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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Shrestha Khatri N, Stuckey BGA. Vertebral fractures after denosumab discontinuation for dental procedures: a consequence of distorted perceptions of risk. Med J Aust 2022; 216:283-284. [DOI: 10.5694/mja2.51460] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Revised: 07/06/2021] [Accepted: 07/30/2021] [Indexed: 11/17/2022]
Affiliation(s)
- Nely Shrestha Khatri
- Keogh Institute for Medical Research Perth WA
- Sir Charles Gairdner Hospital Perth WA
| | - Bronwyn GA Stuckey
- Keogh Institute for Medical Research Perth WA
- Sir Charles Gairdner Hospital Perth WA
- University of Western Australia Perth WA
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Zandi M, Dehghan A, Najafi A, Kamyari N, Abbasi S. Effect of teriparatide on healing of mandibular condylar osteochondral defects: a preclinical study. Br J Oral Maxillofac Surg 2022; 60:1068-1073. [DOI: 10.1016/j.bjoms.2022.02.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2021] [Revised: 02/01/2022] [Accepted: 02/18/2022] [Indexed: 11/28/2022]
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Ikeda H, Yoshiga D, Kokabu S, Ariyoshi W, Tsurushima H, Sakaguchi O, Tanaka J, Kaneko J, Habu M, Sasaguri M, Jimi E, Nishihara T, Yoshioka I, Tominaga K. Evaluation of therapeutic effects of teriparatide in a rat model of zoledronic acid-induced bisphosphonate-related osteonecrosis. Journal of Oral and Maxillofacial Surgery, Medicine, and Pathology 2019; 31:333-41. [DOI: 10.1016/j.ajoms.2019.03.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Zandi M, Dehghan A, Zandipoor N, Amini P, Doulati S. Effect of different doses and durations of teriparatide therapy on resolution of medication-related osteonecrosis of the jaw: A randomized, controlled preclinical study in rats. J Craniomaxillofac Surg 2018; 46:466-72. [DOI: 10.1016/j.jcms.2017.12.027] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2017] [Revised: 12/08/2017] [Accepted: 12/21/2017] [Indexed: 11/18/2022] Open
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Abstract
Osteonecrosis of the jaw (ONJ) is a severe complication of therapy with antiresorptive agents (e.g. bisphosphonates and denosumab), which are used to manage bone metastases from cancer, to reduce the incidence of skeletal-related events. Available data indicate that 0-27, 5% of patients exposed to antiresorptive agents may develop ONJ, depending on the number of infusions and the duration of therapy. Besides antiresorptive therapy, a number of risk factors for osteonecrosis have been identified. Oral surgical procedures, tooth extractions and infection to the jawbones are considered the main risk factors for developing ONJ, when receiving antiresorptive therapy. However, a growing number of patients develop ONJ without apparent risk factors, raising concern for other predisposing factors. Jaw bone necrosis may be irreversible, resulting in a chronic disease with negative impact on the quality of patients' lives. The role of risk reduction strategies like meticulous dental screening and optimal oral hygiene is fundamental for preventing development of ONJ. ONJ is usually treated conservatively to relieve the symptoms and manage jaw bone necrosis. In certain cases, surgical intervention is required. Future research should emphasize individual predisposition to ONJ, more effective preventive measures and more efficient therapeutic procedures.
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Affiliation(s)
- Evangelos Eleutherakis-Papaiakovou
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, Athens, Greece.,Department of Clinical Therapeutics, Alexandra Hospital, Athens, Greece
| | - Aristotelis Bamias
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, Athens, Greece.,Department of Clinical Therapeutics, Alexandra Hospital, Athens, Greece
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Aljohani S, Fliefel R, Ihbe J, Kühnisch J, Ehrenfeld M, Otto S. What is the effect of anti-resorptive drugs (ARDs) on the development of medication-related osteonecrosis of the jaw (MRONJ) in osteoporosis patients: A systematic review. J Craniomaxillofac Surg 2017; 45:1493-502. [DOI: 10.1016/j.jcms.2017.05.028] [Citation(s) in RCA: 61] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2017] [Revised: 05/03/2017] [Accepted: 05/29/2017] [Indexed: 01/12/2023] Open
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Zandi M, Dehghan A, Mohammadi-Mofrad A, Amini P, Vahdatinia F. Short-term perioperative teriparatide therapy for the prevention of medication-related osteonecrosis of the jaw: A randomized, controlled preclinical study in rats. J Craniomaxillofac Surg 2016; 45:275-280. [PMID: 28087282 DOI: 10.1016/j.jcms.2016.12.010] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2016] [Revised: 10/18/2016] [Accepted: 12/08/2016] [Indexed: 12/01/2022] Open
Abstract
OBJECTIVE Dentoalveolar procedures in patients receiving bisphosphonates and other antiresorptive agents are associated with an increased risk of medication-related osteonecrosis of the jaw (MRONJ). The aim of present study was to evaluate the effects of perioperative teriparatide (TPD) therapy in prevention of MRONJ. SUBJECTS AND METHODS Two protocols of TPD therapy were studied. For protocol A, 25 TPD-treated (AT) and 25 control (AC) rats received 5 weekly injection of 0.06 mg/kg zoledronate. At the end of week 5, extraction of bilateral mandibular first molars was performed for all rats, and 4-week TPD (20 μg/kg/day) and saline therapy was started for AT and AC rats, respectively. For protocol B, 25 TPD-treated (BT) and 25 control (BC) rats received 5 weekly injection of 0.06 mg/kg zoledronate. One week later, 4-week TPD and saline therapy was started for BT and BC rats, respectively. Both groups underwent tooth extraction at the end of week 7 of the experiment. All rats were sacrificed 8 weeks after tooth extraction and assessed clinically for bone exposure/fistula, and histologically for density of osteocytes in newly formed bone and empty osteocyte lacunae in alveolar bone. RESULTS Incidence of bone exposure/fistula and mean numbers of osteocytes and empty lacunae per 25 mm2 (at 400× magnification) were 20%, 15.36, and 2.63 in AT group; 78%, 5.78, and 6.81 in AC group; 14%, 16.94, and 2.08 in BT group; and 78%, 7.54, and 5.95 in BC group; respectively. The differences between AT and AC and between BT and BC were statistically significant (P < 0.001). However, no statistically significant difference between AT and BT and between AC and BC was found. CONCLUSION Four weeks of TPD therapy, beginning at the same day or 2 weeks before tooth extraction, had a potential role in prevention of ONJ.
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Affiliation(s)
- Mohammad Zandi
- Department of Oral and Maxillofacial Surgery (Head: Prof. Dr. M. Zandi), Hamadan University of Medical Sciences, Hamadan, Iran; Dental Research Center, Hamadan University of Medical Sciences, Hamadan, Iran
| | - Arash Dehghan
- Department of Pathology, Hamadan University of Medical Sciences, Hamadan, Iran
| | - Amirhossein Mohammadi-Mofrad
- Department of Oral and Maxillofacial Surgery (Head: Prof. Dr. M. Zandi), Hamadan University of Medical Sciences, Hamadan, Iran.
| | - Payam Amini
- Department of Biostatistics, Hamadan University of Medical Sciences, Hamadan, Iran
| | - Farshid Vahdatinia
- Faculty of Dentistry, Hamadan University of Medical Sciences, Hamadan, Iran
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Rodriguez-Lozano FJ, Oñate-Sánchez RE. Treatment of osteonecrosis of the jaw related to bisphosphonates and other antiresorptive agents. Med Oral Patol Oral Cir Bucal 2016; 21:e595-600. [PMID: 27475683 PMCID: PMC5005097 DOI: 10.4317/medoral.20980] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2015] [Indexed: 11/14/2022] Open
Abstract
Background The clinical management of medication-related osteonecrosis of the jaw (MRONJ) in patients treated with bisphosphonates and other antiresorptive agents is subject to controversy. The American Association of Oral and Maxillofacial Surgeons (AAOMS) has developed guidelines for the correct management of the disorder which are revised and updated by a panel of experts. Material and Methods The present systematic review analyzes the different treatments currently used to treat this clinical condition, based on the PRISMA® (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement published in 2009. An electronic Medline search was made of the PubMed database, covering the period 2006-2014. The last search date was 31 December 2014. Results A total of 29 articles were selected from the initial search according to the different drugs implicated in the appearance of osteonecrosis; the treatment modality used according to the stage of the disease; and the recorded success rate. Conclusions It is currently still recommended that the management of MRONJ should be decided according to the stage of the disease – conservative treatment being preferred in early stages without symptoms, while surgical management is preferred in the case of bone exposure with symptoms. Key words:Osteonecrosis, medication, bisphosphonates, treatments, review
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Affiliation(s)
- F-J Rodriguez-Lozano
- Clínica Odontológica Universitaria, Unidad Pacientes Especiales y Gerodontología, University of Murcia, IMIB-Arrixaca. Morales Meseguer Hospital, Avda. Marqués de los Vélez s/n, 30007- Murcia, Spain,
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de Souza Póvoa RC, Marlierè DAA, da Silveira HM, Pires FR. Denosumab-related osteonecrosis of the jaws: successful management with a conservative surgical approach. Spec Care Dentist 2016; 36:231-6. [PMID: 26859582 DOI: 10.1111/scd.12168] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Denosumab-related osteonecrosis of the jaws (DRONJ) is a recently described entity that shares many common clinical and radiological features with bisphosphonate-related osteonecrosis of the jaws (BRONJ). The aim of the present study is to report a case of DRONJ affecting the anterior mandible of a 58-year-old male treated with denosumab to prevent skeletal-related events associated with prostate cancer. Conservative surgery in conjunction with antibiotic therapy and discontinuation of denosumab use were effective in managing the condition and the patient remains free of clinical and radiological changes after a 38 month follow-up.
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Affiliation(s)
| | - Daniel Amaral Alves Marlierè
- Resident, Oral and Maxillofacial Surgery, Pedro Ernesto University Hospital, State University of Rio de Janeiro, Brazil
| | - Henrique Martins da Silveira
- Adjunct Professor, Oral and Maxillofacial Surgery, Pedro Ernesto University Hospital, State University of Rio de Janeiro, Brazil
| | - Fábio Ramoa Pires
- Associate Professor, Oral Pathology, School of Dentistry, State University of Rio de Janeiro, Brazil
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