Effective Treatment of Geniospasm: Case Series and Review of the Literature.

Background: Geniospasm is a rare genetic disorder characterized by paroxysmal rhythmic or irregular movements of the chin and lower lip due to repetitive contractions of the mentalis muscle. Pathophysiology is poorly understood, and optimal treatment has not been established. Methods: Geniospasm was characterized in a series of patients after evaluation in our clinics, and a comprehensive review of all cases in the medical literature was performed. Results: We evaluated four patients (1 female) in four families with geniospasm, aged 4 months to 9 years. Bothersome symptoms were present in one patient, who was treated with regular injections of onabotulinumtoxinA, with complete resolution of symptoms and no adverse effects. 9 patients in the literature have had similar outcomes. Conclusions: Limited data exist with regard to the effective treatment of geniospasm. Several treatments have been used historically, with variable outcomes. Our results, together with those of prior reported cases, demonstrate benefit of the use of botulinum toxin injections for management of this condition.

Role of dendritic cell-mediated immune response in oral homeostasis: A new mechanism of osteonecrosis of the jaw.

Dendritic cells are an important link between innate and adaptive immune response. The role of dendritic cells in bone homeostasis, however, is not understood. Osteoporosis medications that inhibit osteoclasts have been associated with osteonecrosis, a condition limited to the jawbone, thus called medication-related osteonecrosis of the jaw. We propose that disruption of the local immune response renders the oral microenvironment conducive to osteonecrosis. We tested whether zoledronate (Zol) treatment impaired dendritic cell (DC) functions and increased bacterial load in alveolar bone in vivo and whether DC inhibition alone predisposed the animals to osteonecrosis. We also analyzed the role of Zol in impairment of differentiation and function of migratory and tissue-resident DCs, promoting disruption of T-cell activation in vitro. Results demonstrated a Zol induced impairment in DC functions and an increased bacterial load in the oral cavity. DC-deficient mice were predisposed to osteonecrosis following dental extraction. Zol treatment of DCs in vitro caused an impairment in immune functions including differentiation, maturation, migration, antigen presentation, and T-cell activation. We conclude that the mechanism of Zol-induced osteonecrosis of the jaw involves disruption of DC immune functions required to clear bacterial infection and activate T cell effector response.

Botulinum neurotoxin a therapy efficacy and safety for oromandibular dystonia: a meta-analysis.

Oromandibular dystonia (OMD) is a focal dystonia involving the mouth, jaw, and tongue. Botulinum neurotoxin (BoNT) therapy might be one form of treatment in OMD. Systematic pooling of BoNT studies in OMD remains wanting, as the derived data could provide useful information in regard to efficacy and safety issues. This meta-analysis determined the effects of botulinum neurotoxin type A (BoNT/A) on the reduction of dystonic movement and its safety among patients with OMD. A systematic search of the literature that met the following eligibility criteria were done: (1) patients treated with BoNT/A for OMD, (2) studies of high methodological quality and (3) outcome criteria specified as regard to efficacy. Risk of unresolved dystonia was computed before and after BoNT/A intervention. Random effect size (p < 0.05ɑ) and test of heterogeneity (< I2 50%) were computed as meta-analysis tool using REVMAN ver 5.3 program. Safety data, where available, were systematically reviewed. Nine studies involved 387 cases in total of OMD. The pooled risk ratio is 0.607 with a confidence interval of 0.371-0.783, a z value of 3.85, and a p value of 0.0001. Results indicate that risk of dystonic movements is lower by 39.30% in the treatment group than in the control group. A total of 105/387 patients (27.1%) experienced adverse events most commonly dysphagia. Whilst cited literatures have inherent weaknesses, results show that BoNT/A is efficacious in reducing dystonic movements of patients with OMD. Majority of studies employed electromyography (EMG) guidance in muscle targeting. Given the potential adverse event of dysphagia, one may take a cautious stand while delivering injections to target muscles. These findings are congruent with what has been published in regard to efficacy of BoNT/A in focal dystonia.

Management of osteoradionecrosis of the jaws with pentoxifylline-tocopherol: a systematic review of the literature and meta-analysis.

Osteoradionecrosis (ORN) of the jaws remains among the most commonly encountered and challenging complications of radiotherapy to the head and neck. The purpose of this study was to provide a review of the medical management for ORN and evaluate the reported outcomes with the use of pentoxifylline and tocopherol (PENTO), by means of a systematic review and meta-analysis. The predictor variable was the use of PENTO in the treatment of ORN. The outcome variable was the proportion of full recovery or significant improvement not requiring further intervention. The likelihood function was used to combine the studies and estimate the proportion and standard deviation of each outcome by the maximum likelihood estimation. Seven studies met the inclusion criteria. A total 211 patients were treated. One hundred twenty-six patients recovered fully or improved significantly not requiring further intervention. Sixty patients remained the same, 10 were lost to follow-up, and the disease progressed in 15. The current literature supports the use of PENTO in the treatment of ORN of the jaws. Additional well-designed prospective studies are needed in order to further validate the regimen that can then be employed in the treatment of ORN.

Life threatening bleeding from an osteonecrosis of the jaw: Are bisphosphonates safe in irradiated head and neck cancer patients?

Osteonecrosis of the jaw is a significant complication secondary to radiation therapy or drug therapy, most commonly bisphosphonates. Safety data regarding the administration of bisphosphonates in bone metastatic head and neck cancer patients with history of jaw irradiation are almost non-existent. In this paper, we report the case of a Head and Neck (HNC) patient, with history of radiation therapy to the mandible region, treated with intravenous bisphosphonates for bone metastases that resulted in gross, life threatening mouth hemorrhage secondary to advanced, locally invasive ONJ.

Immunoexpression of calcitonin and glucocorticoid receptors in central giant cell lesions of the jaws.

BACKGROUND: This study analyzed the immunoexpression of calcitonin receptor (CTR) and glucocorticoid receptor (GR) in central giant cell lesions (CGCLs) and verified potential associations with patient's response to clinical treatment with intralesional injection of triamcinolone. MATERIALS AND METHODS: Fifty-four cases of CGCLs, including 22 non-aggressive, and 32 aggressive, were investigated by immunohistochemistry. RESULTS: Surgery was the therapeutic choice for 53.1% of the aggressive CGCLs, and 46.9% were submitted to the conservative treatment with intralesional triamcinolone injections. Among patients submitted to conservative treatment, 60% (n = 9) showed favorable response. CTR expression was observed in 68.51%, and GR in 94.44% of the total sample. There were no differences in the expression of CTR, neither GR in mononucleated stromal cells (MSCs) or multinucleated giant cells (MGCs), in relation to aggressiveness, treatment performed for and the response to conservative treatment. Both markers showed a positive correlation between their expression in MSCs and MGCs in the total sample (P < 0.0001). CTR expression on MSCs showed a positive correlation with MGCs in the aggressive and non-aggressive groups (P < 0.0001). CONCLUSIONS: Calcitonin receptor and GR expression were diffuse and similar in non-aggressive and aggressive cases, and it did not influence the response to clinical treatment with triamcinolone in the sample studied.

Follow-up of patients with systemic immunological diseases undergoing fatty-degenerative osteolysis of the jawbone surgery and treated with RANTES 27CH.

Regulated-on-activation, normal T cell expressed and secreted (also called RANTES, CCL5 or R/C) is a chemotactic cytokine that plays a key role in recruiting immune cells to inflammatory sites. R/C is involved in the pathogenesis of many systemic immune-mediated diseases (SIDs) and is upregulated in fatty-degenerative osteolysis jawbone (FDOJ) cavitations. Surgical cleaning of degenerative areas reduces the source of chronic R/C but might not be sufficient to re-establish the altered immunological patterns. The aim of the present study was to collect clinical data from patients suffering from sids who underwent dental surgery of FDOJ areas (n=46), by measuring R/C serum levels at the first visit (V0) prior to surgery, and at the second visit (V1). The majority of patients (n=41) were treated one month with ultra-low dose RANTES (27CH), a medicine used in micro-immunotherapy, while five patients were not. Mean and standard deviation of R/C serum levels at V0 in treated and untreated patients were respectively 48.5±25.8ng/ml and 42.48±22.22ng/ ml. Untreated patients had a tendency towards higher R/C levels at V1 (68.36±30.7ng/ml; p=0.062), while an opposite tendency was observed in treated patients (40.9±20.3ng/ml; p=0.129). Investigators observed that a cut-off set at 40ng/ml at V0 seemed to be predictive of the efficacy of the dental surgery/treatment (p=0.0013, n=26) and that gender could influence R/C levels and patient's responsiveness. The Authors, being aware that this is a preliminary follow-up, wanted to lay the basis for forthcoming studies, in which a larger cohort of patients and well-defined inclusion/exclusion criteria will be established.

Effect of different doses and durations of teriparatide therapy on resolution of medication-related osteonecrosis of the jaw: A randomized, controlled preclinical study in rats.

OBJECTIVE: To evaluate the effects of different doses and durations of teriparatide therapy on MRONJ resolution in rats. SUBJECTS AND METHODS: A total of 120 rats that had been affected with MRONJ (after six weekly zoledronate injections and tooth extraction) were randomly divided into eight subgroups: 2, 10, and 20 µg/kg/day teriparatide were administered to L4, M4, and H4 for 4 weeks, and to L8, M8, and H8 for 8 weeks, respectively. C4 and C8 received saline for 4 and 8 weeks, respectively. One week after the final injection, rats were sacrificed and assessed clinically (bone exposure/fistula) and histologically (number of osteocytes in extraction socket and empty lacunae in alveolar bone). RESULTS: MRONJ was clinically improved in 72.2%, 61.5%, and 40% of stage I, II, and III experimental rats, respectively. In the control rats, the results were 20.8% for stage I and no improvement for stages II and III. Aside from L4 and L8, the experimental subgroups had a significantly higher rate of clinical and histological improvement compared with their corresponding controls. There was a significantly higher number of osteocytes and lower number of empty lacunae in M4 and H4 compared with C4, in H4 compared with L4, in M8 and H8 compared with C8, and in H8 compared with L8. CONCLUSION: Teriparatide therapy improved clinical and histological features of MRONJ in a dose-dependent manner, but clinically relevant doses of teriparatide might not be sufficient for MRONJ resolution in rats. Extending the duration of teriparatide therapy from 4 to 8 weeks did not affect treatment outcomes.

Denosumab as a Treatment Alternative for Central Giant Cell Granuloma: A Long-Term Retrospective Cohort Study.

PURPOSE: Giant cell granuloma (GCG) of the jaw is a rare disease with high morbidity. Various treatment options have been discussed in the past. Since 2010, a pharmaceutical therapy with denosumab seems to have been successful for giant cell tumors of the femur. The authors hypothesized the equally successful use of denosumab for GCGs of the jaws. MATERIALS AND METHODS: In the present retrospective cohort study, 5 patients with large GCGs of the jaws were treated with denosumab with a follow-up of 25 to 49 months. Frequent clinical follow-ups and a radiologic follow-up were performed and systematically analyzed. RESULTS: All patients showed a curative treatment response and complete metabolic resolution of the GCGs under treatment with denosumab. CONCLUSION: A brief review of the relevant literature and a detailed evaluation of current cases led to the conclusion that denosumab therapy should be considered a therapeutic option for large central GCGs of the jaws. The results of this study suggest denosumab is a successful treatment option. A treatment length no shorter than 12 months is recommended and monitoring of treatment response can be well managed by positron-emission tomographic computed tomography or magnetic resonance imaging.

Adjudication of osteonecrosis of the jaw in phase III randomized controlled trials of denosumab: a systematic review.

PURPOSE: Denosumab (an anti RANKL antibody) is known to be associated with an increased risk for osteonecrosis of the jaw (ONJ). Due to the variety of clinical presentation, many ONJ definitions are used. Evaluation of ONJ's frequency during phase III randomized controlled trials (RCTs) is crucial to assess benefit-risk ratio. We verified that phase III RCTs involving denosumab reported the definition of ONJ used. METHODS: We systematically searched in Central, Medline, Cochrane, and Scopus, until 31 August 2015. We included original phase III RCTs, involving denosumab. Post hoc analysis and trial extension were excluded. Articles that did not mention ONJ in their methods or results were excluded. The primary outcome was the prevalence of a complete definition of ONJ. When no definition was provided, ONJ adjudication process was analyzed. RESULTS: Of 313 articles found, 13 RCTs were included. A definition of ONJ was detailed in two RCTs (15%). For the remaining 11 RCTs, adjudication process was mentioned for nine. In those processes, "blinded," "expert," and "independent" were the most used words. CONCLUSION: Most of the published phase III RCTs involving denosumab did not specify the definition of ONJ used to adjudicate events in the study. Instead of definition, non-scientific and non-reproducible expressions were used. Because the chosen definition could impact the ONJ estimated frequency, it should be mandatory to give the precise definition used in each RCT publication involving denosumab.

Use of Vancomycin-Impregnated Calcium Sulfate in the Treatment of Osteomyelitis of the Jaw.

PURPOSE: The aim of this study was to describe the effect of vancomycin-impregnated calcium sulfate in the treatment of osteomyelitis of the jaw. MATERIALS AND METHODS: Twelve patients who were diagnosed with osteomyelitis of the jaw underwent treatment with vancomycin-impregnated calcium sulfate since July 2014 at the Department of Oral and Maxillofacial Surgery, School of Stomatology, China Medical University (Shenyang, China). All patients underwent debridement of nonviable bone and implantation of vancomycin-impregnated calcium sulfate. The wounds were covered with an acellular dermal matrix and sutured. RESULTS: Ten patients had satisfactory wound healing. However, 2 cases of maxillary central osteomyelitis had delayed wound healing. The wounds healed after the surgical site was resutured under local anesthesia. At 3 months, the panoramic radiograph showed that most implants had been reabsorbed and replaced by new bone formation. All patients in this study had no recurrence of infection at 6 to 18 months (mean, 10.8 months) of follow-up. CONCLUSIONS: The use of vancomycin-impregnated calcium sulfate in the surgical debridement site for chronic osteomyelitis of the jaw has shown encouraging results. In addition, calcium sulfate can promote the formation of new bone to a certain extent.

Denosumab: Prevention and management of hypocalcemia, osteonecrosis of the jaw and atypical fractures.

Denosumab, a bone-modifying agent, reduces the risk of skeletal-related events in patients with bone metastases from solid tumors and is generally well tolerated. However, hypocalcemia, osteonecrosis of the jaw (ONJ) and atypical fracture are potential and important toxicities of denosumab therapy that require attention. In pivotal phase III trials in patients with bone metastases from solid tumors, the incidence of hypocalcemia was 9.6% in denosumab-treated patients, with most events being asymptomatic, grade 2 and resolving by week 4. Established hypocalcaemia requires additional short-term calcium and vitamin D supplementation and, if severe, administration of intravenous calcium. ONJ was reported in 1.8% of patients receiving denosumab over 3 years in these trials. Involvement of an experienced oro-maxillary surgeon is important if ONJ is suspected. Atypical fractures were rare in a large study of denosumab using the dose and scheduling approved for the treatment of osteoporosis. To prevent toxicities, patients should maintain calcium and vitamin D supplementation, good oral hygiene and regular dental reviews throughout treatment. This article presents case studies from our clinical practice and discusses the pathophysiology of these toxicities along with guidance on prevention, diagnosis and management.

Pentoxifylline - a review of its use in osteoradionecrosis.

Pentoxifylline has been used to treat complications related to fibrosis for over 20 years. Formerly used to treat those after radiotherapy such as osteoradionecrosis (ORN), it is now being tried for medication-related osteonecrosis of the jaw (MRONJ), which can occur after prolonged use of bisphosphonates. We review theories on the formation of fibrosis in patients with ORN, discuss the pharmacology of pentoxifylline and vitamin E, and report published outcomes. To our knowledge no prospective randomised controlled trial has investigated the benefits of these agents in cases of ORN, but reported outcomes in many published case series are encouraging.