Medication-Related Osteonecrosis of the Jaw: MASCC/ISOO/ASCO Clinical Practice Guideline.

PURPOSE: To provide guidance regarding best practices in the prevention and management of medication-related osteonecrosis of the jaw (MRONJ) in patients with cancer. METHODS: Multinational Association of Supportive Care in Cancer/International Society of Oral Oncology (MASCC/ISOO) and ASCO convened a multidisciplinary Expert Panel to evaluate the evidence and formulate recommendations. Guideline development involved a systematic review of the literature and a formal consensus process. PubMed and EMBASE were searched for studies of the prevention and management of MRONJ related to bone-modifying agents (BMAs) for oncologic indications published between January 2009 and December 2017. Results from an earlier systematic review (2003 to 2008) were also included. RESULTS: The systematic review identified 132 publications, only 10 of which were randomized controlled trials. Recommendations underwent two rounds of consensus voting. RECOMMENDATIONS: Currently, MRONJ is defined by (1) current or previous treatment with a BMA or angiogenic inhibitor, (2) exposed bone or bone that can be probed through an intraoral or extraoral fistula in the maxillofacial region and that has persisted for longer than 8 weeks, and (3) no history of radiation therapy to the jaws or metastatic disease to the jaws. In patients who initiate a BMA, preventive care includes comprehensive dental assessments, discussion of modifiable risk factors, and avoidance of elective dentoalveolar surgery (ie, surgery that involves the teeth or contiguous alveolar bone) during BMA treatment. It remains uncertain whether BMAs should be discontinued before dentoalveolar surgery. Staging of MRONJ should be performed by a clinician with experience in the management of MRONJ. Conservative measures comprise the initial approach to MRONJ treatment. Ongoing collaboration among the dentist, dental specialist, and oncologist is essential to optimal patient care.

Antiresorptive agent-related osteonecrosis of the jaw in osteoporosis patients from Asian countries.

Bisphosphonate (BP)-associated osteonecrosis of the jaw (ONJ) was first reported in oncology patients in 2003 and subsequently in osteoporosis patients in 2004. Since oral surgical procedures, such as tooth extraction, are also considered one of the major risk factors for ONJ, there is confusion among physicians, dentists, and patients-particularly osteoporosis patients currently taking BPs-regarding the safety of remaining on therapy surrounding these procedures. Many papers about BP-related ONJ (BRONJ) have been published to date. In addition to BRONJ, recent studies have reported an association between ONJ and the antiresorptive therapy denosumab (Dmab; a RANKL-inhibitor). BRONJ and Dmab-related ONJ are together referred to as antiresorptive agent-related ONJ (ARONJ). The pathogenesis of ARONJ still remains unknown. It is forecasted that there will be an increased incidence of patients with osteoporotic fractures and an increased number of prescriptions for antiresorptive agents in Asia in the future. However, prescriptions for antiresorptives for osteoporosis may be restricted in the Asian population as the occurrence of ARONJ may be higher as compared with those in other countries. In this review, we focused on the following topics as it pertains to the Asian osteoporotic population: the oral condition specific for osteoporosis patients; definition, staging, prevalence and incidence of ARONJ; imaging modalities for ARONJ; specific risk factors for ARONJ; prevention strategies for ARONJ, and; cooperation between physicians and dentists in the prevention of ARONJ. Ideally, the Asian Federation of Osteoporosis Societies would cooperate with one another and find more population-specific evidence for the prevention of ARONJ.

Case-Based Review of Osteonecrosis of the Jaw (ONJ) and Application of the International Recommendations for Management From the International Task Force on ONJ.

Osteonecrosis of the jaw (ONJ) has been associated with antiresorptive therapy in both oncology and osteoporosis patients. This debilitating condition is very rare and advances in diagnosis and management may now effectively reduce the risk of its development and offer valuable treatment options for affected patients. This paper provides a case-based review of ONJ and application of the International Task Force on ONJ (referred to as the "Task Force") recommendations for the diagnosis and management of ONJ. The Task Force was supported by 14 international societies and achieved consensus from representatives of these multidisciplinary societies on key issues pertaining to the diagnosis and management of ONJ. The frequency of ONJ in oncology patients receiving oncology doses of bisphosphonate (BP) or denosumab is estimated at 1%-15%, and the frequency in the osteoporosis patient population receiving much lower doses of BP or denosumab is estimated at 0.001%-0.01%. Although the diagnosis of ONJ is primarily clinical, imaging may be helpful in confirming the diagnosis and staging. In those with multiple risk factors for ONJ for whom major invasive oral surgery is being planned, interruption of BP or denosumab therapy (in cancer patients) is advised, if possible, before surgery, until the surgical site heals. Major oral surgery in this context could include multiple extractions if surgical extractions are required, not simple forceps extractions. ONJ development may be reduced by optimizing oral hygiene and postoperatively using topical and systemic antibiotics as appropriate. Periodontal disease should be managed before starting oncology doses of BP or denosumab. Local debridement may be successful in disease unresponsive to conservative therapy. Successful surgical intervention has been reported in those with stage 3 disease; less severe disease is best managed conservatively. Teriparatide may be helpful in healing ONJ lesions and may be considered in osteoporosis patients at a high fracture risk in the absence of contraindications. Resumption of BP or denosumab therapy following healing of ONJ lesions is recommended, and there have not been reports of subsequent local recurrence.

Diagnosis and management of osteonecrosis of the jaw: a systematic review and international consensus.

This work provides a systematic review of the literature from January 2003 to April 2014 pertaining to the incidence, pathophysiology, diagnosis, and treatment of osteonecrosis of the jaw (ONJ), and offers recommendations for its management based on multidisciplinary international consensus. ONJ is associated with oncology-dose parenteral antiresorptive therapy of bisphosphonates (BP) and denosumab (Dmab). The incidence of ONJ is greatest in the oncology patient population (1% to 15%), where high doses of these medications are used at frequent intervals. In the osteoporosis patient population, the incidence of ONJ is estimated at 0.001% to 0.01%, marginally higher than the incidence in the general population (<0.001%). New insights into the pathophysiology of ONJ include antiresorptive effects of BPs and Dmab, effects of BPs on gamma delta T-cells and on monocyte and macrophage function, as well as the role of local bacterial infection, inflammation, and necrosis. Advances in imaging include the use of cone beam computerized tomography assessing cortical and cancellous architecture with lower radiation exposure, magnetic resonance imaging, bone scanning, and positron emission tomography, although plain films often suffice. Other risk factors for ONJ include glucocorticoid use, maxillary or mandibular bone surgery, poor oral hygiene, chronic inflammation, diabetes mellitus, ill-fitting dentures, as well as other drugs, including antiangiogenic agents. Prevention strategies for ONJ include elimination or stabilization of oral disease prior to initiation of antiresorptive agents, as well as maintenance of good oral hygiene. In those patients at high risk for the development of ONJ, including cancer patients receiving high-dose BP or Dmab therapy, consideration should be given to withholding antiresorptive therapy following extensive oral surgery until the surgical site heals with mature mucosal coverage. Management of ONJ is based on the stage of the disease, size of the lesions, and the presence of contributing drug therapy and comorbidity. Conservative therapy includes topical antibiotic oral rinses and systemic antibiotic therapy. Localized surgical debridement is indicated in advanced nonresponsive disease and has been successful. Early data have suggested enhanced osseous wound healing with teriparatide in those without contraindications for its use. Experimental therapy includes bone marrow stem cell intralesional transplantation, low-level laser therapy, local platelet-derived growth factor application, hyperbaric oxygen, and tissue grafting.

Bilateral mandibular condylysis from systemic sclerosis: case report of surgical correction with bilateral total temporomandibular joint replacement.

Systemic sclerosis (SSc) is a multisystem connective tissue disease of unknown etiology. The hallmark of SSc is scleroderma, referring to the presence of thickened, hardened skin. Oral and maxillofacial manifestations of the disease are numerous including masklike appearance, trismus, muscular atrophy, thin atrophied lips, secondary microstomia, xerostomia, rigidity of tongue and lips, widening of the periodontal ligament space, trigeminal neuralgia, and resorption of the mandible. A 35-year-old woman with limited cutaneous SSc presented with bilateral mandibular condylysis, severe class II mandibular deficiency, and large anterior open bite and limited range of mandibular opening at 27 mm. Surgical correction consisted of bilateral total temporomandibular joint reconstruction with stock prostheses combined with Le Fort I maxillary impaction and functional advancement genioplasty. This resulted in a functional occlusion with elimination of her open bite and a more esthetic profile. Her occlusion has remained stable at 7 months. The incidence of mandibular resorption in SSc has been found to be 20% to 33%. The mandibular angles are most commonly involved (37.6%), followed by the condyle (20.8%), coronoid process (20.0%), and the posterior border of the ascending ramus (14.4%). Bilateral condylysis is present in 13.7% of the cases. Very few cases of surgical correction of malocclusion induced by SSc-related condylysis have been reported in the literature. To the best of our knowledge, this is the first case report of bilateral condylysis from SSc where surgical replacement of the resorbed condyles was attempted. Bilateral total temporomandibular joint replacement can give these patients a functional occlusion, improved facial balance, and improved quality of life.

Mandibular reconstruction using nonvascularized autogenous bone grafting.

PURPOSE OF REVIEW: This paper will discuss reconstruction of the mandible with autogenous nonvascularized bone grafting. New developments in this area will be investigated by reviewing the most recent literature on this topic as compared with other techniques currently employed. With the advances of vascularized free flap reconstruction it is important to investigate the indication for nonvascularized techniques. RECENT FINDINGS: Replacement of a portion of the mandibular bone is a common procedure for patients undergoing ablative cancer surgery or for infection as well as temporomandibular joint replacement secondary to disease or trauma. The subject of mandibular reconstruction has seen great advances in recent years with the advent of vascularized free tissue transfer. Other newer areas of mandibular replacement include tissue engineering and distraction osteogenesis. Traditional nonvascularized autogenous bone graft replacement can still play a vital role in rehabilitating these patients. SUMMARY: Although vascularized free flap reconstruction of mandibular defects has become the more common method of treating the postablative cancer surgery patient, there remain indications for nonvascularized reconstruction of mandibular defects as well as other techniques.

Dental burs and endodontic files: are routine sterilization procedures effective?

PURPOSE: The complex miniature architecture of dental burs and endodontic files makes precleaning and sterilization difficult. Devising a sterilization protocol for endodontic files and dental burs requires care, and some have suggested that these instruments be considered single-use devices. One purpose of this study was to determine the effective-ness of various sterilization techniques currently used in dentistry for the resterilization of dental burs and endodontic files. The second aim was to determine whether new dental burs and endodontic files, as supplied in packages from the manufacturer, are sterile. MATERIALS AND METHODS: The sterility of new (unused) and used dental burs and endodontic files before and after various sterilization procedures was analyzed. New burs and files were tested immediately after removal from manufacturers' packaging, with or without prior sterilization. Burs and files that had been used in various dental offices were precleaned, packaged, resterilized and then tested for various pathogens. Each item was individually removed from the sterilization packaging, transferred by sterile technique into Todd-Hewitt broth, incubated at 37degreesC for 72 hours and observed for bacterial growth. RESULTS: Sterilization procedures were 100 percent effective for unused burs and unused files but were less than 100 percent effective for all other test groups. Contamination rates following sterilization ranged from 15 percent for one group of used burs (p = 0.01) to 58 percent for one group of used files (p <0.001). CONCLUSIONS: Dental burs and endodontic files, as packaged by the manufacturer, are not sterile and should therefore be sterilized before first use. The resterilization procedures tested here were not adequate, and more rigorous sterilization procedures are needed. If such procedures cannot be devised, these instruments should perhaps be considered single-use devices.

Dental burs and endodontic files: are routine sterilization procedures effective?

PURPOSE: The complex miniature architecture of dental burs and endodontic files makes precleaning and sterilization difficult. Devising a sterilization protocol for endodontic files and dental burs requires care, and some have suggested that these instruments be considered single-use devices. One purpose of this study was to determine the effectiveness of various sterilization techniques currently used in dentistry for the resterilization of dental burs and endodontic files. The second aim was to determine whether new dental burs and endodontic files, as supplied in packages from the manufacturer, are sterile. MATERIALS AND METHODS: The sterility of new (unused) and used dental burs and endodontic files before and after various sterilization procedures was analyzed. New burs and files were tested immediately after removal from manufacturers" packaging, with or without prior sterilization. Burs and files that had been used in various dental offices were precleaned, packaged, resterilized and then tested for various pathogens. Each item was individually removed from the sterilization packaging, transferred by sterile technique into Todd-Hewitt broth, incubated at 37 degrees C for 72 hours and observed for bacterial growth. RESULTS: Sterilization procedures were 100% effective for unused burs and unused files but were less than 100% effective for all other test groups. Contamination rates following sterilization ranged from 15% for one group of used burs (p = 0.01) to 58% for one group of used files (p < 0.001). CONCLUSIONS: Dental burs and endodontic files, as packaged by the manufacturer, are not sterile and should therefore be sterilized before first use. The resterilization procedures tested here were not adequate, and more rigorous sterilization procedures are needed. If such procedures cannot be devised, these instruments should perhaps be considered single-use devices.

Mental nerve function after inferior alveolar nerve transposition for placement of dental implants.

BACKGROUND: One option for successful placement of dental implants in an atrophic posterior mandible without injury to the inferior alveolar nerve (IAN) is to transpose or lateralize the nerve. This procedure carries the risk of numbness along the distribution of the nerve, the complication that the procedure is undertaken to avoid in the first place. The purpose of the present study was to assess mental nerve function after transposition of the IAN. METHOD: We determined the outcomes of 20 IAN transposition procedures in 12 consecutive patients at the Queen Elizabeth II Health Sciences Centre in Halifax, Nova Scotia. The study included objective testing of sensory nerve function as well as subjective assessment by the participants. RESULTS: All subjects reported initial transient sensory disturbance. Objective testing after a minimum of 6 months revealed that, for each patient, affected sites had the same level of sensation as unoperated areas. Eighty percent of the patients said that the lower lip and chin felt normal. The others said that these structures did not feel exactly normal but that the difference was of no consequence. CLINICAL SIGNIFICANCE: It is concluded that IAN transposition can be safely and predictably performed with low risk to the mental nerve sensibility.