Denosumab and osteonecrosis of the jaws - the pharmacology, pathogenesis and a report of two cases.

Denosumab (Amgen, Thousand Oaks, California, USA) is a new bone antiresorptive agent used in patients with osteoporosis or metastatic cancer to the bones. As with the bisphosphonates that are used as antiresorptive medications, denosumab has been associated with osteonecrosis of the jaws (ONJ). Over the past two years there has been an increase in the literature describing ONJ in patients receiving agents such as denosumab. Due to promising study results that demonstrate the effectiveness of denosumab in avoiding skeletal complications related to osteoporosis and metastatic bone disease, more patients will receive denosumab in the future. It is reported that this has the potential to become a comparable challenge to bisphosphonate related osteonecrosis of the jaws (BRONJ) for clinicians. This article describes the management of two patients that developed ONJ while receiving denosumab, reviews the incidence of ONJ associated with denosumab, and contrasts the pharmacokinetics of denosumab and the bisphosphonates. The importance of avoiding interventional dental treatment until denosumab has been withdrawn for six months cannot be overstated.

An in vivo and in vitro comparison of the effects of vasoactive mediators on pulpal blood vessels in rat incisors.

The effects of endogenous vasoactive substances were evaluated in anaesthetized rats using a laser Doppler flowmeter to monitor changes in pulpal blood flow, as well as directly in isolated pulpal arteriole preparations utilising a microperfusion and monitoring system to observe changes in vessel diameter. In anaesthetized rats, while systemic arterial blood pressure remained relatively stable, intra-arterial delivery of adrenaline (epinephrine) (A), noradrenaline (norepinephrine) (NA), phenylephrine (PHE), dopamine (DOPA), 5-hydroxytryptamine (5-HT), or endothelin-1 (ET-1) produced a dose-dependent reduction in pulpal blood flow (order of potency: ET-1>>A=NA>PHE=DOPA=5-HT); acetylcholine induced a dose-dependent increase in pulpal blood flow; histamine, isoproterenol and adenosine produced no significant changes. In isolated arteriole preparations, intraluminal delivery of A, NA, PHE, DOPA or 5-HT produced dose-dependent vasoconstriction (A=NA>PHE=DOPA=5-HT). Acetylcholine relaxed NA-precontracted vessels dose-dependently. Histamine and isoproterenol produced a small vasodilatation. Intraluminal ET-1 produced a small vasoconstriction at 10(-8)M, whereas extraluminal ET-1 produced a dose-dependent vasoconstriction from 10(-10)M and above. Intraluminal adenosine failed to dilate vessels precontracted with ET-1, whereas extraluminal adenosine caused a complete relaxation. These combined in vivo and in vitro data suggest that, in the rat incisor, the pulpal microcirculation is capable of functional regulation and that pulpal blood flow may be modulated by endothelium-related factors, metabolic (tissue-related) factors, as well as humoral (blood-borne) factors.

Oxygen distribution and consumption in rat lower incisor pulp.

The aim was to determine the oxygen tension (P(O(2))) and rate of oxygen consumption in the pulp. Twelve rats were anaesthetised and artificially ventilated. Under an operating microscope, a recessed oxygen-sensitive microelectrode was inserted into the pulp through a small saline-covered cavity on the labial surface of the lower incisor. P(O(2)) was measured as a function of the transverse distance from the saline medium through to the middle of the pulp. Oxygen profiles were characterised by a decline of oxygen tension outside the pulp in the saline medium and a steeper gradient across the interface, before a localised oxygen consuming region corresponding to the odontoblasts. A plateau with some localised fluctuations was then followed by an increase in oxygen tension in the middle of the pulp. The average oxygen tension in the plateau region was 23.2 mmHg+/-2.1 mmHg (n=12). A mathematical model was used to extract oxygen consumption data from P(O(2)) profiles recorded from non-perfused pulp (created by reducing systemic blood pressure). The analysis revealed that there was a distinct oxygen consumption zone in the outer pulp, which anatomically corresponded to the odontoblast layer. The average oxygen consumption rate of the odontoblasts was 3.2+/-0.2 ml O(2)/min per 100g pulp tissue. The zone of high oxygen consumption was 68.7 micro m+/-6.9 micro m (n=24) thick. It is concluded that pulpal oxygen distribution is heterogeneous and that the odontoblast could be a major oxygen consumer within the rat incisor pulp.

Agonist-induced vasoactive responses in isolated perfused porcine dental pulpal arterioles.

A novel isolated perfused pulpal arteriole preparation and microperfusion system was used to evaluate the direct vasoactive responses of pulpal arterioles to selected agonists. Short lengths of porcine pulpal arterioles (101.7+/-2.2 microm o.d., n=105) were dissected out and placed in an environment-controlled bath on the stage of an inverted microscope. Both ends of the vessel were cannulated and perfused at a controlled rate through the lumen. The diameter of the vessel was measured online. Following equilibration, the vessel was challenged with various agonists: adrenaline (epinephrine), noradrenaline (norepinephrine), phenylephrine, dopamine, isoproterenol, 5-hydroxytryptamine, histamine and adenosine. The endothelium-dependent vasodilator acetylcholine was used to evaluate endothelial cell function. Adrenaline, noradrenaline, phenylephrine, 5-hydroxytryptamine and dopamine caused dose-dependent contractions (adrenaline=noradrenaline>phenylephrine>dopamine>5-hydroxytryptamine). Isoproterenol and histamine provoked a dose-dependent dilation. Adenosine produced pronounced vasodilatation in vessels precontracted with 10(-8)M endothelin-1. Functional adrenergic, histamine, 5-hydroxytryptamine and adenosine receptors are, therefore, present in porcine pulpal arterioles. The isolated perfused pulpal arteriole preparation may prove valuable in understanding local control mechanisms of pulpal microcirculation.

Acetylcholine-induced vasodilation of isolated pulpal arterioles.

The presence of cholinergic mechanisms in the control of pulpal microcirculation has been a controversial issue. In this study, we aimed to determine the direct vasoactive responses of isolated pulpal arterioles to acetylcholine, and to investigate whether such responses are endothelium-dependent. Using an in vitro micro-perfusion system, we isolated pig pulpal arterioles, cannulated and perfused them intraluminally, and monitored the diameter. Following equilibration, the vessels were contracted with 10(-5) M noradrenaline, and the effect of increasing doses of acetylcholine was determined. The influence of the muscarinic antagonist, atropine, or the loss of endothelial cell function following saponin treatment was also determined. Acetylcholine induced a dose-dependent vasodilation, reaching 94.6+/-1.4% (n = 22) of the uncontracted diameter at 10(-4) M. The vascular relaxation effect of acetylcholine was abolished in the presence of atropine, and by saponin treatment. Analysis of these data suggests that, in the pig, the acetylcholine-induced vasodilation of incisor pulpal arterioles is endothelium-dependent and mediated by muscarinic receptors.

An extension of a phenomenological model for dental composites.

OBJECTIVES: The aims of this study are firstly to demonstrate the limitations of a phenomenological model proposed for filler/resin dental composites, and secondly, to modify the model to accommodate these limitations. METHODS: A power-law rule of mixtures (ROM) is established by a simple modification of the elastic contact mechanics. A scaling parameter from the modification links the composite modulus Ec to the filler and resin moduli, Ef and Er. Computer simulation results available in the literature are used to determine the scaling parameter. Difference between the previous phenomenological model and the current approach is evaluated using correlation coefficients and standard errors. RESULTS: The results demonstrate that the previous phenomenological model is deficient if the modulus ratio Ef/Er is higher than 10 (the normal Ef/Er ratio for filler/resin dental composites is around 20-30). A modified approach keeps the simplicity of the previous model, gives much improved predictions for composite moduli and satisfies the boundary conditions for bulk filler and resin materials. SIGNIFICANCE: Dental researchers investigating a variety of combinations of different fillers and resins can have accurate first-hand estimates of the potential composite modulus even before the composites are actually made. Therefore, the dental researchers will be able to tailor their composite modulus more purposefully to match either the dentin or enamel modulus. Such a useful design tool would obviously promote much wanted further research and application of polymeric dental composites.

Structure of hamster palatal gingiva and intermolar mucosa after intraperitoneal dosing with N-methyl-N-nitrosourea: a scanning electron microscope study.

The palatal gingiva and intermolar mucosa from normal hamsters and from hamsters that had received N-methyl-N-nitrosourea (NMU) intraperitoneally were examined by scanning electron microscopy over a 22-week period. The normal gingiva and rostral two-thirds of the intermolar mucosa were covered by flat polygonal cells that had a regular honeycomb surface pattern of interconnecting micro-ridges, distinct cell boundaries and imprints of cells that had been desquamated. The caudal third of the intermolar mucosa in normal and NMU-treated hamsters was covered by soft-palate type mucosa whose smooth surfaced cells surrounded scattered fungiform-like papillae. In NMU-treated hamsters changes were more common in the rostral two-thirds of the intermolar mucosa than in the gingiva. At 10 weeks there were sessile and conical surface projections and saucer-shaped and conical epithelial-lined depressions. At 16 weeks these projections and depressions were larger and more numerous, and groups of conical projections formed papillomatous-like lesions. At 22 weeks the projections and depressions were further increased in number and size and there were distinct papillomas. At 10 and 16 weeks the entire epithelium showed cells, cell boundaries and cell imprints resembling those in the controls, except that there were defects or dilated intercellular spaces at the base of the conical depressions and some of the cells were thicker. Much of the 22-week epithelial had a similar structure, but in some areas that did not show the projections or depressions the cells varied in size and shape and were covered by elongated micro-ridges. Here the surface was irregular as were the cell boundaries. Examination of sections by light microscopy, both from these irregular areas and from areas that appeared normal by scanning electron microscopy, revealed that the deeper epithelial strata could be either normal, dysplastic or at times malignant. However, scanning electron microscopy failed to reveal dysplastic or malignant epithelium.

Temporal alterations in cytokeratin expression during experimental oral mucosal carcinogenesis.

Precancerous lesions and squamous cell carcinomas (SCCs) were induced in the oral mucosa of outbred male Sprague-Dawley rats by repeated application of the carcinogen 4-nitroquinoline-1-oxide. Temporal alterations in the pattern of cytokeratins expressed by epithelial cells in these developing neoplasms were investigated by means of one- and two-dimensional polyacrylamide gel electrophoresis and by probing electrophoretic blots of these gels with anticytokeratin antibodies. Progressive diminution in the expression of a 58.3 kDa cytokeratin was detected in moderately dysplastic epithelium and subsequent lesions, as was reduced expression of a 53.5 kDa cytokeratin after a stage of severe dysplasia had been induced. Analysis of two-dimensional electrophoretograms indicated an alkaline shift of acidic variants of a 49.0 kDa cytokeratin in moderately dysplastic epithelium; this shift was more pronounced in the induced, severely dysplastic epithelium and SCCs. The latter finding of an alkaline shift in cytokeratins of dysplastic epithelial cells has not been previously reported in preneoplastic lesions.

Oral hairy leukoplakia-like lesions in an HIV-negative male: a case report.

Oral hairy leukoplakia is generally found only in HIV-seropositive individuals or in those who are at risk of developing this infection; its occurrence is accepted to be a reliable predictor for the development of AIDS in those patients who are not already suffering from this disease. This report describes an 18-year-old male who was proven to be HIV-seronegative, was not in any of the at-risk groups associated with this infection, but who had the typical features of oral hairy leukoplakia, clinically and histologically. In such individuals these lesions should be described as hairy leukoplakia-like lesions.

Differences between preneoplastic cells, neoplastic cells and their normal counterparts.

A number of changes occur in preneoplastic and neoplastic cells as they progress towards a greater degree of malignancy. These alterations include genetic changes, epigenetic changes, surface alterations and alterations in intercellular interactions. In some instances, these changes are contributing factors to the degree of pathology noted, whilst other are resultant. In many situations, the relationship between these changes and the progression towards neoplasia is not understood. Nevertheless, it seems probable that these changes are ultimately involved in driving cells further along the path to neoplastic transformation. It is the purpose of this review to consider the changes which occur as cells progress from normality to being neoplastic, with particular reference to the cells of the oral mucosa, and the use to which detectable changes can be used as prognostic indicators.

Mechanisms of carcinogenesis with particular reference to the oral mucosa.

Three types of stimulus, chemical, physical and viral, are known to be carcinogenic to susceptible animals. This review considers these stimuli and their possible mechanisms in general terms and their possible relevance to the induction of oral mucosal carcinoma in particular.

Factors associated with the development of neoplasia.

A number of factors have been associated with the development of the phenotypic expression of neoplastic disease. The following article reviews the evidence implicating these factors in carcinogenesis and considers them under the groupings of familial or genetic factors, dietary factors, hormonal factors, age and gender.