA, PRPF31, CASP8, UQCRB, ACTR2, CFLAR, and FAS. Interactions were found for several established and novel anticancer chemotherapeutic, kinase inhibitor, caspase inhibitor, antiangiogenic, and immunomodulatory agents. Aspirin, metformin, atrovastatin, thrombin, androgen and antiandrogen drugs, progesterone, Vitamin D, and Ginsengoside 20(S)-Protopanaxadiol were also documented. Conclusions. A bioinformatic data mining strategy identified several anticancer, immunomodulator, and other candidate drugs that may affect the risk of BRONJ in cancer patients.
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Lara SMDC, Muniz FWMG, Gerônimo ABC, Santos CSD, Barbosa Calcia TB. A systematic review assessing occurrence of medication-related osteonecrosis of the jaw following dental procedures. BRAZILIAN JOURNAL OF ORAL SCIENCES 2022. [DOI: 10.20396/bjos.v21i00.8666585] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
Aim: This study aimed to systematically review existing literature regarding the association between dental procedures—such as tooth extractions and periodontal therapy—and occurrence of medication-related osteonecrosis of the jaw (MRONJ) in individuals using bone-modifying drugs. Methods: Search strategies were performed in PubMed, Scopus, Web of Science and Cochrane Library for a timeframe ending in December 2021. Study selection, data extraction and risk of bias were analyzed independently by two researchers. Three meta-analyses were performed, estimating the crude risk ratio (RR), the adjusted odds ratio (OR) and the adjusted hazard ratio (HR) for the association between tooth extraction and MRONJ. Results: Of the 1,654 studies initially retrieved, 17 were ultimately included. The majority of patients with MRONJ in these studies were female, with a mean age of 64 years. Zoledronic acid was the most commonly used drug among patients with MRONJ, and cancer was the most frequent underlying health condition. Regarding the performed meta-analyses, crude and adjusted analyses demonstrated that tooth extraction increased the risk for MRONJ by 4.28 (95% confidence interval [95%CI]: 1.73–10.58), the OR for MRONJ by 26.94 (95%CI: 4.17–174.17), and the HR for MRONJ by 9.96 (95%CI: 4.04–24.55). Conclusion: It was concluded that performing dental procedures, especially tooth extraction, in patients using bone-modifying drugs increased the risk of MRONJ occurrence and, therefore, should be avoided. Further studies, using adjusted data, are warranted.
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Medication-Related Osteonecrosis of the Jaw in Dental Practice: A Retrospective Analysis of Data from the Milan Cohort. Dent J (Basel) 2022; 10:dj10050089. [PMID: 35621542 PMCID: PMC9139814 DOI: 10.3390/dj10050089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Revised: 05/11/2022] [Accepted: 05/13/2022] [Indexed: 02/01/2023] Open
Abstract
A retrospective analysis was performed with the aim of understanding whether the risk factors showed in the literature for medication-related osteonecrosis of the jaws (MRONJ) in cancer patients are also relevant in osteoporotic patients taking antiresorptive drugs (ARDs). Data were retrospectively pooled from health records of patients on ARDs who requested a dental visit between January 2006 and April 2020 in the Dental Unit at Fondazione Ca’ Granda IRCCS Ospedale Maggiore Policlinico, University of Milan. A total of 434 patients were included. The following variables were collected: sex, age, smoking habit, type of ARD, duration of treatment, route of administration, therapeutic indication, concurrent systemic therapies and pathologies. Statistical analysis confirmed the relevance of chemotherapy, smoking, and immunosuppressive drugs as risk factors. In addition, a higher frequency of MRONJ in osteoporotic patients was reported in our cohort in association with an immunodeficiency disorder of variable origin. In conclusion, the identification of individual risk-profile before dental treatments is crucial for prevention. Anamnesis should include main risk factors, such as immunosuppression, dental extractions, smoking, trauma, and poor dental health. Nevertheless, our suggestion for dental professionals is to conduct a complete medical history of patients who mention long-term per oral therapies with ARDs for osteoporosis. Osteoporotic, as well as cancer patients, may also benefit from periodic monitoring of the ARDs therapy in order to prevent MRONJ.
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Anastasilakis AD, Pepe J, Napoli N, Palermo A, Magopoulos C, Khan AA, Zillikens MC, Body JJ. Osteonecrosis of the Jaw and Antiresorptive Agents in Benign and Malignant Diseases: A Critical Review Organized by the ECTS. J Clin Endocrinol Metab 2022; 107:1441-1460. [PMID: 34922381 PMCID: PMC9016445 DOI: 10.1210/clinem/dgab888] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Indexed: 11/19/2022]
Abstract
CONTEXT Antiresorptive therapy significantly reduces fracture risk in patients with benign bone disease and skeletal-related events (SREs) in patients with bone metastases (BM). Osteonecrosis of the jaw (ONJ) is a rare but severe condition manifested as necrotic bone lesion or lesions of the jaws. ONJ has been linked to the use of potent antiresorptive agents, termed medication-related ONJ (MRONJ). OBJECTIVE We aimed to identify the differences various aspects of MRONJ among distinct patient categories and provide recommendations on how to mitigate the risk and optimally manage MRONJ in each of them. METHODS A working group of the European Calcified Tissue Society (ECTS) and 2 experts performed an updated detailed review of existing literature on MRONJ incidence, characteristics, and treatment applied in bone diseases with variable severity of skeletal insult, ranging from osteoporosis to prevention of cancer treatment-induced bone loss and SREs in cancer patients with BM. RESULTS The risk for MRONJ is much higher in patients with advanced malignancies compared to those with benign bone diseases because of the higher doses and more frequent administration of antiresorptive agents in individuals with compromised general health, along with coadministration of other medications that predispose to MRONJ. The overall risk for MRONJ is considerably lower than the benefits in all categories of patients. CONCLUSION The risk for MRONJ largely depends on the underlying bone disease and the relevant antiresorptive regimen applied. Physicians and dentists should keep in mind that the benefits of antiresorptive therapy far outweigh the risk for MRONJ development.
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Affiliation(s)
- Athanasios D Anastasilakis
- Department of Endocrinology, 424 General Military Hospital, 564 29 N Efkarpia Thessaloniki, Greece
- Correspondence: Athanasios D. Anastasilakis, PhD, Department of Endocrinology, 424 General Military Hospital, Ring Rd, 564 29 N Efkarpia, Thessaloniki, Greece.
| | - Jessica Pepe
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, “Sapienza” University of Rome, 00185 Rome, Italy
| | - Nicola Napoli
- Unit of Endocrinology and Diabetes, Departmental Faculty of Medicine and Surgery, Campus Bio-Medico University of Rome, 00128 Rome, Italy
| | - Andrea Palermo
- Unit of Endocrinology and Diabetes, Departmental Faculty of Medicine and Surgery, Campus Bio-Medico University of Rome, 00128 Rome, Italy
| | - Christos Magopoulos
- Department of Oral and Maxillofacial Surgery, 424 General Military Hospital, 56429 Thessaloniki, Greece
| | - Aliya A Khan
- Division of Endocrinology and Metabolism and Geriatrics, McMaster University, L8N3Z5 Hamilton, Ontario, Canada
| | - M Carola Zillikens
- Bone Center, Department of Internal Medicine, Erasmus MC, 2040 Rotterdam, the Netherlands
| | - Jean-Jacques Body
- Department of Medicine, CHU Brugmann, Université Libre de Bruxelles, 1050 Brussels, Belgium
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Hu Y, Lu C, Lin H. Concurrence of osteonecrosis and steroid myopathy secondary to oral steroid therapy in a patient with ABCB1 gene polymorphisms: A case report. Front Endocrinol (Lausanne) 2022; 13:1016687. [PMID: 36277691 PMCID: PMC9585659 DOI: 10.3389/fendo.2022.1016687] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Accepted: 09/26/2022] [Indexed: 11/19/2022] Open
Abstract
Glucocorticoids (GCs) are widely used in various autoimmune diseases. Side effects may occur in patients with long-term or high-dose GC usage. Among them, steroid myopathy and osteonecrosis are two severe forms. We report a patient with pemphigus vulgaris on GC-treatment who developed muscle weakness when a cumulative dose of methylprednisolone reached about 20g (14-80mg/d for 2.5 years). Laboratory tests showed slightly elevated lactate dehydrogenase and hydroxybutyrate dehydrogenase. MRI revealed osteonecrosis in the femoral head, distal femur, and proximal tibia of both legs. The biopsy of the right quadriceps revealed atrophy of type II myofiber without leukocyte infiltration, which was suggestive of steroid myopathy. Genotyping of the patient showed 5G/5G genotype of the PAI-1 gene and CC genotype of the ABCB1 gene (C3435T), suggesting she was sensitive to GCs. The patient's lesions were considered to be GC-induced adverse events, which were improved with tapering GC. Therefore, it is important to recognize steroid-induced musculoskeletal side effects and genotyping favors personalized medication.
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LIMA-SOUZA RAD, LEONEL ACLDS, DUARTE ÂLBP, CASTRO JFLD, CARVALHO EJDA, PEREZ DEDC. Awareness of patients receiving bisphosphonates: a cross-sectional study. Braz Oral Res 2022; 36:e0126. [DOI: 10.1590/1807-3107bor-2022.vol36.0126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2011] [Accepted: 06/02/2022] [Indexed: 11/13/2022] Open
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AlRowis R, Aldawood A, AlOtaibi M, Alnasser E, AlSaif I, Aljaber A, Natto Z. Medication-Related Osteonecrosis of the Jaw (MRONJ): A Review of Pathophysiology, Risk Factors, Preventive Measures and Treatment Strategies. Saudi Dent J 2022; 34:202-210. [PMID: 35935720 PMCID: PMC9346931 DOI: 10.1016/j.sdentj.2022.01.003] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Revised: 01/03/2022] [Accepted: 01/12/2022] [Indexed: 12/05/2022] Open
Abstract
Medication-related osteonecrosis of the jaw (MRONJ) is a major problem that can occur in people taking certain medications such bisphosphonates and denosumab. It can be used to treat osteoporosis or cancer. Bisphosphonate exposure, dental diseases and procedures, age, sex, anatomical factors, medical issues, and hereditary factors are all variables that enhance the risk of MRONJ. Even though MRONJ and antiresorptive medications have a close association, the pathophysiology of MRONJ is unknown. Careful dental preparation and oral hygiene instructions significantly minimize the risk of osteonecrosis of the jaw (ONJ). It is ideal to start antiresorptive treatment after the completion of required dental treatment; it is not contraindicated and carries low risk in patients who are on oral antiresorptive medications for less than three years. Drug holidays are one proposed solution to address MRONJ. However, there is still inadequate evidence to support their effectiveness. The objectives of this literature review are to recognize the main diagnostic principles and risk factors and to review the pathophysiology, protective procedures and treatment modalities related to MRONJ. The following topics are covered in the review: epidemiology, diagnostic criteria, risk factors, pathogenesis and mechanism, MRONJ staging and symptoms, clinical and radiographic findings, treatment strategies, prevention and drug holiday.
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Affiliation(s)
- Raed AlRowis
- Department of Periodontics and Community Dentistry, College of Dentistry, King Saud University, Saudi Arabia
| | | | | | - Essam Alnasser
- Intern. College of Dentistry, King Saud University, Saudi Arabia
| | - Ibrahim AlSaif
- Intern. College of Dentistry, King Saud University, Saudi Arabia
| | - Abdullah Aljaber
- Intern. College of Dentistry, King Saud University, Saudi Arabia
| | - Zuhair Natto
- Department of Dental Public Health, School of Dentistry, King Abdulaziz University, Jeddah, Kingdom of Saudi Arabia
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Kim JW, Kwak MK, Han JJ, Lee ST, Kim HY, Kim SH, Jung J, Lee JK, Lee YK, Kwon YD, Kim DY. Medication Related Osteonecrosis of the Jaw: 2021 Position Statement of the Korean Society for Bone and Mineral Research and the Korean Association of Oral and Maxillofacial Surgeons. J Bone Metab 2021; 28:279-296. [PMID: 34905675 PMCID: PMC8671025 DOI: 10.11005/jbm.2021.28.4.279] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Accepted: 11/15/2021] [Indexed: 12/27/2022] Open
Abstract
Antiresorptives are the most widely prescribed drugs for the treatment of osteoporosis. They are also used in malignant bone metastases, multiple myeloma, and Paget's disease, and provide therapeutic efficacy on those diseases. However, it was reported that the occurrence of osteonecrosis of the jaw (ONJ) could be related to antiresorptive exposures, and there have been many cases regarding this issue. Therefore, a clearer definition and treatment guidelines were needed for this disease. The American Society for Bone and Mineral Research and the Amnerican Association of Oral and Maxillofacial Surgeons reported statements on bisphosphonate-related ONJ (BRONJ), and a revised version was recently presented. In the revised edition, the diagnosis BRONJ was changed to medication-related ONJ (MRONJ), which reflects consideration of the fact that ONJ also occurs for denosumab, a bone resorption inhibitor of the receptor activator of the nuclear factor-κB ligand antibody family, and bevacizumab, an anti-angiogenesis inhibitor. The Korean Society for Bone and Mineral Research and the Korean Association of Oral and Maxillofacial Surgeons had collectively formed a task force for the preparation of an official statement on MRONJ based on a previous position paper in 2015. The task force reviewed current knowledge and coordinated dental and medical opinions to propose the guideline customized for the local Korean situation.
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Affiliation(s)
- Jin-Woo Kim
- Department of Oral and Maxillofacial Surgery, School of Medicine, Ewha Womans University, Seoul, Korea
| | - Mi Kyung Kwak
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Hallym University Dongtan Sacred Heart Hospital, Hwaseong, Korea
| | - Jeong Joon Han
- Department of Oral and Maxillofacial Surgery, School of Dentistry, Dental Research Institute, Seoul National University, Seoul, Korea
| | - Sung-Tak Lee
- Department of Oral and Maxillofacial Surgery, School of Dentistry, Kyungpook National University, Daegu, Korea
| | - Ha Young Kim
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Gangneung Asan Hospital, University of Ulsan College of Medicine, Gangneung, Korea
| | - Se Hwa Kim
- Division of Endocrinology and Metabolism, Department of Internal Medicine, International St. Mary's Hospital, Catholic Kwandong University College of Medicine, Incheon, Korea
| | - Junho Jung
- Department of Oral and Maxillofacial Surgery, School of Dentistry, Kyung Hee University, Seoul, Korea
| | - Jeong Keun Lee
- Department of Oral and Maxillofacial Surgery, Institute of Oral Health Science, Ajou University Dental Hospital, Ajou University School of Medicine, Suwon, Korea
| | - Young-Kyun Lee
- Department of Orthopaedic Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Yong-Dae Kwon
- Department of Oral and Maxillofacial Surgery, School of Dentistry, Kyung Hee University, Seoul, Korea
| | - Deog-Yoon Kim
- Department of Nuclear Medicine, Kyung Hee University Hospital, Kyung Hee University School of Medicine, Seoul, Korea
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Ikesue H, Doi K, Morimoto M, Hirabatake M, Muroi N, Yamamoto S, Takenobu T, Hashida T. Risk evaluation of denosumab and zoledronic acid for medication-related osteonecrosis of the jaw in patients with bone metastases: a propensity score-matched analysis. Support Care Cancer 2021; 30:2341-2348. [PMID: 34738163 PMCID: PMC8794983 DOI: 10.1007/s00520-021-06634-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Accepted: 10/16/2021] [Indexed: 11/30/2022]
Abstract
PURPOSE This study evaluated the risk of medication-related osteonecrosis of the jaw (MRONJ) in patients with cancer who received denosumab or zoledronic acid (ZA) for treating bone metastasis. METHODS The medical records of patients were retrospectively reviewed. Patients who did not undergo a dental examination at baseline were excluded. The primary endpoint was a comparison of the risk of developing MRONJ between the denosumab and ZA groups. Propensity score matching was used to control for baseline differences between patient characteristics and compare outcomes for both groups. RESULTS Among the 799 patients enrolled, 58 (7.3%) developed MRONJ. The incidence of MRONJ was significantly higher in the denosumab group than in the ZA group (9.6% [39/406] vs. 4.8% [19/393], p = 0.009). Multivariate Cox proportional hazards regression analysis revealed that denosumab treatment (hazard ratio [HR], 2.89; 95% confidence interval [CI], 1.65-5.25; p < 0.001) and tooth extraction after starting ZA or denosumab (HR, 4.26; 95% CI, 2.38-7.44; p < 0.001) were significant risk factors for MRONJ. Propensity score-matched analysis confirmed that the risk of developing MRONJ was significantly higher in the denosumab group than in the ZA group (HR, 2.34; 95% CI, 1.17-5.01; p = 0.016). CONCLUSION The results of this study suggest that denosumab poses a significant risk for developing MRONJ in patients treated for bone metastasis, and thus these patients require close monitoring.
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Affiliation(s)
- Hiroaki Ikesue
- Department of Pharmacy, Kobe City Medical Center General Hospital, 2-1-1 Minatojima-Minamimachi, Chuo-ku, Kobe, Hyogo, 650-0047, Japan.
| | - Kohei Doi
- Department of Pharmacy, Kobe City Medical Center General Hospital, 2-1-1 Minatojima-Minamimachi, Chuo-ku, Kobe, Hyogo, 650-0047, Japan
| | - Mayu Morimoto
- Department of Pharmacy, Kobe City Medical Center General Hospital, 2-1-1 Minatojima-Minamimachi, Chuo-ku, Kobe, Hyogo, 650-0047, Japan
| | - Masaki Hirabatake
- Department of Pharmacy, Kobe City Medical Center General Hospital, 2-1-1 Minatojima-Minamimachi, Chuo-ku, Kobe, Hyogo, 650-0047, Japan
| | - Nobuyuki Muroi
- Department of Pharmacy, Kobe City Medical Center General Hospital, 2-1-1 Minatojima-Minamimachi, Chuo-ku, Kobe, Hyogo, 650-0047, Japan
| | - Shinsuke Yamamoto
- Department of Oral and Maxillofacial Surgery, Kobe City Medical Center General Hospital, 2-1-1 Minatojima-Minamimachi, Chuo-ku, Kobe, Hyogo, 650-0047, Japan
| | - Toshihiko Takenobu
- Department of Oral and Maxillofacial Surgery, Kobe City Medical Center General Hospital, 2-1-1 Minatojima-Minamimachi, Chuo-ku, Kobe, Hyogo, 650-0047, Japan
| | - Tohru Hashida
- Department of Pharmacy, Kobe City Medical Center General Hospital, 2-1-1 Minatojima-Minamimachi, Chuo-ku, Kobe, Hyogo, 650-0047, Japan
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Treatment of Glucocorticoid-Induced Osteoporosis and Risk Factors for New Vertebral Fractures in Female Patients with Autoimmune Diseases. J Osteoporos 2021; 2021:5515653. [PMID: 34733465 PMCID: PMC8560280 DOI: 10.1155/2021/5515653] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Accepted: 10/16/2021] [Indexed: 11/18/2022] Open
Abstract
We aimed to evaluate the compliance of physicians with the 2014 guidelines of the Japanese Society for Bone and Mineral Research, for the prevention and treatment of glucocorticoid (GC) induced osteoporosis (GIO) and to investigate the risk of fracture and other associated risk factors in bisphosphonate-treated patients. We evaluated 90 female patients with nonrheumatoid arthritis autoimmune diseases who received long-term GC treatment (≥12 months). Clinical characteristics, including age, GC dose, history of fragility fractures, osteoporosis treatments, as well as lumbar (L2-L4) and femoral neck bone mineral density, were collected from the patients' medical charts. New vertebral fractures during the study period were evaluated using thoracic and lumbar spine radiographs by quantitative measurements. The GIO score was calculated for each patient according to 2014 Japanese guidelines. Of the 90 patients evaluated, 60 were indicated for osteoporosis treatment, based on the 2014 guidelines of Japan. We observed a high compliance rate, with 93% of patients receiving osteoporosis treatment and 50% receiving bisphosphonates. In total, eight patients developed new vertebral fractures during the study, six of whom received bisphosphonates. In bisphosphonate-treated patients, fracture risk was associated with GC treatment and a lack of active vitamin D3 supplementation. The compliance rate with the updated Japanese 2014 guidelines at our institution was very high. Large randomized controlled trials are needed to confirm our findings that suggest that active vitamin D3 should be used in combination with bisphosphonates for the treatment of GIO to reduce fracture risk.
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Bacci C, Cerrato A, Bardhi E, Frigo AC, Djaballah SA, Sivolella S. A retrospective study on the incidence of medication-related osteonecrosis of the jaws (MRONJ) associated with different preventive dental care modalities. Support Care Cancer 2021; 30:1723-1729. [PMID: 34580783 PMCID: PMC8727393 DOI: 10.1007/s00520-021-06587-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Accepted: 09/21/2021] [Indexed: 12/03/2022]
Abstract
Purpose To assess the efficacy of different preventive dental visits and treatments in reducing the risk of medication-related osteonecrosis of the jaws (MRONJ). Methods In this retrospective study, patients diagnosed with MRONJ were divided into 5 groups based on available data: no preventive dental visits (group 0); dental visits and compliance with recommended treatments, at the university hospital’s dental clinic (group 1) or maxillofacial surgery unit (group 2), or at a private dentist’s (group 3); dental visits at one of the above and noncompliance with proposed treatments (group 4); patients judged eligible by the oncologist on panoramic radiography (group 5). Patients were classified on severity of MRONJ according to the Italian SIPMO/SICMF 2.0 staging system. A descriptive analysis was performed on the results. Fisher’s exact test was applied (p < 0.05). Results Ninety-three patients diagnosed with MRONJ were considered for the study, but 22 were excluded due to a lack of data, leaving a sample of 71 cases. MRONJ staging was only 0 for some patients (26.92%) in group 0. In all groups, the majority of patients had stage 2 MRONJ. The proportions of cases in stage 3 were 7.69% in group 0, 18.18% in group 3, and 43.48% in group 5. Groups 0 and 3 were somewhat similar as regard MRONJ staging. Most patients in group 5 had MRONJ stage 2 or 3. No statistically significant differences emerged between the groups. Conclusions Preventive dental care can reduce the risk of MRONJ providing patients comply with the specialist’s recommendations.
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Affiliation(s)
- Christian Bacci
- Section of Clinical Dentistry, Department of Neurosciences, University of Padova, Via Giustiniani, 1, 35128, Padua, Italy.
| | - Alessia Cerrato
- Section of Clinical Dentistry, Department of Neurosciences, University of Padova, Via Giustiniani, 1, 35128, Padua, Italy
| | - Elisa Bardhi
- Section of Clinical Dentistry, Department of Neurosciences, University of Padova, Via Giustiniani, 1, 35128, Padua, Italy
| | - Anna Chiara Frigo
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, Padua, Italy
| | | | - Stefano Sivolella
- Section of Clinical Dentistry, Department of Neurosciences, University of Padova, Via Giustiniani, 1, 35128, Padua, Italy
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Lu H, Pundole X, Lee HC. The role of bone-modifying agents in myeloma bone disease. JBMR Plus 2021; 5:e10518. [PMID: 34368608 PMCID: PMC8328802 DOI: 10.1002/jbm4.10518] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Revised: 05/13/2021] [Accepted: 05/19/2021] [Indexed: 01/23/2023] Open
Abstract
Bone disease is common in patients with multiple myeloma (MM), which manifests as bone pain and skeletal-related events (SREs) such as pathological fractures and spinal cord compression. Myeloma bone disease (MBD) can adversely affect the quality of life of patients and have negative effects on morbidity and mortality. The pathogenesis of MBD is complex, and several factors are involved in the dysregulation of bone metabolism and uncoupling of bone remodeling, which result in net bone loss and devastating SREs. Broadly speaking, elevated osteoclast activity, suppressed osteoblast activity, and an aberrant marrow microenvironment play a role in MBD. Interaction of MM cells with the main bone cell osteocytes also promote further bone destruction. This review focuses on the role of bone-modifying agents in the prevention and treatment of MBD. The mainstay of MBD prevention are antiresorptive agents, bisphosphonates and denosumab. However, these agents do not play a direct role in bone formation and repair of existing MBD. Newer agents with anabolic effects such as anti-sclerostin antibodies, parathyroid hormone, anti-Dickkopf-1 antibodies, and others have shown potential in repair of MBD lesions. With the development of several new agents, the treatment landscape of MBD is likely to evolve in the coming years. © 2021 The Authors. JBMR Plus published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research.
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Affiliation(s)
- Huifang Lu
- Department of General Internal Medicine Section of Rheumatology and Clinical Immunology Houston Texas USA
| | - Xerxes Pundole
- Department of Health Services Research The University of Texas MD Anderson Cancer Center Houston Texas USA.,Present address: Amgen Inc. Thousand Oaks CA USA
| | - Hans C Lee
- Department of Lymphoma/Myeloma The University of Texas MD Anderson Cancer Center Houston Texas USA
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Ikesue H, Mouri M, Tomita H, Hirabatake M, Ikemura M, Muroi N, Yamamoto S, Takenobu T, Tomii K, Kawakita M, Katoh H, Ishikawa T, Yasui H, Hashida T. Associated characteristics and treatment outcomes of medication-related osteonecrosis of the jaw in patients receiving denosumab or zoledronic acid for bone metastases. Support Care Cancer 2021; 29:4763-4772. [PMID: 33527228 PMCID: PMC8236436 DOI: 10.1007/s00520-021-06018-x] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Accepted: 01/19/2021] [Indexed: 12/13/2022]
Abstract
Purpose This study aimed to evaluate the association between clinical characteristics and development of medication-related osteonecrosis of the jaw (MRONJ) in patients who underwent dental examinations before the initiation of treatment with denosumab or zoledronic acid, which are bone-modifying agents (BMAs), for bone metastases. Additionally, the clinical outcomes of patients who developed MRONJ were evaluated along with the time to resolution of MRONJ. Methods The medical charts of patients with cancer who received denosumab or zoledronic acid for bone metastases between January 2012 and September 2016 were retrospectively reviewed. Patients were excluded if they did not undergo a dental examination at baseline. Results Among the 374 included patients, 34 (9.1%) developed MRONJ. The incidence of MRONJ was significantly higher in the denosumab group than in the zoledronic acid (27/215 [12.6%] vs 7/159 [4.4%], P = 0.006) group. Multivariate Cox proportional hazards regression analysis revealed that denosumab treatment, older age, and tooth extraction before and after starting BMA treatments were significantly associated with developing MRONJ. The time to resolution of MRONJ was significantly shorter for patients who received denosumab (median 26.8 months) than for those who received zoledronic acid (median not reached; P = 0.024). Conclusion The results of this study suggest that treatment with denosumab, age > 65 years, and tooth extraction before and after starting BMA treatments are significantly associated with developing MRONJ in patients undergoing treatment for bone metastases. However, MRONJ caused by denosumab resolves faster than that caused by zoledronic acid.
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Affiliation(s)
- Hiroaki Ikesue
- Department of Pharmacy, Kobe City Medical Center General Hospital, 2-2-1, Minatojima-Minamimachi, Chuo-ku, Kobe, 650-0047, Japan.
- Graduate School of Pharmaceutical Sciences, Kobe Gakuin University, 1-1-3 Minatojima, Chuo-ku, Kobe, 650-8586, Japan.
| | - Moe Mouri
- Department of Pharmacy, Kobe City Medical Center General Hospital, 2-2-1, Minatojima-Minamimachi, Chuo-ku, Kobe, 650-0047, Japan
- Department of Pharmacy, Kishiwada City Hospital, 1001, Gakuhara-cho, Kishiwada-shi, Osaka, 596-8501, Japan
| | - Hideaki Tomita
- Department of Pharmacy, Kobe City Medical Center General Hospital, 2-2-1, Minatojima-Minamimachi, Chuo-ku, Kobe, 650-0047, Japan
| | - Masaki Hirabatake
- Department of Pharmacy, Kobe City Medical Center General Hospital, 2-2-1, Minatojima-Minamimachi, Chuo-ku, Kobe, 650-0047, Japan
| | - Mai Ikemura
- Division of Education and Research Promotion for Clinical Pharmacy, Faculty of Pharmaceutical Sciences, Kobe Gakuin University, 1-1-3 Minatojima, Chuo-ku, Kobe, 650-8586, Japan
| | - Nobuyuki Muroi
- Department of Pharmacy, Kobe City Medical Center General Hospital, 2-2-1, Minatojima-Minamimachi, Chuo-ku, Kobe, 650-0047, Japan
- Graduate School of Pharmaceutical Sciences, Kobe Gakuin University, 1-1-3 Minatojima, Chuo-ku, Kobe, 650-8586, Japan
| | - Shinsuke Yamamoto
- Department of Oral and Maxillofacial Surgery, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Toshihiko Takenobu
- Department of Oral and Maxillofacial Surgery, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Keisuke Tomii
- Department of Respiratory Medicine, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Mutsushi Kawakita
- Department of Urology, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Hironori Katoh
- Department of Breast Surgery, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Takayuki Ishikawa
- Department of Hematology, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Hisateru Yasui
- Department of Medical Oncology, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Tohru Hashida
- Department of Pharmacy, Kobe City Medical Center General Hospital, 2-2-1, Minatojima-Minamimachi, Chuo-ku, Kobe, 650-0047, Japan
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Kim SH, Lee YK, Kim TY, Ha YC, Jang S, Kim HY. Incidence of and risk for osteonecrosis of the jaw in Korean osteoporosis patients treated with bisphosphonates: A nationwide cohort-study. Bone 2021; 143:115650. [PMID: 32956854 DOI: 10.1016/j.bone.2020.115650] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Revised: 09/09/2020] [Accepted: 09/11/2020] [Indexed: 12/29/2022]
Abstract
PURPOSE To estimate the incidence of osteonecrosis of the jaw (ONJ) in patients treated with bisphosphonates (BPs) and to identify clinical risk factors that increase the risk for ONJ in Korean osteoporosis patients. METHODS We used data acquired from the Korean National Health Insurance Service. Among 2,140,149 participants with osteoporosis in 2012, we selected 164,926 new BP users and 164,926 age- and sex-matched control subjects. The control group included only patients with no prescriptions for BPs between January 1, 2011, and December 31, 2016. Participants were followed for 4 years. RESULTS Over the 4-year follow-up period, the cumulative incidence rates of ONJ were 20.9 and 6.9 per 100,000 person-years in the BP and control groups, respectively. The BP group had an increased risk for ONJ compared to the control group after adjusting for multiple variables (hazard ratio [HR] 3.72, 95% CI 2.70-5.11). Advanced age (≥70 years), comorbid diseases such as diabetes, hypertension, and rheumatoid arthritis (RA) were independent risk factors for the development of ONJ. In addition, tooth extraction (HR 9.85), gingivitis, and periodontal disease (HR 4.78) were strongly associated with ONJ. CONCLUSIONS ONJ incidence was 21 per 100,000 person-years in osteoporosis patients receiving bisphosphonates. Clinical factors including advanced age, diabetes, RA, dental disease, as well as BP use were significantly associated with ONJ.
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Affiliation(s)
- Se Hwa Kim
- Department of Internal Medicine, Catholic Kwandong University College of Medicine, International St. Mary's Hospital, Incheon, Republic of Korea
| | - Young-Kyun Lee
- Department of Orthopaedic Surgery, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Tae-Young Kim
- Department of Orthopaedic Surgery, School of Medicine, Konkuk University, Seoul, Republic of Korea
| | - Yong-Chan Ha
- Department of- Orthopaedic Surgery, College of Medicine, Chung-Ang University, Seoul, Republic of Korea
| | - Sunmee Jang
- College of Pharmacy and Gachon Institute of Pharmaceutical Sciences, Gachon University, Incheon, Republic of Korea
| | - Ha Young Kim
- Department of Internal Medicine, Wonkwang University College of Medicine, Sanbon Hospital, Gunpo, Republic of Korea.
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Abstract
PURPOSE OF REVIEW We aim to critically review recent recommendations regarding preventative strategies for glucocorticoid-induced osteoporosis and provide a summary of key evidence regarding available interventions. RECENT FINDINGS Lifestyle optimization remains the hallmark of bone health preservation. Early initiation of anti-osteoporotic agents in the setting of glucocorticoid exposure is essential, guided by appropriate risk stratification. Recommendations for calcium and vitamin D intake optimization are well-supported across all risk strata. Bisphosphonates are the mainstay of pharmacological therapy. Newer agents such as denosumab and teriparatide have demonstrated comparative benefit in terms of incident fracture risk reduction and bone mineral density preservation, with comparable adverse events. With due consideration to cost, resource availability, and patient values and preferences, these agents may warrant use as the first-line agents in this setting. Glucocorticoid-induced osteoporosis remains preventable and warrants early and targeted evidence-based therapy.
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Affiliation(s)
- Arnav Agarwal
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Jonathan D Adachi
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada.
- Division of Rheumatology, Department of Medicine, McMaster University, 501-25 Charlton Ave E, Hamilton, ON, L8N 1Y2, Canada.
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21
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Influence of prostate cancer status on the prevalence of medication-related osteonecrosis of the jaw. Oral Surg Oral Med Oral Pathol Oral Radiol 2020; 131:312-318. [PMID: 33431343 DOI: 10.1016/j.oooo.2020.12.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Revised: 12/20/2020] [Accepted: 12/21/2020] [Indexed: 12/24/2022]
Abstract
OBJECTIVE The aim of this study was to evaluate the risk of osteonecrosis of the jaw (ONJ) in patients with prostate cancer, particularly the relationship between prostate cancer progression and ONJ development. STUDY DESIGN This single-center, retrospective, observational study included 113 patients who received zoledronic acid or denosumab for prostate cancer with bone metastasis between January 2012 and March 2020. The risk of ONJ was evaluated regarding age; antiresorptive drugs; duration of antiresorptive treatment; prostate cancer status, including castration-resistant prostate cancer (CRPC) and prostate-specific antigen level; chemotherapy; radium-223 treatment; corticosteroid treatment; diabetes mellitus; and dental extractions. RESULTS Overall, 28 patients had ONJ; 10 patients received zoledronic acid and 18 patients received denosumab. Multiple logistic regression analysis demonstrated that CRPC (odds ratio = 6.01; 95% confidence interval, 1.76-20.05; P = .004) and dental extractions (odds ratio = 12.40; 95% confidence interval, 3.42-44.70; P < .001) were significantly associated with ONJ. In addition, antiresorptive treatment lasting more than 1 year partially mediated between CRPC and development of ONJ. CONCLUSION CRPC and dental extraction are risk factors for developing ONJ, and antiresorptive treatment lasting more than 1 year is a partial mediator between CRPC and ONJ.
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Okamura M, Fujita K, Yamamoto Y, Kanai O, Nakatani K, Horimoto K, Hashimoto M, Sawai S, Shimosato M, Yoshida K, Mio T. Single-center analysis of antiresorptive agent-related osteonecrosis of the jaw in lung cancer patients. Asia Pac J Clin Oncol 2020; 16:380-384. [PMID: 32893984 DOI: 10.1111/ajco.13395] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Accepted: 05/14/2020] [Indexed: 11/27/2022]
Abstract
BACKGROUND Over the past two decades, antiresorptive agent-related osteonecrosis of the jaw (ARONJ) has become a growing concern. We examined the incidence of ARONJ and identified its risk factors in lung cancer patients in the real-world clinical setting. To our knowledge, we are the first to do so. PATIENTS AND METHODS We retrospectively analyzed lung cancer patients with bone metastases who had received anti-resorptive agents (zoledronate or denosumab) at the National Hospital Organization Kyoto Medical Center from October 2012 to September 2018. All ARONJ cases were diagnosed by the dentists according to the established diagnostic criteria. RESULTS A total of 171 patients were reviewed, 13 (7.6%) of whom experienced ARONJ. Among the 13 patients, six (46.2%), four (30.8%) and three (23.1%) had adenocarcinoma, squamous carcinoma and not otherwise specified, respectively. ARONJ was stage 2 in three (23.1%) patients and stage 3 in 10 (76.9%). More cycles of antiresorptive agents (odds ratio [OR] = 11.54; 95% confidence interval [CI], 2.47-53.99; P < 0.01), use of immune checkpoint inhibitors (ICIs; OR = 5.05; 95% CI, 1.56-16.37; P < 0.01) and longer survival duration (≥2 years; OR = 12.16; 95% CI, 3.17-46.65; P < 0.01) were independently associated with ARONJ in a multivariate analysis. CONCLUSIONS The incidence of ARONJ was relatively high in lung cancer patients with bone metastases. When using antiresorptive agents, oncologists should closely monitor patients for ARONJ during the course of treatment and regularly consult with dentists, especially in patients receiving ICIs.
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Affiliation(s)
- Misato Okamura
- Division of Respiratory Medicine, Center for Respiratory Diseases, National Hospital Organization Kyoto Medical Center, Kyoto, Japan
| | - Kohei Fujita
- Division of Respiratory Medicine, Center for Respiratory Diseases, National Hospital Organization Kyoto Medical Center, Kyoto, Japan
| | - Yuki Yamamoto
- Division of Respiratory Medicine, Center for Respiratory Diseases, National Hospital Organization Kyoto Medical Center, Kyoto, Japan.,Department of Drug Discovery for Lung Diseases, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Osamu Kanai
- Division of Respiratory Medicine, Center for Respiratory Diseases, National Hospital Organization Kyoto Medical Center, Kyoto, Japan
| | - Koichi Nakatani
- Division of Respiratory Medicine, Center for Respiratory Diseases, National Hospital Organization Kyoto Medical Center, Kyoto, Japan
| | - Kanna Horimoto
- Division of Thoracic Surgery, Center for Respiratory Diseases, National Hospital Organization Kyoto Medical Center, Kyoto, Japan
| | - Masayuki Hashimoto
- Division of Thoracic Surgery, Center for Respiratory Diseases, National Hospital Organization Kyoto Medical Center, Kyoto, Japan
| | - Satoru Sawai
- Division of Thoracic Surgery, Center for Respiratory Diseases, National Hospital Organization Kyoto Medical Center, Kyoto, Japan
| | - Maiko Shimosato
- Department of Oral and Maxillofacial Surgery, National Hospital Organization Kyoto Medical Center, Kyoto, Japan
| | - Kazuya Yoshida
- Department of Oral and Maxillofacial Surgery, National Hospital Organization Kyoto Medical Center, Kyoto, Japan
| | - Tadashi Mio
- Division of Respiratory Medicine, Center for Respiratory Diseases, National Hospital Organization Kyoto Medical Center, Kyoto, Japan
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23
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Lesclous P, Cloitre A, Catros S, Devoize L, Louvet B, Châtel C, Foissac F, Roux C. Alendronate or Zoledronic acid do not impair wound healing after tooth extraction in postmenopausal women with osteoporosis. Bone 2020; 137:115412. [PMID: 32404281 DOI: 10.1016/j.bone.2020.115412] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Revised: 04/29/2020] [Accepted: 05/07/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND Bisphosphonates (BPs) are widely used for the prevention or treatment of osteoporosis. One of the most serious complications associated with BPs is medication-related osteonecrosis of the jaw (MRONJ) but its incidence in patients with osteoporosis is very low ranging from 0.001-0.15%. A major predisposing factor for MRONJ is tooth extraction (TE). Controversies persist about the influence of current BP therapy regarding socket healing after TE. The aims of this study were to investigate prospectively, (i) alveolar bone healing, i.e., filling of the bony socket by new bone and (ii) mucosal healing, i.e., closure of the overlying mucosa, after TE in women receiving current BP therapy for the prevention or the treatment of postmenopausal osteoporosis. METHODS Women with osteoporosis under current treatment with BPs (BP+ group) or other anti-osteoporotic medications (BP- group) undergoing single TE were included in this study. No antibiotic prophylaxis was prescribed solely for the BP therapy, but antibiotic treatment may have been required for local infectious conditions. Chlorohexidine mouthwashes were systematically prescribed in all study patients for one week after TE. New bone height (NBH) and rate of socket filling (RSF) were recorded using intraoral standardized radiographs one month and 3 months after TE (T30 and T90 respectively). The closure of the overlying mucosa was assessed by measuring the wound extent with an electronic caliper at 1 week and at 1 month after TE (T7 and T30 respectively). RESULTS At T30, NBH was not statistically different between the BP+ and BP- groups (p = .76). At T90, more than a two-fold in NBH increase was recorded for both groups with no statistically significant difference between them (p = .76). At T30 and T90, RSF was similar in both groups (p = .58 and p = .32 respectively). More than a two-fold RSF increase was founded between T30 and T90 in both groups. No demographic or BPs-related factors were correlated with the RSF at T90. At T7, the mucosa wound extent was reduced by more than two-fold with no statistically significant difference between both groups (p = .80). At this time, mucosa healing was achieved in 11.9% of the BP+ group and 10% of the BP- group (p = .99). At T30, mucosal healing was achieved in all patients but two, and at T90 it was achieved in all patients. CONCLUSION This study provides new insights into bone and mucosal healing in patients with osteoporosis taking BPs after TE. In this population, TE can be managed successfully with an appropriate surgical protocol and without discontinuation of BP treatment.
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Affiliation(s)
- Philippe Lesclous
- Inserm, UMR 1229, RMeS, Regenerative Medicine and Skeleton, Université de Nantes, UFR Odontologie, CHU de Nantes, Unité Fonctionnelle de Chirurgie Orale, PHU4 OTONN, ONIRIS, Nantes F-44042, France.
| | - Alexandra Cloitre
- Inserm, UMR 1229, RMeS, Regenerative Medicine and Skeleton, Université de Nantes, UFR Odontologie, CHU de Nantes, Unité Fonctionnelle de Chirurgie Orale, PHU4 OTONN, ONIRIS, Nantes F-44042, France
| | - Sylvain Catros
- Inserm, UMR 1026, BioTis, Tissue Bioengineering, Service de Chirurgie Orale, Université de Bordeaux, UFR Odontologie, CHU de Bordeaux, F-33076, France
| | - Laurent Devoize
- Université Clermont Auvergne, Neuro-Dol BP 10448, Clermont-Ferrand & Inserm U1107, F-63001 Clermont Ferrand, France
| | | | - Cécile Châtel
- Service de Chirurgie Plastique et Maxillo-Faciale, CHU Grenoble, Grenoble F-38000, France
| | | | - Christian Roux
- Inserm UMR 1153 Clinical epidemiology and biostatistics, Université Paris Descartes, PRES Sorbone Paris-Cité Service de Rhumatologie-Hôpital Cochin, AP -HP centre, Université de Paris, Paris, France
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24
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Chotiyarnwong P, McCloskey EV. Pathogenesis of glucocorticoid-induced osteoporosis and options for treatment. Nat Rev Endocrinol 2020; 16:437-447. [PMID: 32286516 DOI: 10.1038/s41574-020-0341-0] [Citation(s) in RCA: 208] [Impact Index Per Article: 52.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/24/2020] [Indexed: 12/31/2022]
Abstract
Glucocorticoids are widely used to suppress inflammation or the immune system. High doses and long-term use of glucocorticoids lead to an important and common iatrogenic complication, glucocorticoid-induced osteoporosis, in a substantial proportion of patients. Glucocorticoids mainly increase bone resorption during the initial phase (the first year of treatment) by enhancing the differentiation and maturation of osteoclasts. Glucocorticoids also inhibit osteoblastogenesis and promote apoptosis of osteoblasts and osteocytes, resulting in decreased bone formation during long-term use. Several indirect effects of glucocorticoids on bone metabolism, such as suppression of production of insulin-like growth factor 1 or growth hormone, are involved in the pathogenesis of glucocorticoid-induced osteoporosis. Fracture risk assessment for all patients with long-term use of oral glucocorticoids is required. Non-pharmacological interventions to manage the risk of fracture should be prescribed to all patients, while pharmacological management is reserved for patients who have increased fracture risk. Various treatment options can be used, ranging from bisphosphonates to denosumab, as well as teriparatide. Finally, appropriate monitoring during treatment is also important.
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Affiliation(s)
- Pojchong Chotiyarnwong
- Department of Orthopaedic Surgery, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
- Academic Unit of Bone Metabolism, Department of Oncology and Metabolism, The Mellanby Centre For Bone Research, University of Sheffield, Sheffield, UK
| | - Eugene V McCloskey
- Academic Unit of Bone Metabolism, Department of Oncology and Metabolism, The Mellanby Centre For Bone Research, University of Sheffield, Sheffield, UK.
- Centre for Metabolic Diseases, University of Sheffield Medical School, Beech Hill Road, Sheffield, UK.
- Centre for Integrated Research into Musculoskeletal Ageing, University of Sheffield Medical School, Sheffield, UK.
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25
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Song M. Dental care for patients taking antiresorptive drugs: a literature review. Restor Dent Endod 2019; 44:e42. [PMID: 31799170 PMCID: PMC6875544 DOI: 10.5395/rde.2019.44.e42] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2019] [Revised: 10/04/2019] [Accepted: 10/09/2019] [Indexed: 12/13/2022] Open
Abstract
Antiresorptive drugs (ARDs), such as bisphosphonates or denosumab, that prevent bone resorption are widely used in patients with osteoporosis or with cancer that has metastasized to the bones. Although osteonecrosis of the jaw (ONJ) is a well-documented complication of ARD use, the benefits ARDs outweigh the complication. Thus, research has focused on finding ways to prevent or reduce the risk of developing ONJ. Dentists, as part of a multi-professional team, have a critical role in preventing ONJ. However, many dentists tend to hesitate to provide dental care to patients with ONJ, or tend to think that it is a problem to be dealt with by oral surgeons. This review gives an overview of ARD-related ONJ and provides the guidelines for dental care in patients taking ARDs to lower the risk of developing ONJ.
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Affiliation(s)
- Minju Song
- Department of Conservative Dentistry, College of Dentistry, Dankook University, Cheonan, Korea
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26
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McGowan K, Ware RS, Acton C, Ivanovski S, Johnson NW. Full blood counts are not predictive of the risk of medication-related osteonecrosis of the jaws: a case-control study. Oral Surg Oral Med Oral Pathol Oral Radiol 2019; 128:373-380. [DOI: 10.1016/j.oooo.2019.04.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2019] [Revised: 04/01/2019] [Accepted: 04/08/2019] [Indexed: 11/25/2022]
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27
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Souza Tolentino E, Castro TF, Michellon FC, Passoni ACC, Ortega LJA, Iwaki LCV, Silva MC. Adjuvant therapies in the management of medication‐related osteonecrosis of the jaws: Systematic review. Head Neck 2019; 41:4209-4228. [DOI: 10.1002/hed.25944] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2019] [Revised: 06/26/2019] [Accepted: 08/15/2019] [Indexed: 11/12/2022] Open
Affiliation(s)
| | - Tamara F. Castro
- Oral Oncology CenterSão Paulo State University (Unesp), School of Dentistry, Araçatuba, São Paulo, Brazil
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28
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Yarom N, Shapiro CL, Peterson DE, Van Poznak CH, Bohlke K, Ruggiero SL, Migliorati CA, Khan A, Morrison A, Anderson H, Murphy BA, Alston-Johnson D, Mendes RA, Beadle BM, Jensen SB, Saunders DP. Medication-Related Osteonecrosis of the Jaw: MASCC/ISOO/ASCO Clinical Practice Guideline. J Clin Oncol 2019; 37:2270-2290. [PMID: 31329513 DOI: 10.1200/jco.19.01186] [Citation(s) in RCA: 177] [Impact Index Per Article: 35.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE To provide guidance regarding best practices in the prevention and management of medication-related osteonecrosis of the jaw (MRONJ) in patients with cancer. METHODS Multinational Association of Supportive Care in Cancer/International Society of Oral Oncology (MASCC/ISOO) and ASCO convened a multidisciplinary Expert Panel to evaluate the evidence and formulate recommendations. Guideline development involved a systematic review of the literature and a formal consensus process. PubMed and EMBASE were searched for studies of the prevention and management of MRONJ related to bone-modifying agents (BMAs) for oncologic indications published between January 2009 and December 2017. Results from an earlier systematic review (2003 to 2008) were also included. RESULTS The systematic review identified 132 publications, only 10 of which were randomized controlled trials. Recommendations underwent two rounds of consensus voting. RECOMMENDATIONS Currently, MRONJ is defined by (1) current or previous treatment with a BMA or angiogenic inhibitor, (2) exposed bone or bone that can be probed through an intraoral or extraoral fistula in the maxillofacial region and that has persisted for longer than 8 weeks, and (3) no history of radiation therapy to the jaws or metastatic disease to the jaws. In patients who initiate a BMA, preventive care includes comprehensive dental assessments, discussion of modifiable risk factors, and avoidance of elective dentoalveolar surgery (ie, surgery that involves the teeth or contiguous alveolar bone) during BMA treatment. It remains uncertain whether BMAs should be discontinued before dentoalveolar surgery. Staging of MRONJ should be performed by a clinician with experience in the management of MRONJ. Conservative measures comprise the initial approach to MRONJ treatment. Ongoing collaboration among the dentist, dental specialist, and oncologist is essential to optimal patient care.
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Affiliation(s)
- Noam Yarom
- Sheba Medical Center, Tel Hashomer, Ramat Gan, Israel.,Tel Aviv University, Tel Aviv, Israel
| | | | | | | | - Kari Bohlke
- American Society of Clinical Oncology, Alexandria, VA
| | - Salvatore L Ruggiero
- Hofstra North Shore-LIJ School of Medicine, Hempstead, NY.,Stony Brook School of Dental Medicine, Stony Brook, NY.,New York Center for Orthognathic and Maxillofacial Surgery, New York, NY
| | | | - Aliya Khan
- McMaster University, Hamilton, Ontario, Canada
| | - Archie Morrison
- Dalhousie University, Halifax, Nova Scotia, Canada.,Queen Elizabeth II Health Sciences Centre, Halifax, Nova Scotia, Canada
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29
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Gkouveris I, Hadaya D, Soundia A, Bezouglaia O, Chau Y, Dry SM, Pirih FQ, Aghaloo TL, Tetradis S. Vasculature submucosal changes at early stages of osteonecrosis of the jaw (ONJ). Bone 2019; 123:234-245. [PMID: 30953717 PMCID: PMC6763394 DOI: 10.1016/j.bone.2019.03.031] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2018] [Revised: 03/16/2019] [Accepted: 03/22/2019] [Indexed: 02/09/2023]
Abstract
Osteonecrosis of the jaw (ONJ), a rare, but potentially severe side effect of anti-resorptive medications, presents as exposed bone in the maxillofacial region lasting for at least 8 weeks. While clinical experience and animal models concur in finding that systemic antiresorptive treatment in conjunction with local risk factors, such as tooth extraction or dental disease may lead to ONJ development, the subclinical molecular changes that precede bone exposure remain poorly understood. The identification of these changes is not only important in understanding disease pathophysiology, but could provide potential for treatment development. Here, we evaluated the early stages of ONJ utilizing a model of experimental periodontitis (EP) in mice treated with two different types of antiresorptives, targeting potential changes in vasculature, hypoxia, oxidative stress, and apoptosis. Antiresorptive treatment in animals with EP increased levels of empty osteocytic lacunae and increased ONJ prevalence compared to Veh animals. The arteriole and venule network seen around EP areas was diminished in animals treated with antiresorptives. Higher levels of vascular endothelial growth factor A (VEGF-A) and vascular cell adhesion protein-1 (VCAM-1) were observed 1-week following EP in treated animals. Finally, levels of hypoxia, oxidative stress, and apoptosis remained high in antiresorptive treated animals with EP through the duration of the experiment. Together, our data point to subclinical vasculature organizational disturbances that subsequently affect levels of hypoxia, oxidative stress, and apoptosis in the area of developing ONJ.
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Affiliation(s)
- Ioannis Gkouveris
- Division of Diagnostic and Surgical Sciences, UCLA School of Dentistry, Los Angeles, CA 90095, USA
| | - Danny Hadaya
- Division of Diagnostic and Surgical Sciences, UCLA School of Dentistry, Los Angeles, CA 90095, USA
| | - Akrivoula Soundia
- Division of Diagnostic and Surgical Sciences, UCLA School of Dentistry, Los Angeles, CA 90095, USA
| | - Olga Bezouglaia
- Division of Diagnostic and Surgical Sciences, UCLA School of Dentistry, Los Angeles, CA 90095, USA
| | - Yee Chau
- Division of Diagnostic and Surgical Sciences, UCLA School of Dentistry, Los Angeles, CA 90095, USA
| | - Sarah M Dry
- Department of Pathology and Laboratory Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA 90095, USA
| | - Flavia Q Pirih
- Division of Constitutive and Regenerative Sciences, UCLA School of Dentistry, Los Angeles, CA 90095, USA
| | - Tara L Aghaloo
- Division of Diagnostic and Surgical Sciences, UCLA School of Dentistry, Los Angeles, CA 90095, USA.
| | - Sotirios Tetradis
- Division of Diagnostic and Surgical Sciences, UCLA School of Dentistry, Los Angeles, CA 90095, USA.
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30
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Veszelyné Kotán E, Bartha-Lieb T, Parisek Z, Meskó A, Vaszilkó M, Hankó B. Database analysis of the risk factors of bisphosphonate-related osteonecrosis of the jaw in Hungarian patients. BMJ Open 2019; 9:e025600. [PMID: 31122970 PMCID: PMC6537976 DOI: 10.1136/bmjopen-2018-025600] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
OBJECTIVE Bisphosphonate-related osteonecrosis of the jaw (BRONJ) is a rare but serious side effect of bisphosphonates (BPs). Since this disease has no independent code in either of the diseases' or in the medical procedures' classifications, it is hard to estimate how many BP patients are affected. DESIGN A retrospective observational epidemiological registry-based study was carried out, using the data of the national service of Hungary on the incidence of BRONJ and related factors. SETTING A data analysis was performed, which is relevant for the whole Hungarian population from 2010 to 2014. The socioeconomic and medication data of 236 207 BP patients were analysed, and a method was worked out to define BRONJ patients from the Hungarian BP population. PRIMARY AND SECONDARY OUTCOME MEASURES The incidences of BRONJ were analysed according to genders and the types of the BP drugs administered. The marginal interdependence between the types of BP drugs, modes of administration and main indication was calculated. RESULTS 340 BP patients (0.1%) developed BRONJ. The incidence of BRONJ in Hungary in the malignant indication of BPs is 0.9%, and 0.1% in the non-malignant indication, and the OR to develop BRONJ was OR=9.7 (95% CI 7.8 to 12.1) between them. Although more women developed BRONJ, the proportion of men was significantly higher than that of women. Steroids increase the risk of jaw osteonecrosis, and differences were also found between the BP drugs. CONCLUSIONS Oncology indicated, intravenously administered and steroid comedicated BP therapies pose a high risk of developing BRONJ in the Hungarian population.
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Affiliation(s)
- Edit Veszelyné Kotán
- University Pharmacy Department of Pharmacy Administration, Semmelweis Egyetem Gyogyszeresztudomanyi Kar, Budapest, Hungary
| | - Tímea Bartha-Lieb
- Department of Information Technology, Allami Egeszsegugyi Ellato Kozpont, Budapest, Hungary
| | - Zsolt Parisek
- Department of Information Technology, Allami Egeszsegugyi Ellato Kozpont, Budapest, Hungary
| | - Attiláné Meskó
- University Pharmacy Department of Pharmacy Administration, Semmelweis Egyetem Gyogyszeresztudomanyi Kar, Budapest, Hungary
| | - Mihály Vaszilkó
- Department of Oro-Maxillofacial Surgery and Stomatology, Semmelweis University, Budapest, Hungary
| | - Balázs Hankó
- University Pharmacy Department of Pharmacy Administration, Semmelweis Egyetem Gyogyszeresztudomanyi Kar, Budapest, Hungary
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31
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Response to Comment-Osteonecrosis of the Jaw in Myeloma Patients Receiving Denosumab or Zoledronic Acid. Comment on Pivotal Trial by Raje et al. Published in Lancet Oncology. Dent J (Basel) 2019; 7:dj7020054. [PMID: 31100871 PMCID: PMC6631159 DOI: 10.3390/dj7020054] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2019] [Revised: 04/09/2019] [Accepted: 04/14/2019] [Indexed: 11/17/2022] Open
Abstract
We read the commentary by Fusco et al [...].
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32
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McGowan K, Ware RS, Acton C, Ivanovski S, Johnson NW. Both non-surgical dental treatment and extractions increase the risk of medication-related osteonecrosis of the jaw: case-control study. Clin Oral Investig 2019; 23:3967-3975. [DOI: 10.1007/s00784-019-02828-w] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Accepted: 01/17/2019] [Indexed: 01/25/2023]
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33
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Comorbid conditions are a risk for osteonecrosis of the jaw unrelated to antiresorptive therapy. Oral Surg Oral Med Oral Pathol Oral Radiol 2019; 127:140-150. [DOI: 10.1016/j.oooo.2018.09.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2018] [Revised: 08/23/2018] [Accepted: 09/23/2018] [Indexed: 02/06/2023]
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34
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Tamaoka J, Takaoka K, Hattori H, Ueta M, Maeda H, Yamamura M, Yamanegi K, Noguchi K, Kishimoto H. Osteonecrosis of the jaws caused by bisphosphonate treatment and oxidative stress in mice. Exp Ther Med 2018; 17:1440-1448. [PMID: 30680026 DOI: 10.3892/etm.2018.7076] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2018] [Accepted: 09/06/2018] [Indexed: 12/31/2022] Open
Abstract
Aging is a significant risk factor for the development of bisphosphonate-related osteonecrosis of the jaws (BRONJ). Accumulating evidence suggests that bone aging is associated with oxidative stress (OS), and OS is associated with osteonecrosis. To elucidate the mechanisms of the onset of BRONJ, the present study focused on OS and the effects of treatment with the pro-oxidant DL-buthionine-(S,R)-sulfoximine (BSO), an oxidative stressor, on healing of a surgically induced penetrating injury of the palate. Six-week-old C57BL/6J mice were randomly divided into four groups (n=5 each) and treated with or without zoledronic acid (ZOL) and with or without BSO (experimental groups: ZOL, BSO, and ZOL+BSO; control group: saline solution). A penetrating injury of the midline palate was surgically created using a root elevator. ZOL (250 µg/kg/day) was injected intraperitoneally every day from 7 days prior to the surgical treatment to 4 days following the surgical treatment. BSO (500 µg/kg/day) was administered 7 days prior to the surgical treatment as a single intraperitoneal injection. The maxillae were harvested at 5 days following the surgical treatment for histological and histochemical studies. The presence of empty osteocyte lacunae in the palatal bone was increased by ZOL and BSO treatment. The highest number of empty osteocyte lacunae was observed in the ZOL+BSO group. The number of tartrate-resistant acid phosphatase-positive cells was decreased by ZOL treatment and increased by BSO treatment. The number of canaliculi per osteocyte lacuna was significantly decreased by BSO treatment. The mineral apposition rate was significantly lower in the treatment groups than the control group. Bisphosphonates and OS suppressed bone turnover. The present study has demonstrated that BSO treatment affects osteocytes, and OS in osteocytes exacerbates impairment of the osteocytic canalicular networks. As a result, bisphosphonates and OS may induce osteonecrosis following invasive dentoalveolar surgery. OS has been identified as an additional risk factor for the development of BRONJ.
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Affiliation(s)
- Joji Tamaoka
- Department of Oral and Maxillofacial Surgery, Hyogo College of Medicine, Nishinomiya, Hyogo 663-8501, Japan
| | - Kazuki Takaoka
- Department of Oral and Maxillofacial Surgery, Hyogo College of Medicine, Nishinomiya, Hyogo 663-8501, Japan
| | - Hirokazu Hattori
- Department of Oral and Maxillofacial Surgery, Hyogo College of Medicine, Nishinomiya, Hyogo 663-8501, Japan
| | - Miho Ueta
- Department of Oral and Maxillofacial Surgery, Hyogo College of Medicine, Nishinomiya, Hyogo 663-8501, Japan
| | - Hanako Maeda
- Department of Oral and Maxillofacial Surgery, Hyogo College of Medicine, Nishinomiya, Hyogo 663-8501, Japan
| | - Michiyo Yamamura
- Department of Oral and Maxillofacial Surgery, Hyogo College of Medicine, Nishinomiya, Hyogo 663-8501, Japan
| | - Koji Yamanegi
- Department of Pathology, Hyogo College of Medicine, Nishinomiya, Hyogo 663-8501, Japan
| | - Kazuma Noguchi
- Department of Oral and Maxillofacial Surgery, Hyogo College of Medicine, Nishinomiya, Hyogo 663-8501, Japan
| | - Hiromitsu Kishimoto
- Department of Oral and Maxillofacial Surgery, Hyogo College of Medicine, Nishinomiya, Hyogo 663-8501, Japan
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35
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Dutra KL, Haas LF, Zimmermann GS, Melo G, Minamisako MC, Flores-Mir C, Corrêa M. Prevalence of radiographic findings on jaws exposed to antiresorptive therapy: a meta-analysis. Dentomaxillofac Radiol 2018; 48:20180112. [PMID: 30346802 DOI: 10.1259/dmfr.20180112] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
OBJECTIVES: Determine the prevalence of radiographic findings (RF) on both jaws among patients receiving antiresorptive bone therapy. METHODS: Six electronic databases and partial grey literature were searched. Data was collected based on predetermined criteria. The key features from the included studies were extracted. The MAStARI tool assessed the potential risk of bias (RoB) among the studies, while the GRADE approach determined the level of evidence. RESULTS: 29 studies were identified and included in the qualitative analysis, totalling 1133 patients. 27 studies had sufficient data to be included in a series of meta-analysis reporting 12 types of radiographic findings, and were split in two groups based on their study design. G1 comprised descriptive observational studies and G2 analytical cross-sectional studies. Two studies presented a high RoB, 16 had a moderate RoB, and 11 had low RoB. The overall level of evidence identified was very low. The most frequent RF were mixed lytic-sclerotic areas (73.88%), followed by osteolytic changes (66.18%), osteosclerosis (65.75%), cortical bone erosion (50.83%), persisting alveolar socket (45.77%), periodontal ligament (PDL) widening (44.69%), and inferior alveolar canal (IAC) involvement (43.40%). Less frequent, but equally important, were the periosteal reaction (34.27%), lamina dura thickening (32.97%), sequestrum (29.94%), pathologic fracture (20.90%), and density confluence of cortical and cancellous bone (16.61%). 20 patients reported no signs. CONCLUSIONS: RF prevalence was high and mainly included mixed lytic-sclerotic areas, osteolysis, osteosclerosis, cortical bone erosion, persisting alveolar socket, PDL-widening, IAC-involvement. Due to the very low level of evidence (GRADE) caution should be exercised when considering these findings.
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Affiliation(s)
- Kamile Leonardi Dutra
- 1 School of Dentistry, Federal University of Santa Catarina , Florianópolis, Santa Catarina , Brazil
| | - Letícia Fernanda Haas
- 1 School of Dentistry, Federal University of Santa Catarina , Florianópolis, Santa Catarina , Brazil
| | - Glaucia S Zimmermann
- 2 Department of Dentistry, Federal University of Santa Catarina , Florianópolis, Santa Catarina , Brazil
| | - Gilberto Melo
- 1 School of Dentistry, Federal University of Santa Catarina , Florianópolis, Santa Catarina , Brazil
| | | | - Carlos Flores-Mir
- 4 School of Dentistry, Faculty of Medicine and Dentistry, University of Alberta , Edmonton, AB , Canada
| | - Márcio Corrêa
- 2 Department of Dentistry, Federal University of Santa Catarina , Florianópolis, Santa Catarina , Brazil
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36
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Wazzan T, Kashtwari D, Almaden WF, Gong Y, Chen Y, Moreb J, Katz J. Radiographic bone loss and the risk of medication-related osteonecrosis of the jaw (MRONJ) in multiple myeloma patients-A retrospective case control study. SPECIAL CARE IN DENTISTRY 2018; 38:356-361. [PMID: 30194738 DOI: 10.1111/scd.12318] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2018] [Revised: 07/03/2018] [Accepted: 07/10/2018] [Indexed: 02/06/2023]
Abstract
Risk factors for medication-related osteonecrosis of the jaws (MRONJ) include type and duration of antiresorptive drugs, dental trauma, local anatomy, systemic underlying conditions and therapy, smoking, and the presence of periodontal disease. However, there is a lack of studies elucidating the role of periodontal disease as risk predictor. In the present study, the dental charts of 100 multiple myeloma (MM) patients and 16 MM patients who developed MRONJ were studied. Information about age, gender, smoking history, diabetes, steroid drug intake, type and duration of bisphosphonate (BP) treatments, MRONJ status, missing teeth, periapical lesions, widening of the periodontal ligament, and periodontal status was collected. The periodontal status was determined as a percentage of missing bone at the mesial and distal surfaces of each tooth. Multivariable logistic regression was performed to identify risk factors associated with MRONJ. In the selected model, using the COX analysis, categorical bone loss percentage is significantly associated with MRONJ (P = 0.009), with hazard ratio 0.042 (high vs low) and 95% CI 0.004 to 0.453. Gender, steroid, Aredia BP type, and periapical are also significant in selected model. In conclusion, advanced alveolar bone loss and missing teeth were strongly related to the occurrence of MRONJ in MM patients.
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Affiliation(s)
- Taggreed Wazzan
- Department of Oral Diagnostic Sciences, University of Florida College of Dentistry, Gainesville, FL, USA.,Department of Pharmacotherapy and Translational Research, Gainesville, FL, USA
| | - Deeba Kashtwari
- Department of Oral Diagnostic Sciences, University of Florida College of Dentistry, Gainesville, FL, USA
| | - Wejood F Almaden
- Department of Oral Diagnostic Sciences, University of Florida College of Dentistry, Gainesville, FL, USA
| | - Yan Gong
- Department of Pharmacotherapy and Translational Research, Gainesville, FL, USA
| | - Yiqing Chen
- Department of Pharmacotherapy and Translational Research, Gainesville, FL, USA
| | - Jan Moreb
- Department of Medicine University of Florida College of Medicine, Gainesville, FL, USA
| | - Joseph Katz
- Department of Oral Diagnostic Sciences, University of Florida College of Dentistry, Gainesville, FL, USA
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37
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Otto S, Pautke C, Van den Wyngaert T, Niepel D, Schiødt M. Medication-related osteonecrosis of the jaw: Prevention, diagnosis and management in patients with cancer and bone metastases. Cancer Treat Rev 2018; 69:177-187. [PMID: 30055439 DOI: 10.1016/j.ctrv.2018.06.007] [Citation(s) in RCA: 148] [Impact Index Per Article: 24.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2018] [Revised: 06/13/2018] [Accepted: 06/14/2018] [Indexed: 01/12/2023]
Abstract
Medication-related osteonecrosis of the jaw (MRONJ) is primarily an adverse side effect of denosumab or bisphosphonates (particularly when used at high doses to prevent skeletal-related events [SREs] in patients with cancer and bone metastases) or possibly anti-angiogenic cancer treatment. While the implementation of preventive measures over recent years has reduced the risk of MRONJ in patients with bone metastases due to cancer, it is imperative to balance the risk of MRONJ against the beneficial effects of treatment with denosumab or bisphosphonates on the skeletal health of patients. Despite growing awareness of MRONJ within the medical community, there is a lack of large-scale, prospective clinical studies in this rapidly evolving field. Discussing preventive measures with patients and implementing them, both before and during treatment with bisphosphonates or denosumab, is the best option to reduce the risk of MRONJ. In particular, avoiding bone trauma and preventing and treating dental infections before and during denosumab or bisphosphonate therapy is crucial to minimize the risk of MRONJ. If MRONJ develops, conservative (non-surgical) treatment can provide symptom relief, but achieving mucosal closure remains challenging. When management of symptoms and mucosal healing are the ultimate goals of therapy, or after failure of conservative treatment, a surgical approach may be beneficial. This critical review, based on a best-evidence review of currently available literature, provides clear practical guidelines to help to prevent, manage and treat MRONJ. Overall, a multidisciplinary, pragmatic approach to MRONJ should be adopted, prioritizing patient's quality of life and management of their skeletal malignant disease.
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Affiliation(s)
- Sven Otto
- Department of Oral and Maxillofacial Surgery, Ludwig Maximilian University of Munich, Munich, Germany.
| | - Christoph Pautke
- Department of Oral and Maxillofacial Surgery, Ludwig Maximilian University of Munich, Munich, Germany.
| | - Tim Van den Wyngaert
- Department of Nuclear Medicine, Antwerp University Hospital, Antwerp, Belgium; Molecular Imaging Center Antwerp, University of Antwerp, Antwerp, Belgium.
| | | | - Morten Schiødt
- Department of Oral and Maxillofacial Surgery, Rigshospitalet, Copenhagen, Denmark.
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38
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Saad F, Sternberg CN, Mulders PFA, Niepel D, Tombal BF. The role of bisphosphonates or denosumab in light of the availability of new therapies for prostate cancer. Cancer Treat Rev 2018; 68:25-37. [PMID: 29787892 DOI: 10.1016/j.ctrv.2018.04.014] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2017] [Revised: 04/27/2018] [Accepted: 04/28/2018] [Indexed: 12/28/2022]
Abstract
Most men with advanced prostate cancer will develop bone metastases, which have a substantial impact on quality of life. Bone metastases can lead to skeletal-related events (SREs), which place a burden on patients and healthcare systems. For men with castration-resistant prostate cancer (CRPC) and bone metastases, the treatment landscape has evolved rapidly over the past few years. The relatively recent approvals of the hormonal agents abiraterone acetate and enzalutamide, second-line chemotherapy cabazitaxel, and the radiopharmaceutical radium-223 dichloride (radium-223), have provided clinicians with a greater choice of treatments. These compounds have benefits in terms of overall survival based on the results of pivotal phase 3 studies. The bisphosphonate zoledronic acid and the RANK ligand inhibitor denosumab are indicated for the prevention of SREs in men with metastatic CRPC but studies of these compounds have not demonstrated a survival benefit. The important question of the role of bisphosphonates or denosumab in combination with these new agents has thus materialised. Current and emerging evidence from clinical studies of abiraterone acetate, enzalutamide and radium-223, suggest that addition of bisphosphonates or denosumab to these new therapies may provide further clinical benefits for patients with prostate cancer and bone metastases. This evidence may help to shape clinical practice but are based largely on post hoc analyses of clinical trial data. It is therefore apparent that further data are required from both clinical studies and real-world settings to enable physicians to understand the efficacy and safety of combination therapy with the new agents plus bisphosphonates or denosumab.
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Affiliation(s)
- Fred Saad
- Division of Urology, Centre Hospitalier de l'Université de Montréal, Montréal, Québec, Canada
| | - Cora N Sternberg
- Department of Medical Oncology, San Camillo-Forlanini Hospital, Rome, Italy
| | | | | | - Bertrand F Tombal
- Service d'Urologie, Institut de Recherche Clinique, Université Catholique de Louvain, Brussels, Belgium.
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39
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Lee OL, Horvath N, Lee C, Joshua D, Ho J, Szer J, Quach H, Spencer A, Harrison S, Mollee P, Roberts AW, Talaulikar D, Brown R, Augustson B, Ling S, Jaksic W, Gibson J, Kalff A, Johnston A, Kalro A, Ward C, Prince HM, Zannettino A. Bisphosphonate guidelines for treatment and prevention of myeloma bone disease. Intern Med J 2018; 47:938-951. [PMID: 28782211 DOI: 10.1111/imj.13502] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2017] [Revised: 04/26/2017] [Accepted: 05/15/2017] [Indexed: 01/10/2023]
Abstract
Multiple myeloma (MM) is a haematological malignancy characterised by the clonal proliferation of plasma cells in the bone marrow. More than 80% of patients with MM display evidence of myeloma bone disease (MBD), characterised by the formation of osteolytic lesions throughout the axial and appendicular skeleton. MBD significantly increases the risk of skeletal-related events such as pathologic fracture, spinal cord compression and hypercalcaemia. MBD is the result of MM plasma cells-mediated activation of osteoclast activity and suppression of osteoblast activity. Bisphosphonates (BP), pyrophosphate analogues with high bone affinity, are the only pharmacological agents currently recommended for the treatment and prevention of MBD and remain the standard of care. Pamidronate and zoledronic acid are the most commonly used BP to treat MBD. Although generally safe, frequent high doses of BP are associated with adverse events such as renal toxicity and osteonecrosis of the jaw. As such, optimal duration and dosing of BP therapy is required in order to minimise BP-associated adverse events. The following guidelines provide currently available evidence for the adoption of a tailored approach when using BP for the management of MBD.
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Affiliation(s)
- Oi Lin Lee
- Department of Haematology, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Noemi Horvath
- Department of Haematology, Royal Adelaide Hospital, Adelaide, South Australia, Australia.,Medical and Scientific Advisory Group, Myeloma Australia, Melbourne, Victoria, Australia
| | - Cindy Lee
- Medical and Scientific Advisory Group, Myeloma Australia, Melbourne, Victoria, Australia.,Department of Haematology, Queen Elizabeth Hospital, Adelaide, South Australia, Australia
| | - Doug Joshua
- Medical and Scientific Advisory Group, Myeloma Australia, Melbourne, Victoria, Australia.,Department of Haematology, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.,Department of Cancer and Haematology, Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
| | - Joy Ho
- Medical and Scientific Advisory Group, Myeloma Australia, Melbourne, Victoria, Australia.,Department of Haematology, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.,Department of Cancer and Haematology, Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
| | - Jeff Szer
- Medical and Scientific Advisory Group, Myeloma Australia, Melbourne, Victoria, Australia.,Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Victoria, Australia.,Department of Clinical Haematology and BMT, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Hang Quach
- Medical and Scientific Advisory Group, Myeloma Australia, Melbourne, Victoria, Australia.,Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Victoria, Australia.,Department of Haematology, St Vincent's Hospital, Melbourne, Victoria, Australia
| | - Andrew Spencer
- Medical and Scientific Advisory Group, Myeloma Australia, Melbourne, Victoria, Australia.,Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Victoria, Australia.,Department of Haematology, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Simon Harrison
- Medical and Scientific Advisory Group, Myeloma Australia, Melbourne, Victoria, Australia.,Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Victoria, Australia.,Department of Haematology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Peter Mollee
- Medical and Scientific Advisory Group, Myeloma Australia, Melbourne, Victoria, Australia.,Department of Haematology, Princess Alexandra Hospital, Brisbane, Queensland, Australia.,School of Medicine, University of Queensland, Brisbane, Queensland, Australia
| | - Andrew W Roberts
- Medical and Scientific Advisory Group, Myeloma Australia, Melbourne, Victoria, Australia.,Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Victoria, Australia.,Department of Clinical Haematology and BMT, Royal Melbourne Hospital, Melbourne, Victoria, Australia.,Walter and Eliza Hall Institute of Medical Research, Melbourne, Victoria, Australia
| | - Dipti Talaulikar
- Medical and Scientific Advisory Group, Myeloma Australia, Melbourne, Victoria, Australia.,Department of Haematology, Canberra Hospital, Canberra, Australian Capital Territory, Australia.,College of Medicine, Biology and Environment, Australian National University, Canberra, Australian Capital Territory, Australia
| | - Ross Brown
- Medical and Scientific Advisory Group, Myeloma Australia, Melbourne, Victoria, Australia.,Department of Haematology, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Bradley Augustson
- Medical and Scientific Advisory Group, Myeloma Australia, Melbourne, Victoria, Australia.,Department of Haematology, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
| | - Silvia Ling
- Medical and Scientific Advisory Group, Myeloma Australia, Melbourne, Victoria, Australia.,Department of Haematology, Liverpool Hospital, Sydney, New South Wales, Australia.,South Western Sydney Clinical School, University of New South Wales, Sydney, New South Wales, Australia
| | - Wilfrid Jaksic
- Medical and Scientific Advisory Group, Myeloma Australia, Melbourne, Victoria, Australia.,Department of Haematology, Queen Elizabeth Hospital, Adelaide, South Australia, Australia
| | - John Gibson
- Medical and Scientific Advisory Group, Myeloma Australia, Melbourne, Victoria, Australia.,Department of Haematology, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.,Department of Cancer and Haematology, Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
| | - Anna Kalff
- Medical and Scientific Advisory Group, Myeloma Australia, Melbourne, Victoria, Australia.,Department of Haematology, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Anna Johnston
- Medical and Scientific Advisory Group, Myeloma Australia, Melbourne, Victoria, Australia.,Department of Haematology, Royal Hobart Hospital, Hobart, Tasmania, Australia.,Faculty of Health, University of Tasmania, Hobart, Tasmania, Australia
| | - Akash Kalro
- Medical and Scientific Advisory Group, Myeloma Australia, Melbourne, Victoria, Australia.,Department of Haematology, Royal Darwin Hospital, Darwin, Northern Territory, Australia
| | - Chris Ward
- Medical and Scientific Advisory Group, Myeloma Australia, Melbourne, Victoria, Australia.,Department of Cancer and Haematology, Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia.,Department of Medicine, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - H Miles Prince
- Medical and Scientific Advisory Group, Myeloma Australia, Melbourne, Victoria, Australia.,Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Victoria, Australia.,Department of Haematology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Andrew Zannettino
- Medical and Scientific Advisory Group, Myeloma Australia, Melbourne, Victoria, Australia.,Adelaide Medical School, Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, South Australia, Australia.,Cancer Theme, South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia
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40
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Favia G, Tempesta A, Limongelli L, Crincoli V, Iannone F, Lapadula G, Maiorano E. A Case of Osteonecrosis of the Jaw in a Patient with Crohn's Disease Treated with Infliximab. AMERICAN JOURNAL OF CASE REPORTS 2017; 18:1351-1356. [PMID: 29257800 PMCID: PMC5737229 DOI: 10.12659/ajcr.905355] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Affiliation(s)
- Gianfranco Favia
- Department of Interdisciplinary Medicine, Complex Operating Unit of Odontostomatology, "Aldo Moro" University, Bari, Italy
| | - Angela Tempesta
- Department of Interdisciplinary Medicine, Complex Operating Unit of Odontostomatology, "Aldo Moro" University, Bari, Italy
| | - Luisa Limongelli
- Department of Interdisciplinary Medicine, Complex Operating Unit of Odontostomatology, "Aldo Moro" University, Bari, Italy
| | - Vito Crincoli
- Department of Interdisciplinary Medicine, Complex Operating Unit of Odontostomatology, "Aldo Moro" University, Bari, Italy
| | - Florenzo Iannone
- Department of Emergency and Organ Transplantation, Operating Unit of Rheumatology, "Aldo Moro" University, Bari, Italy
| | - Giovanni Lapadula
- Department of Emergency and Organ Transplantation, Operating Unit of Rheumatology, "Aldo Moro" University, Bari, Italy
| | - Eugenio Maiorano
- Department of Emergency and Organ Transplantation, Operating Unit of Pathological Anatomy, "Aldo Moro" University, Bari, Italy
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41
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Albu-Stan IA, Albu DE, Cerghizan D, Eremie LY, Jánosi K, Baloș M, Copotoiu C. Medication-Related Osteonecrosis of the Jaw: a Brief Review, Treatment and Practical Guidelines for Dentists. JOURNAL OF INTERDISCIPLINARY MEDICINE 2017. [DOI: 10.1515/jim-2017-0046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Abstract
Osteonecrosis of the jaws is a complication after treatment with antiresorptive drugs. Bisphosphonates (BPs) are widely used to treat conditions with bone metastases of malignant tumors such as multiple myeloma, breast cancer, prostatic cancer, as well as hypercalcemia of malignancy, osteoporosis, Paget’s disease, and osteogenesis imperfecta. Denosumab is an antiresorptive agent that is used for the treatment of osteoporosis or metastatic bone diseases. These antiresorptive agents improve the quality of life of patients by increasing strength and bone mineral density, and reducing the risk of bone fractures. More than a decade had passed since the first publication of this pathology, and the occurrence of the disease, its pathophysiology, and proper treatment methods are still not fully elucidated. Prevention is critical in medication-related osteonecrosis of the jaw, because the treatment is difficult, and there are no universally accepted treatment protocols. There is an accepted approach of palliation of symptoms and controlling the associated infections. Treatment may follow one of three procedures: conservative management of pain, conservative or extensive (segmental) surgery, depending on the disease stage.
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Affiliation(s)
| | - Daniel-Emil Albu
- Department of Orthopedic Surgery and Traumatology I , County Emergency Clinical Hospital , Tîrgu Mureș , Romania
| | | | | | - Kinga Jánosi
- University of Medicine and Pharmacy , Tîrgu Mureș , Romania
| | - Monica Baloș
- University of Medicine and Pharmacy , Tîrgu Mureș , Romania
| | - Constantin Copotoiu
- Department of Surgery , University of Medicine and Pharmacy , Tîrgu Mureș , Romania
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42
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Abstract
Postmenopausal osteoporosis is associated with microarchitectural deterioration and increased risk of fracture. Osteoporosis therapy effectively reduces the risk of vertebral, nonvertebral, and hip fracture and has been associated with increased survival. Currently approved treatments for osteoporosis include bisphosphonates, denosumab, selective estrogen receptor modulators, and teriparatide. This article reviews the adverse events of therapy associated with these medical interventions. Hormone replacement therapy is not included, because it is no longer indicated for the treatment of osteoporosis in all countries. Calcitonin and strontium ranelate are also not included, because their indication for osteoporosis has recently been limited or withdrawn.
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Affiliation(s)
- Moin Khan
- McMaster University, 1200 Main Street West, Hamilton, ON L8N 3Z5, Canada
| | - Angela M Cheung
- University of Toronto, 200 Elizabeth Street, 7 Eaton North Room 221, Toronto, ON M5G 2C4, Canada
| | - Aliya A Khan
- McMaster University, 1200 Main Street West, Hamilton, ON L8N 3Z5, Canada.
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43
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Khan AA, Morrison A, Kendler DL, Rizzoli R, Hanley DA, Felsenberg D, McCauley LK, O'Ryan F, Reid IR, Ruggiero SL, Taguchi A, Tetradis S, Watts NB, Brandi ML, Peters E, Guise T, Eastell R, Cheung AM, Morin SN, Masri B, Cooper C, Morgan SL, Obermayer-Pietsch B, Langdahl BL, Dabagh RA, Davison KS, Sándor GK, Josse RG, Bhandari M, El Rabbany M, Pierroz DD, Sulimani R, Saunders DP, Brown JP, Compston J. Case-Based Review of Osteonecrosis of the Jaw (ONJ) and Application of the International Recommendations for Management From the International Task Force on ONJ. J Clin Densitom 2017; 20:8-24. [PMID: 27956123 DOI: 10.1016/j.jocd.2016.09.005] [Citation(s) in RCA: 138] [Impact Index Per Article: 19.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Osteonecrosis of the jaw (ONJ) has been associated with antiresorptive therapy in both oncology and osteoporosis patients. This debilitating condition is very rare and advances in diagnosis and management may now effectively reduce the risk of its development and offer valuable treatment options for affected patients. This paper provides a case-based review of ONJ and application of the International Task Force on ONJ (referred to as the "Task Force") recommendations for the diagnosis and management of ONJ. The Task Force was supported by 14 international societies and achieved consensus from representatives of these multidisciplinary societies on key issues pertaining to the diagnosis and management of ONJ. The frequency of ONJ in oncology patients receiving oncology doses of bisphosphonate (BP) or denosumab is estimated at 1%-15%, and the frequency in the osteoporosis patient population receiving much lower doses of BP or denosumab is estimated at 0.001%-0.01%. Although the diagnosis of ONJ is primarily clinical, imaging may be helpful in confirming the diagnosis and staging. In those with multiple risk factors for ONJ for whom major invasive oral surgery is being planned, interruption of BP or denosumab therapy (in cancer patients) is advised, if possible, before surgery, until the surgical site heals. Major oral surgery in this context could include multiple extractions if surgical extractions are required, not simple forceps extractions. ONJ development may be reduced by optimizing oral hygiene and postoperatively using topical and systemic antibiotics as appropriate. Periodontal disease should be managed before starting oncology doses of BP or denosumab. Local debridement may be successful in disease unresponsive to conservative therapy. Successful surgical intervention has been reported in those with stage 3 disease; less severe disease is best managed conservatively. Teriparatide may be helpful in healing ONJ lesions and may be considered in osteoporosis patients at a high fracture risk in the absence of contraindications. Resumption of BP or denosumab therapy following healing of ONJ lesions is recommended, and there have not been reports of subsequent local recurrence.
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Affiliation(s)
- Aliya A Khan
- Department of Medicine, Divisions of Endocrinology and Metabolism and Geriatrics, McMaster University, Hamilton, ON, Canada.
| | - Archie Morrison
- Division of Oral and Maxillofacial Surgery, Dalhousie University, Halifax, NS, Canada
| | - David L Kendler
- Department of Medicine, Division of Endocrinology, University of British Columbia, Vancouver, BC, Canada
| | - Rene Rizzoli
- Division of Bone Diseases, Geneva University Hospitals, Geneva, Switzerland
| | - David A Hanley
- Departments of Medicine, Community Health Sciences and Oncology, University of Calgary, Calgary, AB, Canada
| | - Dieter Felsenberg
- Centre of Muscle & Bone Research, Charité-University Medicine Berlin, Campus Benjamin Franklin, Free University & Humboldt University Berlin, Berlin, Germany
| | - Laurie K McCauley
- Department of Periodontics and Oral Medicine, University of Michigan School of Dentistry, Ann Arbor, MI, USA
| | - Felice O'Ryan
- Division of Maxillofacial Surgery, Kaiser Permanente Oakland Medical Center, Oakland, CA, USA
| | - Ian R Reid
- Department of Medicine, University of Auckland, Auckland, New Zealand
| | - Salvatore L Ruggiero
- Division of Oral and Maxillofacial Surgery, Hofstra North Shore-LIJ School of Medicine, Hempstead, NY, USA; Stony Brook School of Dental Medicine, Stony Brook, NY, USA; New York Center for Orthognathic and Maxillofacial Surgery, New York, NY, USA
| | - Akira Taguchi
- Department of Oral and Maxillofacial Radiology, School of Dentistry, Matsumoto Dental University, Shojiri, Japan
| | - Sotirios Tetradis
- Division of Diagnostic and Surgical Sciences, UCLA School of Dentistry, Los Angeles, CA, USA
| | - Nelson B Watts
- Mercy Health Osteoporosis and Bone Health Services, Cincinnati, OH, USA
| | - Maria Luisa Brandi
- Department of Surgery and Translational Medicine, University of Florence, Florence, Italy
| | - Edmund Peters
- Department of Dentistry, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Teresa Guise
- Department of Medicine, Division of Endocrinology at Indiana University, Indianapolis, IN, USA
| | - Richard Eastell
- Department of Human Metabolism, University of Sheffield, Sheffield, UK
| | - Angela M Cheung
- Department of Medicine, University of Toronto, Toronto, ON, Canada; Centre of Excellence in Skeletal Health Assessment, Joint Department of Medical Imaging, University Health Network (UHN), Toronto, ON, Canada; Mount Sinai Hospital, University of Toronto, Toronto, ON, Canada
| | - Suzanne N Morin
- Department of Medicine, McGill University, Montreal, QC, Canada
| | - Basel Masri
- Jordan Osteoporosis Center, Jordan Hospital & Medical Center, Amman, Jordan
| | - Cyrus Cooper
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton, UK; NIHR Nutrition Biomedical Research Centre, University of Southampton, Southampton, UK; NIHR Musculoskeletal Biomedical Research Unit, University of Oxford, Oxford, UK
| | - Sarah L Morgan
- Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham Osteoporosis Prevention and Treatment Clinic, Birmingham, AL, USA
| | - Barbara Obermayer-Pietsch
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Medical University Graz, Graz, Austria
| | - Bente L Langdahl
- Department of Endocrinology and Internal Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Rana Al Dabagh
- Faculty of Dentistry, University of Toronto, Toronto, Canada
| | - K Shawn Davison
- Department of Education, University of Victoria,Victoria, BC, Canada
| | - George K Sándor
- Department of Oral and Maxillofacial Surgery, Oulu University Hospital, University of Oulu, Oulu, Finland
| | - Robert G Josse
- Division of Endocrinology and Metabolism, University of Toronto, Toronto, ON, Canada
| | - Mohit Bhandari
- Division of Orthopaedic Surgery, Department of Surgery, Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON, Canada
| | | | | | - Riad Sulimani
- College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Deborah P Saunders
- Department of Dental Oncology, Northeast Cancer Centre/Health Science North, Sudbury, ON, Canada
| | - Jacques P Brown
- Rheumatology Division, CHU de Québec Research Centre, Laval University, Quebec City, QC, Canada
| | - Juliet Compston
- Department of Medicine, Cambridge Biomedical Campus, Cambridge, UK
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44
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Rugani P, Walter C, Kirnbauer B, Acham S, Begus-Nahrman Y, Jakse N. Prevalence of Medication-Related Osteonecrosis of the Jaw in Patients with Breast Cancer, Prostate Cancer, and Multiple Myeloma. Dent J (Basel) 2016; 4:E32. [PMID: 29563474 PMCID: PMC5806952 DOI: 10.3390/dj4040032] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2016] [Revised: 08/27/2016] [Accepted: 09/19/2016] [Indexed: 12/03/2022] Open
Abstract
Medication-related osteonecrosis of the jaw is a known side-effect of antiresorptive therapy in patients with malignant diseases. Nevertheless, the exact pathogenesis is still unknown and published prevalences show a significant range. The aim of the presented paper was to assess the prevalence of osteonecrosis (ONJ) in breast cancer, prostate cancer, and multiple myeloma patients receiving parenteral antiresorptive therapy. For this reason a PubMed search was performed and 69 matching articles comprising 29,437 patients were included in the analysis. Nine-hundred fifty-one cases of jaw necrosis were described. The overall ONJ-prevalence was 2.09% in the breast cancer group, 3.8% in the prostate cancer group, and 5.16% for multiple myeloma patients.
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Affiliation(s)
- Petra Rugani
- Divison of Oral Surgery and Orthodontics, Medical University of Graz, 8010 Graz, Austria.
| | - Christian Walter
- Oral and Maxillofacial Surgery of the Mediplus Clinic, 55128 Mainz, Germany.
| | - Barbara Kirnbauer
- Divison of Oral Surgery and Orthodontics, Medical University of Graz, 8010 Graz, Austria.
| | - Stephan Acham
- Divison of Oral Surgery and Orthodontics, Medical University of Graz, 8010 Graz, Austria.
| | | | - Norbert Jakse
- Divison of Oral Surgery and Orthodontics, Medical University of Graz, 8010 Graz, Austria.
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Legal liability in bisphosphonate-related osteonecrosis of the jaw. Br Dent J 2016; 217:273-8. [PMID: 25256983 DOI: 10.1038/sj.bdj.2014.806] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/10/2014] [Indexed: 02/08/2023]
Abstract
Bisphosphonate-related osteonecrosis of the jaw (BRONJ) is an adverse reaction that may occur in patients administered with bisphosphonates (BP). This condition can cause high morbidity and hinder quality of life. Its treatment is complex and often unsatisfactory, and prevention strategies may have limited effectiveness, if any. Thus, managing patients treated with BP may result in exposure of the practitioner to legal liability or malpractice claims: legal actions pursuant to BRONJ are reported to be underway on three continents. Nonetheless, the attribution of liability, if any, is a complex process requiring, on the basis of current knowledge, a robust and pragmatic approach to the facts, which must be identified from the point of view of the time, place and individuals involved. This means a comprehensive consideration of the sequence of actions from bisphosphonates prescription to BRONJ occurrence (as well as immediately after, and any action potentially related to its causation or worsening) is required in order to determine if a breach in informing, diagnosing, managing or referring the patient took place, as well as determining if the patient was compliant in attending to prescriptions and follow-up programmes.
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Neto T, Horta R, Balhau R, Coelho L, Silva P, Correia-Sá I, Silva Á. Resection and microvascular reconstruction of bisphosphonate-related osteonecrosis of the jaw: The role of microvascular reconstruction. Head Neck 2016; 38:1278-85. [PMID: 27159622 DOI: 10.1002/hed.24395] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2015] [Revised: 10/22/2015] [Accepted: 12/17/2015] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Current treatment guidelines caution against osseous reconstruction using free flap tissue to treat bisphosphonate-related osteonecrosis of the jaw (BRONJ). The primary rationale for this stance is the theoretical risk of nonunion and recurrence of disease within the reconstruction. Emerging evidence suggests that these theoretical risks may be overestimated. We performed a literature review of this procedure for the treatment of advanced BRONJ. We also present a new case report of resection and microvascular reconstruction in a 58-year-old man with stage III BRONJ. METHODS A MEDLINE search was performed to gather all reports of maxillary and mandibular reconstruction using free tissue flap transfer for BRONJ. Inclusion criteria were confirmed stage II or III BRONJ, free tissue transfer and reconstruction, and reported complications. Articles were excluded if they contained only local flap reconstruction, wound closure without reconstruction, or osteoradionecrosis. Outcomes from our case report were added to the analysis. RESULTS We identified 10 articles that met criteria. Adding our case, we identified 40 cases of free flap reconstruction. The rate of nonunion was 5% (2 of 40). Fistulas formed in 4 cases (10%). BRONJ recurred in 2 cases (5%). CONCLUSION Complication rates after free flap microvascular reconstruction in BRONJ seem acceptable. Nonunion is relatively rare and should not be the sole reason to recommend against free flap reconstruction. A randomized clinical trial would help clarify the role of this procedure in refractory BRONJ; however, we believe that segmental resection and microvascular reconstruction is a viable option in select cases of BRONJ. © 2016 Wiley Periodicals, Inc. Head Neck 38:1278-1285, 2016.
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Affiliation(s)
- Tiago Neto
- Maxillofacial Surgery Unit, Department of Plastic, Reconstructive, Aesthetic Surgery, Maxillofacial Surgery, and Burn Unit, Hospital São João, Porto, Portugal
| | - Ricardo Horta
- Department of Plastic, Reconstructive, Aesthetic Surgery, Maxillofacial Surgery, and Burn Unit, Hospital São João, Porto, Portugal.,Faculty of Medicine, University of Porto, Porto, Portugal
| | - Rui Balhau
- Maxillofacial Surgery Unit, Department of Plastic, Reconstructive, Aesthetic Surgery, Maxillofacial Surgery, and Burn Unit, Hospital São João, Porto, Portugal
| | - Lígia Coelho
- Maxillofacial Surgery Unit, Department of Plastic, Reconstructive, Aesthetic Surgery, Maxillofacial Surgery, and Burn Unit, Hospital São João, Porto, Portugal
| | - Pedro Silva
- Department of Plastic, Reconstructive, Aesthetic Surgery, Maxillofacial Surgery, and Burn Unit, Hospital São João, Porto, Portugal
| | - Inês Correia-Sá
- Department of Plastic, Reconstructive, Aesthetic Surgery, Maxillofacial Surgery, and Burn Unit, Hospital São João, Porto, Portugal.,Faculty of Medicine, University of Porto, Porto, Portugal
| | - Álvaro Silva
- Department of Plastic, Reconstructive, Aesthetic Surgery, Maxillofacial Surgery, and Burn Unit, Hospital São João, Porto, Portugal
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López-Delgado L, Riancho-Zarrabeitia L, Riancho JA. Genetic and acquired factors influencing the effectiveness and toxicity of drug therapy in osteoporosis. Expert Opin Drug Metab Toxicol 2016; 12:389-98. [DOI: 10.1517/17425255.2016.1154533] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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Kim KM, Rhee Y, Kwon YD, Kwon TG, Lee JK, Kim DY. Medication Related Osteonecrosis of the Jaw: 2015 Position Statement of the Korean Society for Bone and Mineral Research and the Korean Association of Oral and Maxillofacial Surgeons. J Bone Metab 2015; 22:151-65. [PMID: 26713306 PMCID: PMC4691589 DOI: 10.11005/jbm.2015.22.4.151] [Citation(s) in RCA: 49] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2015] [Revised: 11/29/2015] [Accepted: 11/30/2015] [Indexed: 12/28/2022] Open
Abstract
Bisphosphonates are the most widely prescribed drugs for the treatment of osteoporosis, and are also used in malignant bone metastases, multiple myeloma, and Paget's disease, and provide therapeutic efficacy on those diseases. However, it was reported that occurrence of osteonecrosis of the jaw (ONJ) could be related with bisphosphonate exposures, and there have been many cases regarding this issue. Therefore, a clearer definition and treatment guidelines were needed for this disease. The American Society for Bone and Mineral Research (ASBMR) and American Association of Oral and Maxillofacial Surgeons (AAOMS) reported statements on bisphosphonate-related ONJ (BRONJ), and a revised version was recently presented. In the revised edition, the diagnosis BRONJ was changed to medication-related ONJ (MRONJ), which reflects a consideration of the fact that ONJ also occurs for denosumab, a bone resorption inhibitor of the receptor activator of nuclear factor-kappa B ligand (RANKL) antibody family, and bevacizumab, an anti-angiogenesis inhibitor. In 2009, a statement on ONJ was also reported locally by a relevant organization, which has served as basis for clinical treatment in Korea. In addition to the new official stance of the AAOMS and ASBMR, with an increasing pool of ONJ clinical experience, a revised version of the 2009 local statement is needed. As such, the Korean Society for Bone and Mineral Research (KSBMR) and the Korean Association of Oral and Maxillofacial Surgeons (KAOMS) have collectively formed a committee for the preparation of an official statement on MRONJ, and have reviewed recent local and international data to propose guidelines customized for the local Korean situation.
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Affiliation(s)
- Kyoung Min Kim
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Yumie Rhee
- Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Yong-Dae Kwon
- Department of Oral and Maxillofacial Surgery, School of Dentistry, Kyung Hee University, Seoul, Korea
| | - Tae-Geon Kwon
- Department of Oral and Maxillofacial Surgery, School of Dentistry, Kyungpook National University, Daegu, Korea
| | - Jeong Keun Lee
- Division of Oral and Maxillofacial Surgery, Department of Dentistry, Ajou University School of Medicine, Suwon, Korea
| | - Deog-Yoon Kim
- Department of Nuclear Medicine, School of Medicine, Kyung Hee University, Seoul, Korea
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Shah NP, Katsarelis H, Pazianas M, Dhariwal DK. Periodontal disease, dental implants, extractions and medications related to osteonecrosis of the jaws. ACTA ACUST UNITED AC 2015; 42:878-80, 883-4, 887-89. [DOI: 10.12968/denu.2015.42.9.878] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Affiliation(s)
- Neha P Shah
- Specialty Dentist, Department of Oral Surgery, Guy's Hospital, London
| | - Helen Katsarelis
- Specialty Registrar, Department of Oral and Maxillofacial Surgery, Royal County Surrey Hospital Surrey
| | - Michael Pazianas
- Visiting Scholar, Institute of Musculoskeletal Sciences, Oxford University, Oxford
| | - Daljit K Dhariwal
- Consultant, Department of Oral and Maxillofacial Surgery, John Radcliffe Hospital, Oxford, UK
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Aghaloo T, Hazboun R, Tetradis S. Pathophysiology of Osteonecrosis of the Jaws. Oral Maxillofac Surg Clin North Am 2015; 27:489-96. [PMID: 26412796 DOI: 10.1016/j.coms.2015.06.001] [Citation(s) in RCA: 106] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Osteonecrosis of the jaw (ONJ) is a multifactorial disease in patients with primary or metastatic bone malignancy or osteoporosis undergoing systemic antiresorptive therapy, where pathophysiology has not yet been fully determined. The staging of ONJ is based on severity of symptoms and extent of clinical and radiographic findings. Treatment strategies range from conservative local wound care to aggressive resective surgery of all necrotic bone. The first ONJ cases were reported in 2003 and 2004, and although significant progress has been made in our understanding of the disease, much more work needs to be done to completely explain its pathophysiology.
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Affiliation(s)
- Tara Aghaloo
- Section of Oral and Maxillofacial Surgery, Division of Diagnostic and Surgical Sciences, UCLA School of Dentistry, 10833 Le Conte Ave., Los Angeles, CA 90095-1668, USA.
| | - Renna Hazboun
- Section of Special Patient Care, Division of Advanced Prosthodontics and Section of Restorative Dentistry, Division of Regenerative and Constitutive Sciences, UCLA School of Dentistry, 10833 Le Conte Ave., Los Angeles, CA 90095-1668, USA
| | - Sotirios Tetradis
- Section of Oral and Maxillofacial Radiology, Division of Diagnostic and Surgical Sciences, UCLA School of Dentistry, 10833 Le Conte Ave., Los Angeles, CA 90095-1668, USA; Molecular Biology Institute, UCLA, Los Angeles, CA 90095, USA
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