Maxillofacial Surgeons Position Paper Research Articles

Panoramic Radiography Features of Medication-Related Osteonecrosis of the Jaws (MRONJ)

The diagnosis of medication-related osteonecrosis of the jaws (MRONJ) relies on the application of the clinical criteria stated in the American Association of Oral and Maxillofacial Surgeons position paper. The role of diagnostic imaging in integrating MRONJ clinical assessment is still debated, as pathognomonic imaging features have not been yet recognized. The present study retrospectively evaluated the radiographic signs of MRONJ on panoramic radiography with the aim of describing the characteristics of the lesions at different stages of the disease. The presence of alterations of the lamina dura (thickening or loss), the persistence of the alveolar socket following tooth extraction, and bone alterations (including sequestrum, sclerosis, osteolysis, mandibular canal enhancement, pathologic fracture, sinus involvement, and periosteal reaction) were investigated. The occurrence of each radiographic sign was stratified depending on oral status, antiresorptive pharmacological treatment administered, and general health variables. A weak relationship between radiographic signs and disease stage was observed. Mandibular canal enhancement was associated with the advanced disease stage (p-value < 0.001). The distribution of the different radiographic features was not influenced by the underlying disease (osteoporosis or oncologic disease) treated with antiresorptive drugs. Bone sequestrum was more frequently encountered in the mandible. Panoramic radiography appears to be a valid support in the assessment of MRONJ lesions. The clinician should be aware of the signs associated with MRONJ occurrence in order to improve the diagnostic performance and provide adequate treatment.

What Is MRONJ?

Medication-related osteonecrosis of the jaw (MRONJ) is a rare but serious complication that can damage the jawbone. It can occur after treatments like pulling a tooth or treating severe gum disease. It affects some people who are taking or have taken medications to protect bones. These medications, like bisphosphonates, may be used at high doses to help manage bone cancer or other types of cancer that have spread to the bone. They also may be prescribed to people who have severely weakened bones from conditions like osteogenesis imperfecta. Much lower doses are also used to manage osteoporosis. In people taking these medications, MRONJ may keep the jaw from healing properly after procedures that affect the bone, especially the extraction of 1 or more teeth. MRONJ can cause loss of bone, pain, infection, loose teeth, and exposed bone. Researchers estimate that 10 of 100 people with cancer who have taken these medications develop MRONJ.1American Dental AssociationOncology agents and medication-related osteonecrosis of the jaw. 2019.https://www.ada.org/en/member-center/oral-health-topics/oncology-agents-and-medication-related-osteonecrosis-of-the-jawGoogle Scholar For those taking these medications for osteoporosis this number drops to 1 in 10,000.2American Dental AssociationOsteoporosis medications and medication-related osteonecrosis of the jaw. 2019.https://www.ada.org/en/member-center/oral-health-topics/osteoporosis-medicationsGoogle Scholar Other factors that increase the risk of developing MRONJ include3American Dental AssociationThe ADA Practical Guide to Patients With Medical Conditions. John Wiley & Sons, 2016Google Scholar ▪being older than 65 years▪periodontitis▪smoking▪ill-fitting dentures▪diabetes Symptoms of MRONJ include4Otto S. Pautke C. Van den Wyngaert T. Niepel D. Schiødt M. Medication-related osteonecrosis of the jaw: prevention, diagnosis and management in patients with cancer and bone metastases.Cancer Treat Rev. 2018; 69: 177-187Abstract Full Text Full Text PDF PubMed Scopus (94) Google Scholar ▪pain, swelling, or infection of the gums or jaw▪loose teeth▪numbness or a feeling of heaviness in the jaw▪gums that do not heal or bone that does not have gum tissue protecting it When you are facing cancer, seeing the dentist might not seem important,5Ruggiero S.L. Dodson T.B. Fantasia J. et al.American Association of Oral and Maxillofacial Surgeons. American Association of Oral and Maxillofacial Surgeons position paper on medication-related osteonecrosis of the jaw: 2014 update.J Oral Maxillofac Surg. 2014; 72: 1938-1956Abstract Full Text Full Text PDF PubMed Scopus (1323) Google Scholar but a complete dental examination could help identify disease that should be treated before you start taking medications for bone strength. Give your dentist a complete health history, including any medications you have taken, are taking, or could start taking in the near future. If you are being treated for osteoporosis, consider all of the risks involved. Although taking some osteoporosis medications carries a small risk of developing MRONJ, the risk of breaking a bone due to osteoporosis is much higher. In addition to seeing your dentist, good dental care at home is important:▪brush your teeth twice a day with a fluoride toothpaste▪clean between your teeth daily▪eat a healthy diet that is low in sugar MRONJ is a rare but serious condition that affects the jawbone. It can develop after dental treatments that involve the bone in people taking some bone-strengthening medications. Keeping up with your daily dental care at home and regular visits to your dentist may limit the need for treatments that increase the risk of developing MRONJ.

The impact of medication-related osteonecrosis of the jaws on the quality of life in cancer patients.

BackgroundTo evaluate the impact of oral health on the quality of life (QOL) of individuals undergoing cancer treatment at the time of diagnosis of medication-related osteonecrosis of the jaw (MRONJ). Material and MethodsThe present cross-sectional study analyzed patients with MRONJ from 2013 to 2019. The collected data included demographic data, base disease, medications associated with MRONJ, route of administration and time of use, signs, symptoms, and tomographic features of acute MRONJ, staging according to American Association of Oral and maxillofacial Surgeons position paper 2014 (AAOMS), type of dental treatment performed, outcome, and the responses to the Oral Health Impact Profile questionnaire (OHIP-14). Statistical analysis was performed using the Tukey test to study the association between oral condition and the QOL. A p-value of less than 0.05 was considered statistically significant. ResultsThe sample consisted of 16 medical records of patients with MRONJ. Psychological discomfort showed alarmingly significant results (p< 0.001) with strong negative impact on the QOL of the patients. Functional limitation was the least affected dimension (p = 0.747). The other dimensions did not show statistically significant results. ConclusionsMRONJ compromises oral health and negatively impacts the QOL, especially with respect to the psychological discomfort (worry and stress). The OHIP-14 questionnaire proved to be an effective tool in the assessment of this impact. Key words:Medication-related osteonecrosis of the jaw, quality of life, oral health, OHIP-14.

Advanced Stage of Medication‐Related Osteonecrosis of the Jaw Associated With Oral Bisphosphonates: Report of Three Cases

Introduction: Bisphosphonates (BPs) are prescribed for treating diseases exhibiting high bone turnover rates. Medication‐related osteonecrosis of the jaw (MRONJ) is a major adverse effect of BPs. Cases of MRONJ associated with oral BPs for treatment of osteoporosis are much less common compared with intravenous BPs. Most reports of oral BP–associated MRONJ are either stage 1 or stage 2 as classified by the 2014 American Academy of Oral and Maxillofacial Surgeons position paper (Ruggiero et al., J Oral Maxillofac Surg 2014;72:1938‐1956). There are ≈24 reported cases of oral BP–induced stage 3 MRONJ presenting as an area of exposed necrotic bone with pain and infection along with a pathologic fracture, an extraoral fistula, oroantral communication, or osteolysis extending to the inferior border of the mandible or sinus floor.Case Series: Three cases of stage 3 MRONJ associated with oral BPs are presented. All three patients had a long history of use of alendronate for over 10 years. Diagnosis of stage 3 MRONJ was made based on clinical, radiographic, and histopathologic findings. Patients were managed with a course of antibiotics and removal of the necrotic bone.Conclusions: Development of stage 3 MRONJ associated with oral BPs is relatively rare. However, there is an increased risk of advanced MRONJ associated with oral BPs in the presence of longer duration of therapy, dentoalveolar surgery, denture trauma, inflammatory oral diseases, and presence of comorbid factors. Therefore, it is recommended that clinicians educate patients about the advanced adverse effects of oral BPs.

Titanium Miniplates

Bisphosphonate-related osteonecrosis of the jaw (BRONJ) is a rare but potentially severe condition, and the etiopathology and risk factors are poorly defined. The American Association of Oral and Maxillofacial Surgeons position paper on BRONJ update 2009 remarks all the risk factors of developing BRONJ. Local anatomy such as lingual tori, mylohyoid ridge or palatal tori, and areas with thin mucosa overlying bony prominences represent some of these local factors. We have recently treated a patient presenting a mandibular osteonecrosis involving a rigid miniplate which had been placed 18 years ago during a surgical excision of a radicular cyst. The patient, a 70-year-old female, did not show any other risk factors which could expose her to BRONJ, such as cortisone therapy, head and neck radiotherapy, chemotherapy, periodontal disease, or other.

Bone Regeneration Without Bone Grafting After Resection of a Segment of the Mandible to Treat Bisphosphonate-Related Osteonecrosis of the Jaw

In 2003, Marx first described an association of exposed necrotic bone of the jaw with long-term application of bisphosphonates (BPh). 1 Marx R.E. Pamidronate (Aredia) and zoledronate (Zometa) induced avascular necrosis: A growing epidemic. J Oral Maxillofac Surg. 2005; 61: 1115 Abstract Full Text Full Text PDF Scopus (2096) Google Scholar Bisphosphonate-related osteonecrosis of the jaw (BRONJ) seems to be resistant to customary dental anti-infective treatment, for example, antimicrobiological rinsing (chlorhexidine, peroxide, etc), curettage of the exposed bone followed by simple closure of the mucosa, or open wound management with regular changing of a gauze wick. Often the severity and stage of the BRONJ is worsened by these procedures. Several articles in the recent literature deal with the question of the most effective treatment for BRONJ. Current concepts described in the literature are based on expert opinion and vary from conservative approaches with antimicrobiological rinsing and oral antibiotics to radical surgery. 2 Ruggiero S.L. Fantasia J. Carlson E. Bisphosphonate-related osteonecrosis of the jaw Background and guidelines for diagnosis, staging and management. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2006; 102: 433 Abstract Full Text Full Text PDF PubMed Scopus (393) Google Scholar , 3 American Association of OralMaxillofacial Surgeons (AAOMS)Position paper on bisphosphonate-related osteonecrosis of the jaws. J Oral Maxillofac Surg. 2007; 65: 369 Abstract Full Text Full Text PDF PubMed Scopus (740) Google Scholar , 4 American Association of Oral and Maxillofacial SurgeonsPosition paper on bisphosphonate-related osteonecrosis of the jaw—2009 Update. http://www.aaoms.org/docs/position_papers/bronj_update.pdfDate: August 2010 Google Scholar , 5 Montebugnoli L. Felicetti L. Gissi D.B. et al. Biphosphonate-associated osteonecrosis can be controlled by nonsurgical management. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2007; 104: 473 Abstract Full Text Full Text PDF PubMed Scopus (80) Google Scholar , 6 Abu-Id M.H. Warnke P.H. Gottschalk J. et al. “Bis-phossy jaws”—High and low risk factors for bisphosphonate-induced osteonecrosis of the jaw. J Craniomaxillofac Surg. 2008; 36: 95 Abstract Full Text Full Text PDF PubMed Scopus (178) Google Scholar , 7 Khan A.A. Sándor G.K. Dore E. Morrison A.D. Alsahli M. Amin F. et al. Canadian consensus practice guidelines for bisphosphonate associated osteonecrosis of the jaw. J Rheumatol. 2008; 35: 1391 PubMed Google Scholar , 8 Khan A.A. Sándor G.K. Dore E. et al. Bisphosphonate associated osteonecrosis of the jaw. J Rheumatol. 2009; 36: 478 Crossref PubMed Scopus (132) Google Scholar , 9 Wutzl A. Biedermann E. Wanschitz F. et al. Treatment results of bisphosphonate-related osteonecrosis of the jaws. Head Neck. 2008; 30: 1224 Crossref PubMed Scopus (80) Google Scholar , 10 Stockmann P. Vairaktaris E. Wehrhan F. et al. Osteotomy and primary wound closure in bisphosphonate-associated osteonecrosis of the jaw: A prospective clinical study with 12-months follow-up. Support Care Cancer. 2010; 18: 449 Crossref PubMed Scopus (116) Google Scholar Increasing evidence seems to indicate, however, that surgical therapy of BRONJ, by resection of the infected and necrotic bone and sealing as primary wound closure, can lead to long-term healing of BRONJ. 6 Abu-Id M.H. Warnke P.H. Gottschalk J. et al. “Bis-phossy jaws”—High and low risk factors for bisphosphonate-induced osteonecrosis of the jaw. J Craniomaxillofac Surg. 2008; 36: 95 Abstract Full Text Full Text PDF PubMed Scopus (178) Google Scholar , 10 Stockmann P. Vairaktaris E. Wehrhan F. et al. Osteotomy and primary wound closure in bisphosphonate-associated osteonecrosis of the jaw: A prospective clinical study with 12-months follow-up. Support Care Cancer. 2010; 18: 449 Crossref PubMed Scopus (116) Google Scholar , 11 Carlson E.R. Basile J.D. The role of surgical resection in the management of bisphosphonate-related osteonecrosis of the jaws. J Oral Maxillofac Surg. 2009; 67: 85 Abstract Full Text Full Text PDF PubMed Scopus (209) Google Scholar , 12 Williamson R.A. Surgical management of bisphosphonate induced osteonecrosis of the jaws. Int J Oral Maxillofac Surg. 2010; 39: 251 Abstract Full Text Full Text PDF PubMed Scopus (92) Google Scholar , 13 Wilde F. Heufelder M. Winter K. et al. The role of surgical therapy in the management of intravenous bisphosphonates-related osteonecrosis of the jaw. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2011; 111: 153 Abstract Full Text Full Text PDF PubMed Scopus (111) Google Scholar However, the question remains of how to reconstruct the mandible when continuous resection is necessary because of extension of the BRONJ.

The surgical treatment of BRONJ: Parma Maxillofacial Surgery School experience

Background The surgical treatment of patients affected by BRONJ (Bisphosphonate-related osteonecrosis of the jaw) represents one of the most debated issues in the international literature becouse the data reported to date are preliminary results of long-term studies. In accordance with the guidelines proposed in 2007 by the American Association of Oral and Maxillofacial Surgeons position paper on bisphosphonate-Related Osteonecrosis of the Jaws and confirmed by the Update 2009 of the same document, surgical treatment should be reserved only to cases of BRONJ in an advanced stage (Stage III) or in the presence of a well-defined bone sequestration. Unfortunately the proposed classification, even if very schematic and user-friendly, in our opinion is still too rigid and does not take into account the patient as a whole.

American Association of Oral and Maxillofacial Surgeons Position Paper on Bisphosphonate‐Related Osteonecrosis of the Jaw – 2009 Update

0 isphosphonate-related osteonecrosis of the jaw BRONJ) adversely affects the quality of life, producing ignificant morbidity in afflicted patients. Strategies for he treatment of patients with, or at risk of, BRONJ were et forth in the American Association of Oral and axillofacial Surgeons (AAOMS) Position Paper on isphosphonate-Related Osteonecrosis of the Jaws Position Paper) and approved by the Board of Trustes in September 2006. The Position Paper was eveloped by a Task Force appointed by the Board nd composed of clinicians with extensive experince in caring for these patients and basic science esearchers. The knowledge base and experience in ddressing BRONJ has expanded, necessitating modfications and refinements to the original Position aper. The Task Force was reconvened in August 2008 to

American Association of Oral and Maxillofacial Surgeons Position Paper on Bisphosphonate-Related Osteonecrosis of the Jaws—2009 Update

Bisphosphonate-related osteonecrosis of the jaw (BRONJ) adversely affects the quality of life, producing significant morbidity in afflicted patients. Strategies for the treatment of patients with, or at risk of, BRONJ were set forth in the American Association of Oral and Maxillofacial Surgeons (AAOMS) Position Paper on Bisphosphonate-Related Osteonecrosis of the Jaws (Position Paper) and approved by the Board of Trustees in September 2006. 1 The Position Paper was developed by a Task Force appointed by the Board and composed of clinicians with extensive experience in caring for these patients and basic science researchers. The knowledge base and experience in addressing BRONJ has expanded, necessitating modifications and refinements to the original Position Paper. The Task Force was reconvened in August 2008 to review the 2006 recommendations, appraise the current published data, and revise the Position Paper and recommendations, where indicated. This update contains revisions to the diagnosis and staging and management strategies and highlights the status of basic science research. AAOMS considers it vitally important that this information be disseminated to other dental and medical specialties.

American Association of Oral and Maxillofacial Surgeons Position Paper on Bisphosphonate-Related Osteonecrosis of the Jaws

American Association of Oral and Maxillofacial Surgeons Position Paper on Bisphosphonate-Related Osteonecrosis of the Jaws