Medication-related osteonecrosis of the jaw: Prevention, diagnosis and management in patients with cancer and bone metastases.

This paper reports on the conclusions of two workshops held in Copenhagen in September 2017 and November 2018 focused on medication-related osteonecrosis of the jaws (MRONJ). The workshops were organized and attended by a European task force on MRONJ, i.e. a multidisciplinary group of European clinical investigators with a special interest in the diagnosis and management of MRONJ and a track record of relevant research and publications. The aim of the workshops were to (i) highlight some of the most controversial aspects of current knowledge on MRONJ, including definition and classification, risk factors and management, and (ii) provide an expert opinion-based consensus with a view to inform clinicians and advise researchers, as a first step of reaching solutions. It should be pointed out that all results and comments presented are the authors (the workshop group members) personal views and the present form of this publication is based on genuine consensus of all authors. This article is protected by copyright. All rights reserved.

https://onlinelibrary.wiley.com/doi/pdf/10.1111/odi.13160

Workshop of European task force on medication-related osteonecrosis of the jaw-Current challenges.

Purpose No consensus has been reached regarding the best treatment option for early-stage lesions in medication-related osteonecrosis of the jaw (MRONJ). The purpose of the present study was to evaluate the long-time outcomes of conservative non-surgical management in stage I patients with underlying malignant disease. Materials and methods We designed and implemented a retrospective cohort study and enrolled, between 2008 and 2018, a sample of patients with the indication for non-surgical conservative treatment stage I lesions. The primary outcome variable was treatment success defined as mucosal integrity without signs of infection. Secondary outcomes were: (i) worsening stage, (ii) necessity for surgical intervention over time, and (iii) discontinuation of antiresorptive therapy. Results The sample included 75 patients with 92 lesions. Eight lesions showed full mucosal coverage, whereas 84 continued with exposed jaw bone (91.3%). Of the treatment-resistent 84 lesions, 67 presented a worsening stage shift over time. Indication for surgical intervention was set in 57 lesions. Of all lesions, 28 developed highly advanced necrotic bone destruction. Antiresorptive medication was paused in all evaluated patients after the first diagnosis of MRONJ. Conclusion Conservative non-surgical therapy in MRONJ stage I leads to a healing in rare cases. Conservative management might be a good option to preserve symptoms in patients either unwilling to undergo surgery or in those whose reduced general condition does not allow surgery. Early and consequent surgical advances should be performed throughout all stages of the disease to prevent the possibility of silent disease progression with the risk of large-scale bone loss.

Is the conservative non-surgical management of medication-related osteonecrosis of the jaw an appropriate treatment option for early stages? A long-term single-center cohort study

Root amputation, immunosuppressive therapy, mandibular tooth extraction, pre-existing inflammation, and longer duration of treatment with bone-modifying agents were significantly associated with an increased risk of medication-related osteonecrosis of the jaw. Hopeless teeth should be extracted without drug holiday before the development of inflammation in cancer patients receiving high-dose bone-modifying agents. No studies have comprehensively analyzed the influence of pre-existing inflammation, surgical procedure–related factors such as primary wound closure, demographic factors, and drug holiday on the incidence of medication-related osteonecrosis of the jaw (MRONJ). The purpose of this study was to retrospectively investigate the relationships between these various factors and the development of MRONJ after tooth extraction in cancer patients receiving high-dose bone-modifying agents (BMAs) such as bisphosphonates or denosumab. Risk factors for MRONJ after tooth extraction were evaluated with univariate and multivariate analyses. The following parameters were investigated in all patients: demographics, type and duration of BMA use, whether BMA use was discontinued before tooth extraction (drug holiday), the duration of such discontinuation, the presence of pre-existing inflammation, and whether additional surgical procedures (e.g., incision, removal of bone edges, root amputation) were performed. We found that root amputation (OR = 22.62), immunosuppressive therapy (OR = 16.61), extraction of mandibular teeth (OR = 12.14), extraction of teeth with pre-existing inflammation, and longer duration (≥ 8 months) of high-dose BMA (OR = 7.85) were all significantly associated with MRONJ. Tooth extraction should not necessarily be postponed in cancer patients receiving high-dose BMA. The effectiveness of a short-term drug holiday was not confirmed, as drug holidays had no significant impact on MRONJ incidence. Tooth extraction may be acceptable during high-dose BMA therapy until 8 months after initiation.

Medication-related Osteonecrosis of the Jaw After Tooth Extraction in Cancer Patients: A Multicenter Retrospective Study

Surgical treatment of osteonecrosis of the jaw with the use of platelet-rich fibrin: a prospective study of 15 patients.

Objectives Principles and workflow are described to prevent bisphosphonate-related osteonecrosis of the jaw (BRONJ) when oral surgery is necessary in patients taking bisphosphonates. Material and Method A total of 117 surgical procedures were performed on 68 patients taking bisphosphonates. The basis of the treatment was (1) use of perioperative antibiotics; (2) after dentoalveolar surgical procedures, bone edges were smoothed and mucoperiosteal flaps were prepared to ensure tension-free wound closure; (3) sutures were not removed until 14 days postsurgery; (4) long-term results were evaluated. Results Ninety-seven percent of all procedures were simple and showed no complications. Only 3 patients with a long history of intravenous bisphosphonate medication developed BRONJ within 4 weeks after surgery. No patient receiving oral bisphosphonates developed BRONJ. No long-term failure was observed when primary wound healing was successful. Conclusions The high success rate of the described surgical procedures imply dentoalveolar surgery with low risk of development of BRONJ is possible for patients taking bisphosphonates.

Principles of oral surgery for prevention of bisphosphonate-related osteonecrosis of the jaw.

Bone regeneration without bone grafting after resection of a segment of the mandible to treat bisphosphonate-related osteonecrosis of the jaw.

Negative pressure wound therapy (NPWT) has been used for a broad range of indications and wound types. However, it can be difficult to maintain an airtight dressing seal when the wound is located in an anatomically challenging area or environment. To address this problem, medical silicone, used to create intraoral vacuum dressings, was used in five patients (one woman, four men, age range 57 to 66 years) to seal leaking NPWT dressings (four polyurethane dressings and one polyurethane silver foam dressing). The wounds were located in the head and neck, abdominal, lower extremity, and anogenital areas. Initial wound sizes ranged from 2.5 cm² to 700 cm², and periwound areas were characterized by irregular surfaces (scars, skin folds, or curved surfaces), humid milieu, or mobile structures. In all five patients, negative pressure was set at -125 mm Hg constant suction, and the silicone was able to seal the leaking dressings. Wound size reductions from 2.5 cm² to 13.5 cm² were observed during 9 to 64 days (range) of NPWT treatment. In these patients, medical silicone was found to be a suitable material to facilitate airtight sealing of the dressings used with NPWT.

Using medical silicone to ensure an airtight negative pressure wound therapy dressing seal in challenging wounds: a case series.

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Principles of oral surgery for prevention of bisphosphonate-related osteonecrosis of the jaw.

Bone regeneration without bone grafting after resection of a segment of the mandible to treat bisphosphonate-related osteonecrosis of the jaw.

Using medical silicone to ensure an airtight negative pressure wound therapy dressing seal in challenging wounds: a case series.