Evolution of bisphosphonate-related osteonecrosis of the jaw in patients with multiple myeloma and Waldenstrom's macroglobulinemia: a retrospective multicentric study

Adjuvant therapies for MRONJ: A systematic review

OBJECTIVE

Medication-related osteonecrosis of the jaw (MRONJ) is a severe adverse reaction caused by the use of antiresorptive antiangiogenic medication. Treating MRONJ is difficult and besides standard treatments, which are conservative medical and surgical approaches, there are some adjuvant therapies that might further stimulate healing. The aim of this systematic review is to compare outcome and effectiveness of currently available adjuvant therapies for MRONJ.

METHODS

This systematic review was conducted following the PRISMA guidelines. Articles focusing on mucosal healing in patients treated with an adjuvant therapy for MRONJ were selected and analysed. Inclusion was not limited to randomized controlled trials to present a complete review of the current literature.

RESULTS

A search was performed in Pubmed, Embase, Web of Science and Cochrane Central Register of Controlled Trials. Thirty articles out of 3297 were included. Laser ablation had a success of 60-95% for complete healing. The controlled trials of leukocyte- and platelet-rich-fibrine (LPRF) showed 60-100% success for the same outcome. Fluorescence guided surgery had a complete healing percentage of 85-90%.

CONCLUSIONS

The results suggest that laser ablation, LPRF and fluorescence guided surgery might have a potential in improving the healing process. Interpreting the results should however be done with great care and a critical point of view, as most articles had a medium to high risk of bias. More randomized controlled trials are necessary to define the most beneficial therapy protocols.

CLINICAL RELEVANCE

It seems that adjuvant surgical therapies for treating MRONJ are beneficial for mucosal healing, but there is only low scientific evidence.

Cloud-Based Multicenter Data Collection and Epidemiologic Analysis of Bisphosphonate-Related Osteonecrosis of the Jaws in a Central European Population

Objective: Bisphosphonate-related osteonecrosis of the jaws is considered to be a rare but severe complication of bisphosphonate therapy. To understand this condition better, data collection is essential. Although the number of scientific papers about this subject is large, to date only a few multicenter reports have been published. Study design: We present a novel cloud-based data collection system for the evaluation of the risk factors of bisphosphonate-related osteonecrosis of the jaws. Web-based questionnaire and database have been set up and made available to voluntary researchers and clinicians in oral and maxillofacial surgery in Hungary and Slovakia. Results: To date, fifteen colleagues from eight maxillofacial units have joined the study. Data of 180 patients have been recorded. Collected data were statistically analysed and evaluated from an epidemiological point of view. Conclusions: Authors consider cloud-based multicenter data collection a useful tool that allows for real-time collaboration between users, facilitates fast data entry and analysis, and thus considerably contributes to widening our knowledge of bisphosphonate-related osteonecrosis of the jaws.

Cloud-Based Multicenter Data Collection and Epidemiologic Analysis of Bisphosphonate-Related Osteonecrosis of the Jaws in a Central European Population

Objective: Bisphosphonate-related osteonecrosis of the jaws is considered to be a rare but severe complication of bisphosphonate therapy. To understand this condition better, data collection is essential. Although the number of scientific papers about this subject is large, to date only a few multicenter reports have been published. Study design: We present a novel cloud-based data collection system for the evaluation of the risk factors of bisphosphonate-related osteonecrosis of the jaws. Web-based questionnaire and database have been set up and made available to voluntary researchers and clinicians in oral and maxillofacial surgery in Hungary and Slovakia. Results: To date, fifteen colleagues from eight maxillofacial units have joined the study. Data of 180 patients have been recorded. Collected data were statistically analysed and evaluated from an epidemiological point of view. Conclusions: Authors consider cloud-based multicenter data collection a useful tool that allows for real-time collaboration between users, facilitates fast data entry and analysis, and thus considerably contributes to widening our knowledge of bisphosphonate-related osteonecrosis of the jaws.

The effect of antiresorptive drugs on implant therapy: Systematic review and meta-analysis

OBJECTIVES

A considerable portion of the adult population has received and/or is receiving treatment with antiresorptive drugs (ARDs). It is thus relevant to assess possible side effects of ARD intake in connection to various aspects of implant therapy. The aim of this study was to answer the focused question "In patients with systemic intake of ARDs, what is the outcome and complication rate of implant therapy including associated bone grafting procedures comparing to patients without systemic intake of ARDs?"

MATERIALS AND METHODS

Original studies fulfilled predefined inclusion criteria (e.g., case series, cohort studies, case-control studies, and controlled and/or randomized controlled clinical trials; retro- or prospective design; and ≥10 patients with systemic intake of ARDs). Various patient-, medication-, and intervention-related parameters [i.e., implant loss, grafting procedure complication/failure, peri-implant marginal bone levels/loss, medication-related osteonecrosis of the jaws (MRONJ), and peri-implantitis] were extracted, and meta-analyses and quality assessment were performed.

RESULTS

Twenty-four studies with bisphosphonate (BP) intake (mainly low dose for osteoporosis treatment) and seven studies on hormone replacement therapy (HRT), including ≥10 patients, and controls not taking the medication were identified. Furthermore, seven studies on MRONJ associated with implants were included. Meta-analyses based on four studies reporting on patient level and eight studies reporting on implant level showed no significant differences in terms of implant loss between patients on BPs (mainly low dose for osteoporosis treatment) and controls. Furthermore, low-dose BP intake did not compromise peri-implant marginal bone levels. Based on two studies, no negative effect of HRT was observed on the implant level, while HRT appeared to exert a marginally significant negative effect regarding implant survival on the patient level and regarding peri-implant marginal bone levels. Based on six studies reporting single-patient data, MRONJ in patients on BP for osteoporosis appeared in 70% of the cases >36 months after start of drug intake, while in patients with cancer, MRONJ appeared in 64% of the cases ≤36 months after first BP intake.

CONCLUSION

Low-dose oral BP intake for osteoporosis treatment, in general, does not compromise implant therapy, that is, patients on ARDs do not lose more implants nor get more implant-related complications/failures comparing to implant patients without BP intake. There is almost no information available on the possible effect on implant therapy of high-dose BPs or other widely used ARDs (e.g., denosumab), or on the success or safety of bone grafting procedures. Patients with high-dose ARD intake for management of malignancies, patients on oral BP over a longer period of time, and patients with comorbidities should be considered as high-risk patients for MRONJ.

Antiresorptive treatment-associated ONJ

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.

Case-Based Review of Osteonecrosis of the Jaw (ONJ) and Application of the International Recommendations for Management From the International Task Force on ONJ

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.

Current Controversies on the Pathogenesis of Medication-Related Osteonecrosis of the Jaw

Medication-related osteonecrosis of the jaw (MRONJ) was first reported more than a decade ago. Since then, numerous cases have been diagnosed. Currently, there are three groups of drugs related to MRONJ: bisphosphonates, denosumab and anti-angiogenic drugs. As MRONJ can lead to debilitating clinical sequels and limited effective treatment options are available, much research has been done in understanding its pathophysiology. Until now, the exact pathogenesis of MRONJ has not been fully elucidated. While history of invasive dental procedures or local trauma may be present, some cases occur spontaneously without any preceding factors. This review aims to examine and discuss the three main hypotheses for the pathogenesis of MRONJ, namely suppressed bone turnover, cellular toxicity and infection.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Bisphosphonate Related Osteonecrosis of the Jaw: An Update

OBJECTIVES

The aim of this paper is to summarize different diagnostic criteria as well as probable aetiopathogenesis of bisphosphonates related osteonecrosis of the jaw.

MATERIALS AND METHODS

The electronic search of peer-reviewed journals were performed in MEDLINE (PubMed) database in order to find the relevant articles on bisphosphonates related osteonecrosis of the jaw (BP-related ONJ). The search was restricted to English language articles, published from January 2002 to May 2013. On the basis of these articles, probable aetiopathogenesis and different diagnostic criteria of BP-related ONJ were summarized.

RESULTS

BP-related ONJ is related to the development of avascular necrosis or dead jaw bones. In recent literature many given hypotheses show the aetiopathogenesis and diagnosis of BP-related ONJ which are interlinked and have multifactorial nature. Their diagnosis revolves around four main diagnostic criteria that differentiate it from other conditions which can delay bone healing.

CONCLUSIONS

Factors like potency of bisphosphonates, biology of jaw bone, antiangiogenic property of bisphosphonates and soft tissue toxicity in combination with present infection, other drugs, pre-existing pathologies, compromised immune response and dentoalveolar trauma may lead to development of BP-related ONJ.

Periapical disease and bisphosphonates induce osteonecrosis of the jaws in mice

Osteonecrosis of the jaw (ONJ) is a well-recognized complication of antiresorptive medications, such as bisphosphonates (BPs). Although ONJ is most common after tooth extractions in patients receiving high-dose BPs, many patients do not experience oral trauma. Animal models using tooth extractions and high BP doses recapitulate several clinical, radiographic, and histologic findings of ONJ. We and others have reported on rat models of ONJ using experimental dental disease in the absence of tooth extraction. These models emphasize the importance of dental infection/inflammation for ONJ development. Here, we extend our original report in the rat, and present a mouse model of ONJ in the presence of dental disease. Mice were injected with high dose zoledronic acid and pulpal exposure of mandibular molars was performed to induce periapical disease. After 8 weeks, quantitative and qualitative radiographic and histologic analyses of mouse mandibles were done. Periapical lesions were larger in vehicle-treated versus BP-treated mice. Importantly, radiographic features resembling clinical ONJ, including thickening of the lamina dura, periosteal bone deposition, and increased trabecular density, were seen in the drilled site of BP-treated animals. Histologically, osteonecrosis, periosteal thickening, periosteal bone apposition, epithelial migration, and bone exposure were present in the BP-treated animals in the presence of periapical disease. No difference in tartrate-resistant acid phosphatase (TRAP)+ cell numbers was observed, but round, detached, and removed from the bone surface cells were present in BP-treated animals. Although 88% of the BP-treated animals showed areas of osteonecrosis in the dental disease site, only 33% developed bone exposure, suggesting that osteonecrosis precedes bone exposure. Our data further emphasize the importance of dental disease in ONJ development, provide qualitative and quantitative measures of ONJ, and present a novel mouse ONJ model in the absence of tooth extraction that should be useful in further exploring ONJ pathophysiological mechanisms.

Evolution and etiopathogenesis of bisphosphonates induced osteonecrosis of the jaw

Bisphosphonates (BPs) is widely used as the first line of treatment choice for osteoporosis, Paget’s disease of bone, bone cancer metastasis and hypercalcemia of malignancy. BPs induced osteonecrosis of the jaw (ONJ) is a relatively rare but severe clinical condition cited in English literature since 2003 while exact pathogenesis of BPs induced ONJ is not known until today, but numerous hypotheses were described in recent literature that promote and interlinked the development of BPs induced ONJ. These hypotheses indicate multifactorial nature of its development and factors responsible for that are; long term administration of intravenous nitrogen containing BPs in cancer patients, biological behavior of jaw, antiangiogenic property of BPs and by soft-tissue toxicity etc., All these factors are compounded by the presence of infection that are responsible for lower the pH of the oral cavity, other drugs like administration of corticosteroid, pathologies that cause hypo-calcification of bone, compromised immune response that alters normal healing such as renal transplantation followed by long term oral BPs therapy or chronic diabetic patients receiving BPs therapy and any dentoalveolar trauma. All literature in this review article is search from PubMed, Med-know and Google search engines.