The Use of L-PRF in the Prophylaxis of Osteoradionecrosis and Medication-Related Osteonecrosis of the Jaw

Abstract

Osteoradionecrosis of the jaws (ORN) has been defined as “exposed irradiated bone that fails to heal over a period of 3 months without any evidence of persisting or recurrent tumor.” Medication-Related Osteonecrosis of the Jaw (MRONJ) has been described as the presence of “exposed bone or bone that can be probed through an intraoral or extraoral fistula(e) in the maxillofacial region that has persisted for more than 8 weeks; current or previous treatment with antiresorptive or antiangiogenic agents; no history of radiation therapy to, or obvious metastatic disease in the jawbones” by AAOMS in its 2014 position paper. Multiple medications are now recognized in the literature as being associated with this condition. With an ageing population, rise in incidence of head and neck cancer requiring radiotherapy and prophylactic bisphosphonate use, reported cases of jaw necrosis will continue to rise. These debilitating conditions can develop spontaneously but are often precipitated by manipulation of soft and hard tissues, including tooth extraction and trauma. The resultant exposed, drug-injured or irradiated bone can impact negatively on patients’ quality of life. The management of “at-risk” patients is clinically challenging; prevention and education play a key role. While routine dentistry can be undertaken, surgical intervention should be limited where possible. No clear consensus is established for prevention of ONJ development; drug holidays, primary wound closure, systemic antibiotics and antiseptic mouthwashes have been suggested. Recent evidence suggests minimally invasive approaches, using fibrin membranes rich in platelets and leukocytes (L-PRF), have a role in prevention and treatment of ONJ. Platelet concentrates as healing adjuncts in oral and maxillofacial surgery were first described by Whitman et al in 1997 and further reports using L-PRF demonstrate positive outcomes in soft and hard tissue healing. L-PRF is an autologous blood product containing a host of platelets, leucocytes, cytokines, and growth factors. It has been increasingly utilized in numerous dentoalveolar procedures including placement in extraction sockets, Guided Tissue Regeneration for periodontal bony defects and Guided Bone Regeneration around implants. Preparation is by separation of blood in a centrifuge to manufacture an “optimized fibrin clot.”