Mandibular and palatal tori exposed by trauma are risk factors for medication-related osteonecrosis of the jaws: a report from the Copenhagen ONJ cohort

Abstract

Objectives Mandibular and palatal tori are usually considered anatomic risk factors for the development of medication-related osteonecrosis of the jaws (MRONJ/ONJ). However, trauma may also be involved in the pathogenesis. The aim of this study was to examine the prevalence and characteristics of MRONJ related to tori within the Copenhagen ONJ cohort and to evaluate trauma as a possible risk factor. Study Design The Copenhagen ONJ Cohort included 391 consecutive patients with MRONJ, comprising seen between January 1, 2010, and December1, 2018. All patients had systematic records of demographic, clinical examination, and radiographic imaging data. The type and duration of antiresorptive treatment was recorded. All patients had ONJ staging, with surgery, including removal of the tori, was performed for stage 2 and 3 as well as some stage 1cases. Results Twenty-nine patients had tori related to MRONJ (7.4%). Of these, 27 had mandibular tori, and 2 had palatal tori. Of the 29 patients, 16 had cancers, 10 had osteoporosis, and 3 had no systemic diseases. Antiresorptive treatment included bisphosphonates (13) and denosumab (12), and methotrexate (1), and 3 cases did not receive any antiresorptives or methotrexate. Onset of MRONJ in 17 cases (59%) was associated with trauma, including tooth extraction, impression taking for dentures, intubation for general anesthesia, denture-related ulcers, and eating hard food items. In 12 cases (41%), no trauma history could be verified or identified. Patients with ONJ and tori underwent surgery in 17 cases (59%). All 17 patients (100%) healed, with 2 patients awaiting surgery. Ten were conservatively treated, and in 4 (40%) a sequestrum was exfoliated and healed spontaneously. The remaining 6 patients had either unchanged or worsening MRONJ. Conclusions Here, we reported a series of 29 cases of MRONJ with related mandibular or palatal tori among 391 consecutive patients in the Copenhagen ONJ Cohort . We documented that 59% of these cases were associated with trauma, and that in some cases, trauma was preventable (e.g., trauma from impression taking and intubation). Dentists as well as anesthesiologists should be aware of the presence of tori in patients on antiresorptive therapy. Surgical treatment was more successful (100%) compared with nonsurgical treatment (40%).