ABSTRACT
Abstract Introduction: Increased incidence of localized osteonecrosis in the jaw bones caused by bisphosphanate use and reduced quality of life of the patients led researchers to diagnose the disease in the early period and to investigate the effective treatment modality. Objective: Treatment of medication-related osteonecrosis of the jaw patients is based on individual protocols from clinical experience, as there are no definitive treatment guidelines. In view of the lack of consensus on the effectiveness of medication-related osteonecrosis of the jaw treatments in the literature, the aim of this study was to evaluate the surgical technique described in the treatment of advanced stages of medication-related osteonecrosis of the jaw patients. Methods: Twenty-one patients affected by Stage 2-3 medication-related osteonecrosis of the jaw were treated with ultrasonic piezoelectric bone surgery for necrotic bone removing, leukocyte and platelet-rich fibrin concentrate obtained from the patient's peripheral blood and Nd:YAG laser for biostimulation. Success was assessed as the maintenance of full mucosal coverage without signs of residual infection at 1-month (T1), 3-months (T2), 6-months (T3) and 1-year (T4) after surgery. Logistic regressions were used to evaluate the association between the different independent variables and treatment outcomes. Results: Two Stage 3 patients had delayed healing at 1 month after the operation. Complete mucosal healing was achieved in all patients at the third month. Multivariate analysis demonstrated that different variables were not significantly correlated with delayed healing (p>0.05). Conclusion: The surgical protocol presented in this study shows promising results for surgical management of advanced stages of medication-related osteonecrosis of the jaw patients. HIGHLIGHTS Removal of necrotic bone is important in the treatment of medication- related osteonecrosis of the jaw. Surgical treatment is more successful than conservative treatment in advanced stages (stage 2-3) of the medication- related osteonecrosis of the jaw. Relatively less invasive and supportive treatments are recommended in patients with advanced medication- related osteonecrosis of the jaw. Patient follow-up, good oral hygiene and patient motivation increase the success rate of the treatment.
Resumo Introdução: O aumento da incidência de osteonecrose localizada nos ossos da mandíbula causada pelo uso de bisfosfonatos e a redução da qualidade de vida dos pacientes levaram os pesquisadores a diagnosticar a doença em período inicial e a investigar a modalidade de tratamento eficaz. Objetivo: O tratamento de pacientes com osteonecrose da mandíbula relacionada a medicamentos é baseado em protocolos individuais de experiência clínica, uma vez que não há diretrizes de tratamento definitivas. Considerando a falta de consenso sobre a eficácia dos tratamentos de osteonecrose da mandíbula relacionada a medicamentos na literatura, o objetivo deste estudo foi avaliar a técnica cirúrgica descrita no tratamento de estágios avançados nesses pacientes. Método: Vinte e um pacientes com osteonecrose da mandíbula relacionada a medicamentos estágio 2-3 foram tratados com cirurgia óssea piezelétrica ultrassônica para remoção de osso necrótico, concentrado de leucócitos e fibrina rica em plaquetas obtido do sangue periférico do paciente e laser Nd: YAG para bioestimulação. O sucesso foi avaliado pela manutenção da cobertura total da mucosa sem sinais de infeçcão residual em um mês (T1), 3 meses (T2), 6 meses (T3) e um ano (T4) após a cirurgia. Regressões logísticas foram usadas para avaliar a associação entre as diferentes variáveis independentes e os resultados do tratamento. Resultados: Em dois pacientes no Estágio 3, a cicatrização foi tardia em um mês após a cirurgia. A cicatrização completa da mucosa foi obtida em todos os pacientes no terceiro mês. A análise multivariada demonstrou que diferentes variáveis não se correlacionaram significativamente com o retardo da cicatrização (p > 0,05). Conclusão: O protocolo cirúrgico apresentado neste estudo mostra resultados promissores para o manejo cirúrgico de estágios avançados de pacientes com osteonecrose da mandíbula relacionada a medicamentos. DESTAQUES A remo¸cão do osso necrótico é importante no tratamento de osteonecrose da mandíbula relacionada a medicamentos. O tratamento cirúrgico é mais bem-sucedido do que o tratamento conservador em estágios avançados (estágio 2-3) de osteonecrose da mandíbula relacionada a medicamentos. Tratamentos relativamente menos invasivos e de suporte são recomendados em pacientes com osteonecrose avançada da mandíbula relacionada a medicamentos. O seguimento do paciente, uma boa higiene oral e a motivação do paciente aumentam a taxa de sucesso do tratamento.
ABSTRACT
RESUMEN: La osteonecrosis mandibular asociada a medicamentos (MRONJ) es una enfermedad grave, pero de baja prevalencia en la cual los márgenes quirúrgicos de la resección ósea son determinados clínicamente por el cirujano basado en parámetros subjetivos. Debido a esto, se ha propuesto la resección ósea guiada por fluorescencia. Describir el conocimiento act ual sobre la resección ósea guiada por fluorescencia en pacientes con MRONJ. Se realizó Scoping Review, buscando en las bases de datos de Pubmed, ScienceDirect y Web of Science, utilizando los operadores booleanos AND y OR. Se aplicaron criterios de inclusión y exclusión. De 66 artículos iniciales, se seleccionaron 13 que cumplieron con los criterios de elegibilidad. Actualm ente se utiliza la técnica de fluorescencia con tetraciclinas (FT) y autofluorescencia (AF), describiéndose un éxito del 85 a 100 % y 7 7,3 a 100 % en un tiempo de seguimiento 1 a 12,9 y 4 a 13,1 meses respectivamente. Hubo 100 % de correlación Clínico-Histopatológica para tejido óseo vital y necrótico. La resección ósea guiada por fluorescencia logra discriminar clínicamente entre tejido óseo vital y necrótico, delimitando los márgenes quirúrgicos de la resección y/o desbridamiento basado en parámetros objetivos y reproducibl es que permiten estandarizar el procedimiento quirúrgico.
ABSTRACT: Medication-related Osteonecrosis of the jaw (MRONJ) is a serious but low prevalence disease in which the surgical margins of bone resection are clinically determinated by the surgeon based on subjetive parameters. Because of this, fluorescence-guided bone resection has been proposed. The objetive of this study is to describe the current knowledge of fluorescence-guided bone resection in patients with MRONJ. Scoping Review was carried out, searching the databases of PubMed, ScienceDirect and Web of Science, using the boolean operator AND and OR. Inclusion and exclusion criteria were applied. Of 66 articles, 13 were selected that met the eligibility criteriaThe technique of fluorescence with tetracyclines (FT) and autofluorescence (AF) is used, describing a success of 85 to 100 % and 77.3 to 100 % in 1 to 12.9 and 4 to 13.1 months respectively. There was 100 % Clinical-Histopathological correlation for vital and necrotic bone tissue. Fluorescence-guided bone resection is able to clinically discriminate between vital and necrotic bone tissue, allowing the delimitation of surgical margins based on objective and reproducible parameters. In addition, it allows to standardize the surgical procedure.
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ABSTRACT: Some adjuvant treatments are available for Medication-Related Osteonecrosis of the Jaw (MRONJ) to help the pain and improve quality of life. Among these treatments is hyperbaric oxygen (HBO) which has presented controversial findings in the literature in recent years. This integrative review analyzed the results among studies published during the pas t 10 years using HBO. The PICO strategy was used and the databases PubMed, LILACS, and SCOPUS. The final search resulted in the inclusion of 7 articles. The main conclusion is that, in the majority of cases, using HBO as an adjuvant to the basic therapy improved the quality of life and/or pain of the patients.
RESUMEN: Existen algunos tratamientos adyuvantes para la osteonecrosis de la mandíbula relacionada con medicamentos (MRONJ) para aliviar el dolor y mejorar la calidad de vida de los pacientes. Entre estos tratamientos se encuentra el oxígeno hiperbárico (OHB) que ha presentado resultados controvertidos en la literatura durante los últimos años. En esta revisión integrada se analizaron los resultados de los estudios publicados durante los últimos 10 años utilizando OHB. Se utilizó la estrategia PICO y las bases de datos PubMed, LILACS y SCOPUS. La búsqueda final resultó en la inclusión de 7 artículos. La principal conclusión es que, en la mayoría de los casos, el uso de OHB como adyuvante de la terapia básica mejoró la calidad de vida y / o el dolor de los pacientes.
ABSTRACT
La acción terapéutica favorable que los antirresortivos (bifosfonatos BPs, denosumab DS) y drogas antiangiogénicas ocasionan en el tejido óseo en aquellos pacientes que presentan como causa etiológica cáncer o discrasias óseas incluyen hipercalcemias malignas o si requieren el consumo de dicha droga a baja concentración como ser: osteoporosis, osteopenia, enfermedad de Paget, displasia fibrosa, Osteogénesis Imperfecta. (1) La presente actualización pretende relacionar el tratamiento odontológico con prescripción crónica y drogas antirresortivas, para lo cual American Association of Oral and Maxillofacial Surgeons AAOMS: define el concepto de Osteonecrosis Maxilar Asociada a drogas Antirresortivas (MRONJ) como: «Área ósea necrótica expuesta al medio bucal con más de ocho semanas de permanencia, en presencia de tratamiento crónico con bifosfonatos en ausencia de radioterapia en cabeza y cuello¼. La AAOMS estableció los siguientes grupos de acuerdo con sus características clínicas en 4 estadios (0, 1 ,2 y 3) de acuerdo con el aspecto clínico y radiológico de la lesión osteonecrótica. Estadío 0: lesión osteonecrótica sin evidencia de hueso necrótico en pacientes bajo consumo de drogas antirresortivas. Estadío 1: lesión osteonecrótica con signos clínicos y ausencia de sintomatología clínica. Estadío 2: lesión osteonecrótica con signo y sintomatología clínica evidente. Estadío 3: lesión osteonecrótica con signo y sintomatología evidente que compromete a estructuras nobles: fracturas patológicas, anestesia del nervio dentario inferior, comunicación buco-nasal, comunicación buco-sinusal, fístulas cutáneas (2) (AU)
It is known the favourable action which antiresorptive (Bisphosphonates BPs, Denosumab: DS) and Antiangiogenic drugs produce in bone tissue. High concentrations are primarily used as an effective treatment in the management of cancer-related disorders, including hypercalcemia of malignant. Besides, low concentrations are used for other metabolic bone diseases including Osteoporosis, Osteopenia, Paget's Disease, Fibrous Dysplasia, Imperfect Osteogenesis. (1) The update relate relationship between dentistry and chronic treatment with antiresorptive drugs. According to the American Association of Oral and Maxillofacial Surgeons (AAOMS), MRONJ is defined as exposed or necrotic bone in the maxillofacial region that has persisted for more than 8 weeks in association with current or previous BPs or DS therapy and with a lack of head and neck radiotherapy. AAOMS divided the MRONJ into 4 stages (0,1, 2 and 3) according to the clinical and radiological aspect of the osteonecrotic lesion: Stage 0: osteonecrotic lesion without sign-pathognomonic evidence of osteonecrosis. Stage 1: osteonecrotic lesion with clinical signs and absence of clinical symptoms. Stage 2: osteonecrotic lesion with sign and evident clinical symptoms. Stage 3: osteonecrotic lesion with signs and evident symptoms that involve noble structures: pathological fractures, anaesthesia of the lower dental nerve, oral-nasal communication, oral-sinus communication, skin fistulas (2) (AU)
Subject(s)
Humans , Female , Aged , Bone Resorption , Diphosphonates/adverse effects , Bone Density Conservation Agents , Bisphosphonate-Associated Osteonecrosis of the Jaw , Bone Diseases , Dental Care for Chronically Ill , Angiogenesis Inhibitors , Denosumab , Mouthwashes/therapeutic useABSTRACT
Osteoporosis is a major, growing healthcare issue. This is especially of concern in an ageing population like that of Singapore. Osteoporotic patients are at risk of fractures, which can result in increased morbidity and mortality. The use of antiresorptive therapy with bisphosphonates or denosumab has been proven to reduce fracture risk. However, the use of these medications has rarely been associated with the development of osteonecrosis of the jaw, a potentially debilitating condition affecting one or both jaws. Appropriate understanding of the patient's antiresorptive therapy regime, as well as early institution of preventive dental measures, can play an important role in preventing medication-related osteonecrosis of the jaw (MRONJ). Regular monitoring and prompt referral to specialist care is warranted for patients with established MRONJ.