Management Of Medication-related Osteonecrosis Of The Jaw Research Articles

Combined Phototherapies (aPDT and PBM Therapy) Protocol for Medication-Related Osteonecrosis of the Jaw (MRONJ) in a Cancer Patient: Scope Literature Review and A Case Report

Purpose: Medication-Related Osteonecrosis of the Jaw (MRONJ) is an oral complication in patients on ongoing or previous treatment with antiresorptive or antiangiogenic drugs. Many treatments have been proposed, but the management of MRONJ lesions is still challenging. The objective of this article is to present a literature review on aPDT and PBM in the management of MRONJ. Accompanying the review, a protocol and its outcome, for treating MRONJ in a cancer patient, where the association of photobiomodulation (PBM) therapy and antimicrobial photodynamic therapy (aPDT) was applied is presented. Methods: This is the clinical case report of a 58-year-old male patient, with prostate cancer presenting a bone metastasis that was treated with chemotherapy and intravenous antiresorptive Zometa®. On intraoral clinical examination, in the region of the lower alveolar ridge, a lesion with necrotic bone exposed was observed. After clinical and radiographic evaluation of the lesion, it was diagnosed as MRONJ. The association of PBM and aPDT was applied at pre, trans and post-surgery. The pre-surgical phase lasted about two months. The post-surgical protocol was implemented 48 hours after surgery and lasted two months. Results: The search included articles in the databases MEDLINE/Pubmed and Scopus. Nine studies were included 6 of combined aPDT and PBM and 3 studies investigated isolated aPDT published in English from 2016 to 2023. The proposed protocol resulted in the complete closure of the lesion. The patient was undergoing clinical follow-up for 3 years without recurrences. Conclusion: Based on the positive outcome of the proposed phototherapy protocol, one can infer that the combination of PBM and aPDT in the pre, trans and post-surgery showed to be efficient in the treatment of MRONJ lesion.

Autologous platelet concentrates as adjuvant in the surgical management of medication-related osteonecrosis of the jaw.

Medication-related osteonecrosis of the jaw (MRONJ) is an infectious side effect associated with bisphosphonates and monoclonal antibodies (denosumab, immune modulators, and antiangiogenic medications). Adjunctive therapies for the surgical management of MRONJ include autologous platelet concentrates (APCs). These APCs serve as a source of various cells and growth factors that aid tissue healing and regeneration. This review evaluated the use of platelet-rich plasma (PRP), plasma-rich in growth factors (PRGF), and leukocyte- and platelet-rich fibrin (L-PRF) as adjuvant therapies for the surgical management of MRONJ by conducting analyses on the results of 58 articles. Compared to surgical treatment alone, the application of PRP and L-PRF after surgery appears to increase healing in the management of patients with MRONJ. No studies have reported unhealed lesions as a result of surgical treatment of MRONJ with PRGF application or compared it with surgical treatment alone. The overall results of this review have shown favorable healing rates of MRONJ lesions managed with the application of APCs after surgical treatment; however, significant methodological limitations may limit the scientific evidence supporting their use. Further randomized controlled trials with strict criteria are needed to establish the extent to which APCs can improve wound healing and quality of life in patients with MRONJ requiring surgical treatment.

The adjunctive use of Leukocyte-Platelet Rich Fibrin (L-PRF) in the management of Medication Related Osteonecrosis of the Jaw (MRONJ): a retrospective observational study.

Medication related osteonecrosis of the jaw (MRONJ) is a risk for patients taking anti-resorptive or anti-angiogenic medications. The American Association of Oral and Maxillofacial Surgeons (AAMOS) has classified MRONJ in stages to reflect the severity of the disease and allows implementation of suitable treatment pathways. MRONJ risk is < 5% in cancer patients and < 0.05% in osteoporosis patients. Management is subdivided into operative and non-operative, with advances in the literature investigating adjuvants. Leukocyte-Platelet Rich Fibrin (L-PRF) is an autologous biomaterial consisting of leukocytes and platelets embedded within a fibrin matrix with the ability to release growth factors enabling angiogenesis, bone regeneration and soft tissue healing. This paper's aim is to investigate the effects of L-PRF in conjuction with surgical debridement for management of MRONJ. Twenty-two cases with established MRONJ were treated with either surgical intervention (Group A) or with surgical intervention and L-PRF (Group B), from 2016 to 2023 at Edinburgh Dental Institute (EDI). Treatments were deemed successful when the patients were asymptomatic, displayed complete soft tissue healing with the absence of infection/inflammation, fistula, or exposed bone. All cases in Group B had healed in contrast to 54.5% not healed in Group A; p value < 0.05 indicating statistical significance. The use of L-PRF as an adjuvant to surgical management of MRONJ is promising with its favourable functional capacity, simple application, and success of treatment outcomes.

Italian position paper (SIPMO-SICMF) on medication-related osteonecrosis of the jaw (MRONJ).

This paper aims to describe the 2023 update position paper on MRONJ developed by the Italian Societies of Oral Pathology and Medicine (SIPMO) and of Maxillofacial Surgery (SICMF). This is the second update following the 2013 and 2020 Italian position papers by the Expert panel, which is a representation of the two scientific societies (SIPMO and SICMF). The paper is based on an extensive analysis of the available literature from January 2003 to February 2020, and the subsequent review of literature conducted between March 2020 and December 2022 to include all new relevant published papers to confirm or modify the previous set of recommendations. This position paper highlights the main issues of MRONJ on risk estimates, disease definition, diagnostic pathway, individual risk assessment, and the fundamental role of imaging in the diagnosis, classification, and management of MRONJ. The Expert Panel confirmed the MRONJ definition, the diagnostic work-up, the clinical-radiological staging system and the prophylactic drug holiday, as recognized by SIPMO-SICMF; while, it presented novel indications regarding the categories at risk of MRONJ, the prevention strategies, and the treatment strategies associated with the therapeutic drug holiday.

Efficiency of Adjuvant Therapies in the Management of Medication-Related Osteonecrosis of the Jaws: A Case Series and a Literature Review

Introduction: Medication-related osteonecrosis of the jaw (MRONJ) is a challenging condition with no established gold standard treatment. This article presents a case series that explores a minimally invasive surgical protocol combined with various adjuvant treatments to manage MRONJ in oncologic patients. Patient and Methods: Seven patients diagnosed with MRONJ, with mandibular involvement at stages 2 and 3 were included in the case series. The treatment protocol consisted of pre-operative steps, including oral cavity sanitation, hygiene motivation, and pre-operative medical treatment. Using operative techniques, the surgical protocol involved fluorescence-guided bone debridement, curettage, and bone smoothing. Adjuvant treatments such as platelet-rich fibrin, buccal fat pad grafts, Pentoxifylline and tocopherol combination, and low-level laser therapy were used. Follow-up assessments were conducted at regular intervals, and the outcomes were evaluated. Result: Improved cicatrization and symptom relief in most cases, with complete healing achieved in all patients. Conclusion: The study highlights the outcome of the use of adjuvant therapies in the management of MRONJ, however, further research is needed in order to acknowledge the potential of adjuvant therapies for MRONJ treatment and establish a standardized protocol.

Effects of daily versus weekly teriparatide for medication-related osteonecrosis of the jaw: A case-control study.

Medication-related osteonecrosis of the jaw (MRONJ) is uncommon but can result in severe destruction of the jaw. This case-control study investigated the therapeutic effects of daily or weekly administration of teriparatide in the management of MRONJ using a cohort for osteonecrosis of the jaw. Patients who were diagnosed with MRONJ and consented to teriparatide administration were assigned either to a group of daily injection or of weekly injection and completed a 4-week course of injection preoperatively and at least an 8-week course postoperatively. The control group received either the intraoperative rhBMP treatment (CG_BMP) or no additional perioperative treatment (CG_noBMP). The state of MRONJ was evaluated 2 months (T1) and 6 months (T2) postoperatively for all participants. Either group of daily injection (8.35 weeks ± 1.58; n = 17) or weekly injection (9.17 ± 3.79; n = 12) showed significantly faster healing than those of CG_BMP (14.40 ± 6.08; n = 25) or CG_noBMP (15.79 ± 9.79; n = 39). MRONJ was resolved completely in 24 out of 29 participants who completed the course of teriparatide injections, whereas 46.9% of CG showed delayed resolution. Multiple regression analysis indicated 7.50 times (95% CI, 1.77-31.82) more likelihood of complete resolution of MRONJ for participants with teriparatide injections. A course of daily or weekly administration of teriparatide injections may improve treatment outcomes for patients with MRONJ.

Intermittent parathyroid hormone enhances the healing of medication-related osteonecrosis of the jaw lesions in rice rats.

Medication-related osteonecrosis of the jaw (MRONJ) is a potentially severe adverse event in patients treated with antiresorptives. Management of MRONJ is challenging, and no non-antibiotic, established medical treatment exists. Intermittent parathyroid hormone (iPTH) has been used off-label to treat MRONJ with favorable results. However, its medical efficacy has rarely been substantiated in clinical or preclinical experiments. Using a validated rice rat, infection-based model of MRONJ, we evaluated the effects of iPTH on established MRONJ. We hypothesize that iPTH contributes to MRONJ resolution by enhancing alveolar bone turnover and healing oral soft tissues. Eighty-four rice rats began a standard rodent chow diet at age 4 weeks to induce localized periodontitis. Rats were simultaneously randomized to receive saline (vehicle, VEH) or zoledronic acid (ZOL, 80 μg/kg IV) every 4 weeks. Oral exams were conducted bi-weekly to assign a gross quadrant grade (GQG, 0-4) to evaluate any lesion at the lingual aspect of the interdental space between maxillary molar (M2) and M3. 14 of 20 VEH-treated rice rats (70%) developed maxillary localized periodontitis with GQG 2-3 after 30 ± 10 weeks of saline. Additionally, 40 of 64 ZOL-treated rice rats with periodontitis developed MRONJ-like lesions after 30 ± 10 weeks of ZOL treatment. Rice rats with localized periodontitis or MRONJ-like lesions were treated with saline or iPTH (40 μg/kg) subcutaneously (SC) 3 times/week For 6 weeks until euthanasia. We found that iPTH -treated ZOL rats had a lower prevalence of MRONJ (p < 0.001), with lower severity extent of oral lesions (p = 0.003) and percentage of empty osteocyte lacunae (p < 0.001). ZOL rats treated with iPTH displayed a higher osteoblast surface (p < 0.001), more osteoblasts (p < 0.001), higher osteoclast surface (p < 0.001) and more osteoclasts (p = 0.002) at alveolar bone surfaces than ZOL/VEH rats. Greater gingival epithelial thickness and epithelial cell proliferation rate was found in the oral mucosa and gingiva of ZOL/PTH rats than in ZOL/VEH rats (p < 0.001). Our data suggest that iPTH is an efficacious non-operative medicinal therapy that accelerates oral healing and enhances the resolution of MRONJ lesions in ZOL-treated rice rats.

An Update on Medication-Related Osteonecrosis of the Jaw in Patients with Osteoporosis

Medication-related osteonecrosis of the jaw (MRONJ) is a feared complication of anti-resorptive or anti-angiogenic therapy, presenting with non-healing areas of bone, which may form de novo or after dental intervention. The condition primarily affects patients under the care of oncologists and rheumatologists. Patients using these medications under the care of rheumatologists are predominantly being treated for osteoporosis, a highly prevalent condition causing considerable morbidity and mortality in the European population. In the two decades since the condition was first described, there has been considerable progress in the understanding of the pathophysiology of the condition, although this remains incomplete. Additionally, clinicians may now benefit from long-term follow-up data to give a more evidence-based approach to MRONJ risk stratification. At present, there is considerable variation between guidelines produced by advisory groups. This paper focuses exclusively on the osteoporotic cohort, and aims to review recent findings to explore the differences in risk profiles between osteoporotic and oncological cohorts, as well as between different anti-resorptive medications. Further sections discuss prevention and management of MRONJ in osteoporosis, including the timing of tooth extraction, and consider the direction of future research. The findings suggest that patients with osteoporosis treated with bisphosphonates carry an extremely low risk of MRONJ, although denosumab presents a higher risk. Nevertheless, the reduced fracture rate from prompt treatment with anti-resorptives likely outweighs the risk of MRONJ. Dental hygiene should be optimised to reduce risk, and tooth extraction should take place in a timely fashion, with no convincing evidence to support the use of drug holidays. Treatment at present favours a surgical approach, with potential roles for antibiotics, but at present there is insufficient evidence for other medical adjuncts.

Management of Medication-Related Osteonecrosis of the Jaw with Photobiomodulation and Minimal Surgical Intervention

Medication-related osteonecrosis of the jaw (MRONJ) is a relatively common pathology occurring in around 5% of patients taking bisphosphate and other antiresorptive or anti-angiogenic medications. Despite the efforts, as of today there is still no consensus on its management. In this case report, the successful management of stage II MRONJ was performed for an eighty-three-year-old female patient suffering from pain and alteration in her normal oral functions (swallowing and phonation). The treatment consisted of three sessions of photobiomodulation therapy (PBM), followed by minimal surgical intervention and three other sessions of PBM. PBM was applied on the sites of osteonecrosis with the follow parameters: 4 J/cm2; a power of 50 mW; 8 mm applicator diameter; a continuous contact mode. Irradiation was performed on three points, including the vestibular, occlusal and lingual parts of each of the bone exposure areas. Each point was irradiated for 40 s, and, in total, nine points were made per session, and nine sessions were conducted. To assess the pain, a visual analogue scale was used in which zero represented no pain at all and ten represented the greatest pain. At the first session and before any intervention, the patient stated that her pain was 8 out of 10. At the end of the treatment, a significant reduction in VAS was noted (2/10) and, clinically, a healing of the soft tissue in the previously exposed bone was observed. This case report suggests that the combination of PBM with surgical intervention is promising in the management of MRONJ.

Case series of medication-related osteonecrosis of the jaw (MRONJ) patients prescribed a drug holiday

The role of a drug holiday in the management of medication-related osteonecrosis of the jaw (MRONJ) remains controversial. Current UK guidance does not recommend this practice given the lack of conclusive evidence, and potential risk of skeletal-related events or cancer metastasis. This paper aims to describe a series of fifty patients with confirmed MRONJ who were prescribed a drug holiday as part of their management. Data were collected on exposures including: anti-resorptive and/or anti-angiogenic drug history, duration of drug, method of administration, concurrent therapy, MRONJ stage, management of MRONJ and duration of drug holiday. The primary outcome was complete healing as documented in the clinical notes. Multivariate Cox regression analysis was performed to evaluate the association between exposures and primary MRONJ outcome. Models were adjusted for age, sex, and index of multiple deprivation. Survival analysis was performed using a log-rank test, censoring any patients with no primary outcome recorded (p < 0.05). A total of 44% of patients stopped their medication for >36 months. Over half of all MRONJ cases presented in the posterior mandible and dental extraction was the most common precipitating factor (76%). Almost three-quarters (72%) of patients achieved complete healing. MRONJ recurrence (new site) was reported at 30%, mainly in those with incomplete healing of the initial area. There was a lack of evidence for an association between all recorded exposures and the primary MRONJ outcome using multivariate Cox regression. Similarly, we did not demonstrate evidence for an association between the duration of the drug holiday and MRONJ outcome. Our results support published guidelines, which do not recommend the discontinuation of bone modifying drugs for the prevention of MRONJ, or as part of treatment for established MRONJ.

Use of Leukocyte-rich and Platelet-rich Fibrin (L-PRF) Adjunct to Surgical Debridement in the Treatment of Stage 2 and 3 Medication-Related Osteonecrosis of the Jaw.

Medication-related osteonecrosis of the jaw (MRONJ) is characterized by exposed necrotic bone persisting for more than 8 weeks in the maxillofacial region in patients using antiresorptive or antiangiogenetic drugs for several treatment options like bone metastasis or osteoporosis. There are several treatment options studied in scientific literature, and one of them with promising results is using platelet concentrates adjunct to surgical therapy. The aim of this study is to examine the therapeutic effect of leukocyte and platelet-rich fibrin (L-PRF) on patients with MRONJ. This 2-centered study investigated patients referred to oral and maxillofacial surgery departments of 2 university clinics between the years 2014 and 2020 with the diagnosis of MRONJ. Demographic data, the indication of the drug usage, drug type, duration, administration route, and systemic comorbidities of the patients were recorded. L-PRF was applied to 20 osteonecrotic lesions of 19 patients following surgical debridement. The male/female ratio was 5/14. Except 1 of the patients, all of the indications of medication were neoplasia-related. The mean follow-up period of patients was 27.9±9.2 months. Most common antirezorptive drug was zoledronate (84.2%). Complete resolution was observed in 16 necrosis sites (80%). It could be concluded that the use of L-PRF may represent an important adjunct in the surgical management of MRONJ.

Efficacy of Adjunctive Photobiomodulation in the Management of Medication-Related Osteonecrosis of the Jaw: A Systematic Review.

Background: Medication-related osteonecrosis of the jaw (MRONJ) is a severe adverse medication response that manifests as progressive bone necrosis in the craniofacial area. There is still no clear treatment protocol for the management of MRONJ. The purpose of this study was to conduct a systematic review to assess the efficacy of photobiomodulation (PBM) as an adjunct to MRONJ therapy. Methods: In line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement, a literature search was performed on PubMed/MEDLINE, Scopus, Web of Science, and Cochrane databases. Two examiners examined eligibility and risk of bias separately before extracting data. Results: Two hundred sixty-nine articles were found through electronic search, out of which only 11 met the inclusion criteria and were included in qualitative synthesis (9 retrospectives, 1 prospective, and 1 case series). A total number of 759 patients and a mean age ranging from 54 to 74 years were reviewed. Females were the most frequent gender in all of the selected studies (72% females to 28% males), and the most frequent stage in the studies mentioned above was stage II (66%). Most of the studies had shown a significant improvement when PBM was used as an adjunctive treatment. Conclusions: Based on the results of this study, PBM as an adjuvant therapy can significantly improve the outcomes of each treatment plan. However, surgical intervention for the complete healing of the lesions is suggested.

Novel Cell Therapy Using Mesenchymal Stromal Cell Sheets for Medication-Related Osteonecrosis of the Jaw.

Despite medication-related osteonecrosis of the jaw (MRONJ) being first reported in 2003, the optimal treatment and prevention modalities for MRONJ are not clear. As a result, dentistry, oral surgery, and departments involved in the treatment of cancer and bone diseases are struggling with the management of MRONJ. Several cases of MRONJ cannot be managed by conventional treatment strategies recommended in various position papers. Therefore, studies have been conducted to investigate the efficacy of novel therapies for MRONJ. However, the optimal treatment is unknown. Several cell therapies including autologous cell transplantation have been reported for MRONJ. Although the efficacy of cell therapy for MRONJ has been demonstrated, large, statistically accurate clinical trials are lacking. We have been investigating the efficacy of MRONJ treatment using mesenchymal stromal cell (MSC) sheets since 2013 and confirmed its efficacy through various experiments, wherein MSC sheets were transplanted in model rats and beagle dogs with MRONJ-like lesions. Based on these results, we are planning to conduct a clinical trial of MRONJ therapy using periodontal ligament-derived MSC sheets.

Medication-related osteonecrosis of the jaw: knowledge and perceptions of medical professionals on the usage of bone modifying agents and dental referrals.

Bone modifying agents (BMA) like bisphosphonates, antiangiogenic, and antiresorptive agents are widely used to manage bone diseases and cancer. Medication-related osteonecrosis of the jaw (MRONJ) is a potentially serious complication seen in patients on BMA therapy. Dental infection is one of the primary risk factors for MRONJ manifestation; hence its complete removal before initiation of BMA is significant. This can be achieved when a medical professional understands MRONJ and its risk factors and implements timely and regular dental referrals. This multicentre study was performed to assess the knowledge about MRONJ and awareness about the implementation of dental referrals among medical professionals. A custom-designed questionnaire tool was designed and validated by a pilot study. 450 practitioners from 6 medical schools and private practitioners in and around the district were surveyed. The results were analyzed using descriptive statistics. 63.5% (n=80) of the respondents prescribed bisphosphonates at a frequency of 0–5 times in a month. However, 62% (n=78) of the practitioners could correctly indicate the most appropriate definition of MRONJ. Only 49.2% (n=62) of them considered dental consultation mandatory. 73% (n=92) of the practitioners were unaware of management guidelines. There exists a significant gap in the knowledge-based applications in the management of MRONJ. Lack of referrals to dentists before BMA therapy can be a pivotal factor in patient morbidity. Practitioners prescribing BMA should advise patients about regular dental visits and monitor for symptoms of MRONJ.

Interpretation of medication-related osteonecrosis of the jaw: MASCC/ISOO/ASCO clinical practice guideline

Medication-related osteonecrosis of the jaw (MRONJ) is a serious adverse event related to administration of antiresorptive or antiangiogenic medications. With the increasing usage of bone-modifying agents in cancer therapy, the incidence of MRONJ enhanced gradually, which affects the life quality of patients and interferes with cancer therapy. In 2019, Multinational Association of Supportive Care in Cancer (MASCC), International Society of Oral Oncology (ISOO) and American Society of Clinical Oncology (ASCO) convened a multidisciplinary Expert Panel to evaluate the evidence and formulate recommendations on practices in the prevention and management of MRONJ in patients with cancer. The present article made an interpretation of Medication-Related Osteonecrosis of the Jaw: MASCC/ISOO/ASCO Clinical Practice Guideline so as to provide clinicians with diagnostic and therapeutic approaches for cancer patients with MRONJ.

Surgical Therapy in Patients With Medication-Related Osteonecrosis of the Jaw Is Associated With Disease Resolution and Improved Quality of Life: A Prospective Cohort Study

Although recent evidence has suggested the value of operative therapy for the management of medication-related osteonecrosis of the jaw (MRONJ), its effectiveness remains controversial. The purpose of this study was to measure and compare MRONJ disease resolution and changes to the quality of life (QoL) between operative and nonoperative management of MRONJ. This is a prospective cohort study. Consecutive MRONJ patients presenting to Mount Sinai Hospital and Sunnybrook Health Sciences Center (September 2016 to August 2020) were recruited and divided by the treatments provided into operative and nonoperative groups. The primary and secondary outcome variables were disease resolution and QoL at 6months, respectively. Disease resolution was defined as mucosal coverage with an absence of pain, and QoL was measured via the MRONJ-QoL questionnaire. The primary and secondary outcomes, after adjusting for potential confounders, were assessed via multivariate logistic regression and multivariate linear regression analyses, respectively, with significance set to P<.05. Sixty patients were included in this study. Of these, 40 patients received operative treatment, and 20 received nonoperative treatment. In the unadjusted analyses, operative therapy was found to be significantly associated with both disease resolution and improvement in QoL (relative risk 6.75, 95% confidence interval [CI] 1.78 to 25.6, P<.001; and MRONJ-QoL score improvement of 3.35, 95% CI 0.16 to 6.54, P=.04). When controlling for potential confounders, operative therapy was found to be significantly associated with disease resolution when compared with nonoperative therapy (adjusted odds ratio 46.2, 95% CI 5.57 to 383.9, P<.001). Linear regression analysis also showed operative therapy to be significantly associated with improved QoL compared with nonoperative therapy (adjusted MRONJ-QoL score improvement of 3.72, 95% CI 0.34 to 7.11, P=.03). Our study demonstrated operative therapy to be significantly associated with disease resolution and improvement in QoL.

BISPHOSPONATE INDUCED OSTEONECROSIS OF JAW – A CASE REPORT

Osteonecrosis of the jaw (ONJ), is the death or necrosis of a bone caused by an insufcient blood supply. It is also called as avascular necrosis, aseptic necrosis or ischemic necrosis of bone. It is a clinically devastating condition that can affect the quality of life of patients. ONJ can be induced by medication such as anti-resorptive agents such as bisphosphonates (BPs) and [1,2,3,4,8,9] antiangiogenic drugs, so is termed as medication related ONJ (MRONJ). The management of MRONJ can be conservative or invasive, [4,7] depending upon the stage of the disease, size of the lesions ,contributing drug therapy and presence of comorbidities. We report a case of bisphosphonate induced osteonecrosis of jaw managed successfully with conservative treatment.

Investigation of the Effectiveness of Surgical Treatment on Maxillary Medication-Related Osteonecrosis of the Jaw: A Literature Review.

Aim: Medication-related osteonecrosis of the jaw (MRONJ) occurs after exposure to medication (antiresorptive or antiangiogenic agents) for bone-related complications. It is more common in the mandible than in the maxilla. The present study investigated maxillary MRONJ in elderly patients through a meta-analysis. Methods: Keywords, including “MRONJ”, “maxilla”, and “surgery”, were entered into databases, including Embase, PubMed/MEDLINE, Cochrane Library, and ProQuest, which were searched systematically. Results: Investigating 77 studies, we found that 18 (2 case reports and 16 case series) papers conformed to the standards. The results revealed a 2.6:1 female-to-male ratio of disease occurrence. The average age of patients was 70.6 ± 5.5 years, and most patients were in the third stage (43.6%). The average time of medication usage was 50.0 ± 20.1 months. The pooled proportion of clinical efficacy of surgery was 86%. Conclusion: To prevent and manage MRONJ, all elderly patients should maintain proper oral hygiene and receive dental examinations regularly. Risk assessment and safety management of MRONJ should be performed by medical teams.

Diagnosis and treatment of medication-related osteonecrosis of the jaws from an oncologist's perspectives

Along with the improvement of cancer treatment and the increasing use of bone-modifying agents, medication-related osteonecrosis of the jaw (MRONJ) has become more and more common, which may lead to reduce quality of life for patients and interrupt their regular tumor treatments. Being an oral condition in the maxillofacial region of patients associated with adverse side effect of certain bone-modifying agent related cancer therapies, MRONJ falls in a gray area between oncology and stomatology and can be challenging to treat and manage if standard clinical practice and care management guideline is not well established. Missed diagnosis and misdiagnosis of MRONJ become common when there is lack of elucidated diagnostic criteria and coordination in treatment planning between patient's oncologist and dentist. Patient's primary attending oncologist who initiates therapy with bone-modifying agent should be aware of MRONJ and well knowledgeable in best practices for preventing and managing MRONJ. With the focus on coordination of care in mind, an oral health assessment of the patient should be undertaken before initiating therapy and a dental treatment plan should be developed and implemented in coordination with the patient's dentist. Based on the systematic review of the 2019 "Medication-Related Osteonecrosis of the Jaw MASCC/ISOO/ASCO (Multinational Association of Supportive Care in Cancer/International Society of Oral Oncology/American Society of Clinical Oncology) Clinical Practice Guideline", combined with clinical experience and academic research progress of related subject in recent years, from the perspective of an oncologist, the author summarizes how oncologists play a pivotal role in every step of the way from the initial cancer diagnosis, pre-cancer treatment assessment, care management during bone-modifying agent therapy, to the diagnosis, treatment, and management of MRONJ. The primary focus of the present article is to formulate optimized recommendations and provide guidance for multidisciplinary teams regarding best practices in the prevention and management of MRONJ in patients with cancer, in terms of early awareness, prevention, detection as well as implementation of effective treatment plan to improve clinical outcome and increase quality of life for the patients.

Use of platelet-rich plasma in the treatment of medication-related osteonecrosis of the jaw. A case report

Introduction : Medication-related osteonecrosis of the jaw (MRONJ) is an area of uncovered bone in the maxillofacial region that does not heal within 8 weeks after identification by a healthcare provider, in a patient who is receiving or has been exposed to bisphosphonate therapy without previous radiation therapy to the craniofacial region. Case Description : The survey was conducted in 2018/2019. It was conducted at the Clinic of Maxillofacial Surgery, St. George University Hospital, Plovdiv, Bulgaria. In order to conduct the study, we obtained informed consent from the patient, who was 63 years of age. We have diagnosed medication-related osteonecrosis of the lower jaw. We performed bone resection and applied platelet-rich plasma (PRF) in order to enhance soft tissue healing. Discussion : Management of MRONJ remains a challenge and controversial topic. Multiple treatment approaches have been introduced to control MRONJ. Surgical treatment remains one of the most reliable methods but it also needs to take advantages of advanced scientific researches and technologies. One of these achievements is the use of a platelet-rich fibrin matrix (PRFM). Conclusion: In addition to the established surgical treatment options, we can add the application of platelet-rich plasma as an adjuvant treatment for MRONJ.