Precursor Radiographic Findings in Patients With Medication-Related Osteonecrosis of the Jaw.

BACKGROUND: Oral surgical treatment, such as tooth extraction, has been identified as a risk factor for the onset of medication-related osteonecrosis of the jaw (MRONJ). However, MRONJ may already be latent, and its manifestation may be triggered by extraction. PURPOSE: The purpose of this study was to examine the association between pre-extraction imaging and MRONJ. STUDY DESIGN, SETTING, SAMPLE: We performed a multicenter case-control analysis of patients receiving antiresorptive agents (ARAs) who underwent extraction between 2012 and 2016. We enrolled patients who had undergone tooth extraction in the setting of ARA exposure. PREDICTOR VARIABLES: The predictor variables comprised preoperative radiographic findings associated with MRONJ stage 0. These findings included alveolar bone loss, thickening or obscuring of the periodontal ligament, and osteosclerosis involving the alveolar bone. They were coded as present or absent before tooth extraction. MAIN OUTCOME VARIABLE: The primary outcome variable was MRONJ status coded as present or absent. COVARIATES: Sex, age, underlying diseases necessitating the administration of ARA, the type of ARA used, corticosteroid use, extraction region, and wound closure were analyzed. ANALYSES: Mann-Whitney U test, χ2 test, Fisher's exact test for univariate analysis, and multiple logistic regression analysis were performed. P values < .05 were significant. RESULTS: The subjects consisted of 26 patients and 110 controls (male: 8/36, female: 18/74). The mean ages of the MRONJ group and the control group were 77.0 ± 11.9 and 63.0 ± 15.8, respectively (P value = .001). The prevalence of osteosclerosis was significantly higher in the MRONJ group than in the control group (14/72, 53.9%/29.3%, P < .01). Multivariate analysis identified osteosclerosis (odds ratio: 8.4, 95% confidence interval: 2.133.9, P < .01) as a significant independent predictor associated with the development of MRONJ after extraction. CONCLUSION AND RELEVANCE: These findings suggest that a precursor to MRONJ is highly likely to be present in patients with osteosclerosis at the time of extraction. The majority of patients who developed MRONJ after extraction had imaging findings that suggested infection in the surrounding alveolar bone.

Key insights into antiresorptive drug use and osteonecrosis in osteoporotic patients undergoing tooth extractions: A clinical and CBCT assessment.

This study investigates the effects of antiresorptive drugs and risk factors for medication-related osteonecrosis of the jaws in osteoporotic patients undergoing tooth extraction. Among the findings, antiresorptive-treated patients had thicker lamina dura and longer healing times. Additionally, corticosteroid intake and multi-rooted teeth carried a higher osteonecrosis risk. Bone sequestrum indicated osteonecrosis. PURPOSE: To describe the effects of antiresorptive drugs (ARD) in the maxilla and mandible and risk factors for medication-related osteonecrosis of the jaws (MRONJ) in osteoporotic patients undergoing tooth extractions using clinical data and cone beam computed tomography (CBCT). METHODS: This retrospective cohort study collected clinical and CBCT data from 176 patients. The study group (n = 78; 224 extractions) received ARD treatment, underwent tooth extraction, and had a pre-operative CBCT. Additionally, age-, sex-, and tooth-matched controls were selected (n = 98; 227 extractions). Radiographic examinations were performed independently by three calibrated examiners. Statistical analysis included Chi-square, Fisher's exact, Mann-Whitney U, and t-tests to contrast clinical and radiographic data between study and control, MRONJ + and MRONJ - , and bisphosphonate and denosumab patients/sites. Significance was set at p ≤ 0.05. RESULTS: From the study group, 4 patients (5%) and 5 sites (2%) developed MRONJ after tooth extraction. ARD-treated patients exhibited significantly more thickening of the lamina dura and a longer average mucosal healing time (4.4 weeks) than controls (2.6 weeks). In the study group, MRONJ risk significantly increased with corticosteroid intake and in multi-rooted teeth. No significant differences between bisphosphonates and denosumab use were seen in the tomographic features (p > 0.05). Lastly, bone sequestrum was exclusively observed in osteoporotic patients, who exhibited post-operative exposed bone or histological evidence of osteonecrosis. CONCLUSION: Osteoporotic patients under ARD may exhibit thickening of the lamina dura and prolonged post-operative healing. Among these patients, multi-rooted teeth are at higher risk for MRONJ than single-rooted teeth. Sequester formation is a radiographic indicator of osteonecrosis.

Radiological manifestations and clinical findings of patients with oncologic and osteoporotic medication-related osteonecrosis of the jaw.

Medication-related osteonecrosis of the jaw (MRONJ) poses a challenging form of osteomyelitis in patients undergoing antiresorptive therapies in contrast to conventional osteomyelitis. This study aimed to compare the clinical and radiological features of MRONJ between patients receiving low-dose medications for osteoporosis and those receiving high-dose medications for oncologic purposes. The clinical, panoramic radiographic, and computed tomography data of 159 patients with MRONJ (osteoporotic group, n = 120; oncologic group, n = 39) who developed the condition after using antiresorptive medications for the management of osteoporosis or bone malignancy were analyzed. The osteoporotic group was older (75.8 vs. 60.4 years, p < 0.01) and had a longer duration of medication usage than the oncologic group (58.1 vs. 28.0 months, p < 0.01). Pus discharge and swelling were more common in the osteoporotic group (p < 0.05), whereas bone exposure was more frequent in the oncologic group (p < 0.01). The mandibular cortical index (MCI) in panoramic radiographs was higher in the osteoporotic group (p < 0.01). The mean sequestra size was larger in the oncologic group than in the osteoporotic group (15.3 vs. 10.6 mm, p < 0.05). The cured rate was significantly higher in the osteoporotic group (66.3% vs. 33.3%, p < 0.01). Oncologic MRONJ exhibited distinct clinical findings including rapid disease onset, fewer purulent signs, and lower cure rates than osteoporotic MRONJ. Radiological features such as sequestrum size on CT scan, and MCI values on panoramic radiographs, may aid in differentiating MRONJ in osteoporotic and oncologic patients.

Sclerotic bone: a sign of bone reaction in patients with medication related osteonecrosis of the jaw.

Medication-related osteonecrosis of the jaw (MRONJ) is a serious adverse reaction associated with antiresorptive drugs such as bisphosphonates and denosumab. When dealing with advanced and/or multiple MRONJ lesions undergoing surgical therapy, the extent of surgery is often a topic of discussion. The aim of this study was to identify the differences in bone density in and around the MRONJ lesion before and after surgical treatment to evaluate the needed surgical extend of the modelling osteotomy. In this retrospective study 26 patients with MRONJ lesions that were surgically treated in our department were observed. Length, width and bone density were measured in panoramic radiograph pre and postoperatively with the Imaging processing software Sidexis and ImageJ (Fiji). The necrotic area, the surrounding sclerotic area as well as the healthy contralateral side were observed. Measurements were performed by two independent observers. Pearson correlation was calculated to determine the interobserver variability. Bone density was significantly reduced in the necrotic bone area compared to the healthy unaffected contralateral reference side. The sclerotic bone area surrounding the necrosis showed increased bone density compared to the contralateral unaffected reference side. The density of the sclerotic bone area was increased in the previously affected MRONJ area in the postoperative panoramic radiograph. The pre and postoperative density showed no significant correlation to healing behaviour. The focus of the modelling osteotomy in surgical treatment of mature MRONJ lesions should be predominantly on the parts that appear necrotic and less dense in the panoramic radiograph as sclerotic areas might be an expression of bone reaction.

Bone pattern changes in post liver transplant patients using bisphosphonates.

OBJECTIVE: To identify radiographic findings suggestive of drug-induced osteonecrosis and evaluate radiomorphometric patterns indicative of changes in bone mineral density in individuals transplanted for liver disorders using bisphosphonates. STUDY DESIGN: The study group included panoramic x-rays of liver transplant patients who are being monitored and who present a clinical status of osteoporosis and use bisphosphonates. The control group was made up of liver transplant patients who did not have osteoporosis. On panoramic radiographs, mental index (MI) and mandibular cortical index (MCI) and the presence of radiographic anomalies suggestive of osteonecrosis were evaluated. RESULTS: There were significant statistical results when comparing the groups in relation to the decrease in bone mineral density (BMD) with MCI-C3 (p = 0.036), however, there were none in relation to MI (p = 0.14). There were no valid statistical results when relating MCI (p = 0.94) and MI (p = 0.66) with reduced BMD and use of bisphosphonates. CONCLUSION: Liver transplant individuals using bisphosphonates present greater radiographic signs of bone sclerosis suggestive of a greater propensity to develop osteonecrosis of the jaw and an increased risk of presenting changes suggestive of reduced bone mineral density on panoramic radiographs when compared to liver transplant individuals not using bisphosphonates.

Ozone infiltration as an adjunctive treatment to piezoelectric surgery in the management of medication-related osteonecrosis of the jaws: case series of 29 patients.

PURPOSE: Medication-related osteonecrosis of the jaws has been reported to be associated with bisphosphonate and RANKL inhibitor medications. This prospective clinical study aimed to assess the outcomes of pre-operative ozone infiltration therapy in patients with established MRONJ. METHODS: The treatment protocol for ozone applications were designed as 20 applications ozone infiltration therapy followed by surgical interventions of necrotic tissue debridement using piezoelectric surgery instruments. The evaluation of the results based on the clinical and radiologic specifications considering the necrotic lesion reduction and healing. The study included 31 lesions in 29 patients. The mean follow-up was 23.6 months. RESULTS: 25 lesions out of 31 healed totally without any remissions. The outcomes were not affected by any variables such as gender, age, type of pharmacological treatment, lesion location, and MRONJ staging. The statistically significant results were found among the clinical condition of the patients (p = 0.01) and administration route of medications (p = 0.004). Healing was significantly less in patients that received intra-vascular administrations. Clinical conditions of the patients were divided as osteoporosis, oncologic, and arthritis. Significantly better results were obtained in osteoporosis patients. 38% of the population experienced spontaneous sequestration with signs of improvements and the surgical interventions were canceled. According to the results, total healing of MRONJ lesions was seen in 79% patients (81% lesions). CONCLUSION: Ozone therapy and debridement with Piezoelectric surgery can be considered as a safe and beneficial adjunctive treatment alternative for osteonecrosis lesions in cases of established MRONJ.

Ozone therapy effect in medication-related osteonecrosis of the jaw as prevention or treatment: microtomographic, confocal laser microscopy and histomorphometric analysis.

OBJECTIVE: This study aimed to evaluate the efficacy of ozone therapy in the preoperative (prevention) and/or postoperative (treatment) of MRONJ. MATERIAL AND METHODS: Forty male Wistar rats were caudally treated with zoledronic acid (ZOL) and to ozone therapy before extraction (prevention, POG), after extraction (treatment, TOG), or both (prevention and treatment, TPOG), and treated with saline (SAL). The animals received intramuscular fluorochrome (calcein and alizarin), and 28 days postoperatively, they were euthanized, and the tissues were subjected to microtomographic computed tomography (microCT), LASER confocal, and histomorphometric analyses. RESULTS: Micro-CT showed a higher bone volume fraction average in all groups than that in the ZOL group (P < 0.001), the ZOL group showed high porosity (P = 0.03), and trabecular separation was greater in the TOG group than in the POG group (P < 0.05). The mineral apposition rate of the POG group was high (20.46 ± 6.31) (P < 0.001), followed by the TOG group (20.32 ± 7.4). The TOG group presented the highest mean newly formed bone area (68.322 ± 25.296) compared with the ZOL group (P < 0.05), followed by the SAL group (66.039 ± 28.379) and ZOL groups (60.856 ± 28.425). CONCLUSIONS: Ozone therapy modulated alveolar bone repair in animals treated with ZOL, mainly after surgery trauma, leading to bone formation as healing tissue. CLINICAL RELEVANCE: Osteonecrosis has been a challenge in dentistry, and owing to the lack of a consensus regarding therapy, studies presenting new therapies are important, and ozone has been one of the therapies explored empirically.

Medication-related osteonecrosis of the lower jaw without osteolysis on computed tomography images.

INTRODUCTION: Surgery is the standard treatment for medication-related osteonecrosis of the jaw (MRONJ). This study reviewed patients with mandibular MRONJ who underwent surgical treatment, and in particular the characteristics of non-osteolytic MRONJ with no evidence of osteolysis on CT were described. MATERIALS AND METHODS: We conducted a retrospective study of patients with mandibular MRONJ who underwent surgery between January 2016 and September 2022. Various clinical and imaging factors regarding treatment outcomes were investigated and analyzed. Additionally, the disease course of non-osteolytic MRONJ was examined in detail. RESULTS: This study included 55 patients (66 surgeries) with a mean age of 74.7. The primary disease was osteoporosis (24 patients) and malignancy (31 patients); the type of antiresorptive agent was bisphosphonate (BP) in 21 patients and denosumab (DMB) in 26. BP was initially administered; however, it was changed to DMB in eight patients. Preoperatively, the cumulative cure rates for all 66 surgeries were 72.8% at 1 year and 77.3% at 2 years. Cure rates were significantly lower in patients with malignancy, those without osteolysis, and those who underwent sequestrum removal or marginal mandibulectomy than those with osteoporosis, osteolysis, and segmental mandibulectomy. Non-osteolytic MRONJ was observed in eight patients, all with malignancy and receiving high-dose DMB. Only two patients were cured after the initial surgery, and most patients ultimately underwent segmental mandibulectomy. CONCLUSIONS: Surgical treatment yielded good treatment outcomes in most patients with mandibular MRONJ; however, the cure rate was lower in patients with malignancy who showed no osteolysis on CT images.

Osteonecrosis maxilar relacionada con la medicación: el papel del radiólogo / Medication-related osteonecrosis of the jaw: the radiologist's role

En las últimas décadas se ha descrito ampliamente y se ha llegado a conocer en profundidad un temido efecto adverso de los bisfosfonatos, la osteonecrosis maxilar, que consiste en la destrucción ósea de parte del hueso maxilar como consecuencia del consumo de estos fármacos antirresortivos. En los últimos años han salido a la luz nuevos fármacos que también pueden ocasionar osteonecrosis maxilar, como algunos anticuerpos monoclonales o fármacos antiangiogénicos. Es por esto por lo que el término de “osteonecrosis maxilar por bisfosfonatos” ha quedado obsoleto, prefiriéndose el término de “osteonecrosis maxilar relacionada con la medicación”. El objetivo de esta revisión es describir las características radiológicas de la osteonecrosis maxilar relacionada con la medicación que, aunque son inespecíficas, es importante que el radiólogo las reconozca en el marco clínico adecuado.(AU)

In recent decades, the dreaded adverse effect of bisphosphonates, osteonecrosis of the jaw, has been widely reported and described in detail. Osteonecrosis of the jaw consists of the destruction of part of the maxilla as a consequence of these antiresorptive drugs. In recent years, new drugs that can also cause osteonecrosis of the jaw (e.g., some monoclonal antibodies or antiangiogenic drugs) have come on the market. For this reason, the term “bisphosphonate-related osteonecrosis of the jaw” has been replaced with “medication-related osteonecrosis of the jaw (MRONJ). This review aims to describe the radiologic characteristics of MRONJ that, although nonspecific, radiologists need to recognize in the appropriate clinical context.(AU)

Colocación de implantes en paciente con antecedentes de toma de bifosfonatos / Placement of implants in a patient with a history of bisphosphonates taken

El uso de bifosfonatos es un excelente tratamiento para pacientes con artritis reumatoide y enfermedades óseas, por ejemplo, osteoporosis. Se realiza un reporte de caso de paciente femenino, quien estuvo bajo consumo de este fármaco por prescripción de su médico para la prevención de artritis reumatoide postmenopausia. La paciente acude a consulta para la colocación de implantes en zona desdentada y comenta haber terminado el tratamiento de bifosfonatos hace un año. Se tomaron pruebas de diagnóstico y se realizó la colocación de implantes sin ninguna complicación. Sus citas de control fueron más frecuentes en cuatro meses, sobre todo por el detalle de consumo de bifosfonatos, pero en ninguna cita hubo algún detalle alarmante, la cicatrización iba en forma. Se dio de alta a la paciente después de sus citas periódicas y de asegurar su buena cicatrización a un implante bien situado (AU))

The use of bisphosphonates is an excellent treatment for patients with rheumatoid arthritis and bone diseases such as osteoporosis. Here is a case report of a female patient, who was under consumption of this drug by prescription of her doctor for the prevention of post-menopausal rheumatoid arthritis. The patient went to the consultation for the placement of implants in the edentulous area and comments having finished the bisphosphonate treatment one year ago. The diagnostic tests were taken, and the implant placement was performed well without any complications. The control appointments were more frequent in four months, especially due to the detail of bisphosphonate consumption, but in no appointment, there were any alarming details, the healing was in good shape. The patient discharged after her regular appointments and to ensure that she was healing well and that implant was well placed (AU)

Computed tomography bone density variations in oncological patients undergoing antiresorptive medication

Background: The purpose of this study was to compare jaw and cervical vertebrae bone density in computed tomography (CT) analyses of oncological patients undergoing antiresorptive medication with control patients, aiming to find information that may assist the radiologist and clinician in predicting risks and monitoring osteonecrosis in the jaw. Material and methods: Thirty-one patients treated with zoledronic acid and 37 control were included in the study. Two areas in regions of interest were chosen and standardized, one in the lower portion of the mandible and another in the axial cervical vertebra (C2) of patients undergoing antiresorptive drug treatment (experimental group) and the control group. Density analysis was performed using Hounsfield scale grayscale values obtained from multislice CT exams. Interclass correlation coefficient test (ICC) was performed to assess reproducibility and repeatability. The test of normality of the samples was demonstrated using the Shapiro-Wilk test and the comparison performed using Mann-Whitney U non-parametric test. Results: When compared to patients in the control group, patients undergoing antiresorptive medication depicted an increase in bone density in both jaw bone (p=0.021) and cervical vertebrae (p=0.002). The same pattern could be observed in patients who used the medication on a monthly basis for analysis of jaw bone (p=0.021), the cervical vertebrae (p=0.002), and the cervical vertebrae of the patients who used the medication on a quarterly basis (p=0.003). Conclusions: CT can be a potentially useful method for detecting alterations associated with antiresorptive therapy, serving as a possible tool in the prediction of the disease progression. (AU)

Osteonecrosis maxilar relacionada con medicamentos en pacientes oncológicos con metástasis óseas: resolución de dos casos / Medication-related osteonecrosis of the jaw in oncological patients with bone metastases: resolution of two cases

La osteonecrosis maxilar relacionada con medicamentos (ONMM) es una patología de características clínicas objetivas con signo-sintomatología patognomónica. El criterio clínico aceptado es la presencia de hueso necrótico expuesto y visible sobre el reborde óseo maxilar que no ha cicatrizado luego de 8 semanas, en pacientes con antecedentes de tratamiento antirresortivo. La denominación "relacionada con medicamentos" se utiliza por el creciente número de casos asociados con otros fármacos antirresortivos como denosumab y con terapias antiangiogénicas, más allá de la conocida relación con bifosfonatos.Si bien la incidencia de ONMM en pacientes tratados por osteopatías metabólicas es muy baja, la situación se torna más compleja en pacientes oncológicos con altas dosis de antirresortivos para tratamiento de metástasis ósea. Varios in-formes de casos describen cuadros de ONMM en pacientes con cáncer que reciben terapias dirigidas, específicamente TKI (inhibidores de tirosina quinasa) y anticuerpos monoclonales-VEGF (anticuerpos dirigidos al factor de crecimiento del endotelio vascular). La ONMM afecta negativamente la calidad de vida del paciente oncológico y produce comorbilidad significativa. Resulta imperioso identificar a los pacientes en riesgo y diseñar un protocolo de atención odontológica específico para estos casos. En este artículo se presentan dos casos de ONMM asociado con altas dosis de denosumab y administración simultánea de anticuerpos monoclonales específicos para el tratamiento del cáncer. Ambos casos sorprenden por la prematura instalación de la necrosis y su cuadro insidio-so. El protocolo de tratamiento descripto permitió controlar el cuadro inicial, limitar el avance de la lesión, asegurar el control del dolor y la infección, y finalmente, la curación total de la lesión. (AU)

Medication-related osteonecrosis of the jaws (MRONJ) is a pathology with objective clinical characteristics, with pathognomonic signs and symptoms. The accepted clinical criterion is the presence of exposed and visible necrotic bone on the maxillofacial region that has not healed after 8 weeks, in patients with history of antiresorptive treatment.The name "medication-related" is justified by the growing number of cases associated with other antiresorptive drugs such as denosumab and antiangiogenic therapies, beyond the known relationship with bisphosphonates. Although the incidence of MRONJ in patients treated for metabolic osteopathies is very low, the situation becomes more complex in cancer patients who receive high doses of antiresorptives for the treatment of skeletal metastases. Several case reports describe the presence of MRONJ in cancer patients receiving targeted therapies, specifically TKI (tyrosine kinase inhibitors) and monoclonal antibodies-targeting VEGF (vascular endothelial growth factor). MRONJ negatively affects the quality of life in cancer patients and produces significant comorbidity. It is imperative to identify patients at risk and design a specific dental care strategy for these cases.In this article, we present two cases of MRONJ associated with high doses of Denosumab and simultaneous administration of specific monoclonal antibodies. Both cases are surprising due to premature onset of necrosis. The described treatment strategies made it possible to control the initial symptoms, limit the lesion progression, ensure pain and infection control, and finally, the total healing of the lesion. (AU)

Clinical profile of individuals with bisphosphonate-related osteonecrosis of the jaw: an integrative review

ABSTRACT BACKGROUND: Bisphosphonate-related osteonecrosis of the jaw (BRONJ) is still the most prevalent type of osteonecrosis with clinical relevance. In Brazil, bisphosphonate use is high but there is a lack of epidemiological studies on BRONJ. OBJECTIVE: To determine the clinical profile of BRONJ in a Brazilian population through an integrative review. DESIGN AND SETTING: Integrative review of BRONJ in a Brazilian population. METHODS: Cases and clinical research on Brazilians with BRONJ between 2010 and 2019, indexed in PubMed/MEDLINE, Scopus, Web of Science and LILACS were reviewed. Age, sex, type and time of bisphosphonate intake, administration route, related diseases, region of the BRONJ, diagnostic criteria, staging, triggering factor and type of treatment were analyzed. RESULTS: Fifteen articles on 128 subjects were included. Most patients were women (82.03%); the mean age was 63 years. Intravenous zoledronic acid was mostly used (62.50%), for breast cancer treatment (46.87%). The main localization of BRONJ was the mandible (54.68%), associated mainly with tooth extractions (45.98%). The diagnostic criteria were clinical (100%) and radiographic (89.06%), mostly in stage II (68.08%). The surgical treatments were sequestrectomy (37.50%) and platelet-rich plasma (PRP) (36.71%). Microbial control was done using chlorhexidine (93.75%) and infection control using clindamycin (53.90%). CONCLUSIONS: BRONJ had higher prevalence in Brazilian women receiving treatment for breast cancer and osteoporosis. The mandible was the region most affected with a moderate stage of BRONJ, particularly when there were histories of tooth extraction and peri-implant surgery. Sequestrectomy with additional drugs and surgical therapy was the treatment most accomplished.

Absceso cervical como forma de presentación excepcional de osteonecrosis mandibular avanzada inducida por bisfosfonatos. A propósito de un caso y revisión de la literatura / Cervical abscess as an exceptional presentation of advance bisphosphonate-related osteonecrosis of the jaw: case report and review of the literature

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Osteonecrosis por bifosfonatos: presentación de un caso clínico / Osteonecrosis of the jaws: report of a clinical case

La osteonecrosis de los maxilares asociada a bifosfonatosfuedefinida como «Área de hueso expuesto en la región máxilo facial que permanece expuesta al menos por 8 semanas, siempre que los pacientes hayan sido prescriptos con bifosfonatos, y en ausencia de terapia radiante¼. (1) En la actualidad se agregó "hueso expuesto o hueso que se puede sondear a través de una fistula intra o extra oral" (2). Presentamos un caso clínico de una paciente femenina de 70 años de edad, diagnosticada con cáncer de hueso (osteosarcoma) con foco en la pelvis, historia de consumo de bifosfonatosvía endovenosa durante tres años, zolendronato 70mg, semanalmente. Al momento de la consulta, se encontraba en periodo de remisión de la enfermedad de base y sin consumo de medicación antiresortiva desde hace un año (AU)

Osteonecrosis of the jaws associated with bisphosphonates was defined as «Area of exposed bone in the maxillofacial region that remains exposed for at least 8 weeks, provided that patients have been prescribed with bisphosphonates, and in the absence of radiant therapy¼. (1) At present, "exposed bone or bone that can be probed through an intra or extra oral fistula" was added (2). We present a clinical case of a 70-year-old female patient, diagnosed with bone cancer (osteosarcoma) with a focus on the pelvis, history of consumption of bisphosphonates intravenously for three years, zolendronate 70 mg, weekly. At the time of the consultation, he was in the period of remission of the underlying disease and without consumption of antiresortive medication for a year (AU)

Tratamento cirúrgico para osteonecrose dos maxilares induzida por bisfosfonatos: relatos de casos / Surgical treatment for bisphosphonate-induced maxillary osteonecrosis: case reports

Introdução: os bisfosfonatos são um grupo de medicamentos utilizados no tratamento de doenças osteolíticas, tais como mieloma múltiplo, osteoporose e doença de Paget. Uma complicação tardia dessa medicação é a osteonecrose em ossos maxilares. Esta é definida como desenvolvimento de osso necrótico na cavidade bucal de paciente em tratamento atual ou prévio com bisfosfonato, após sofrer algum procedimento cirúrgico bucal invasivo, sem ter realizado radioterapia. Objetivo: descrever, por meio de relatos de casos, a opção de técnica cirúrgica para tratamento da osteonecrose por bisfosfonatos. Materiais e método: em todos os casos relatados, a terapêutica cirúrgica contou com osteotomia e remoção cirúrgica do sequestro ósseo, debridamento, irrigação com soro fisiológico e sutura contínua simples. Resultados: o controle clínico pós-operatório evidenciou boa cicatrização, melhora considerável da lesão e reepitelização significativa, em curto e longo período. Conclusão: os pacientes devem passar por um criterioso exame odontológico, antes do uso desses medicamentos. Nenhum tratamento cirúrgico invasivo deve ser realizado durante a terapia com esses fármacos. (AU)

Introduction: Bisphosphonates are a group of medications used to treat osteolytic diseases such as multiple myeloma, osteoporosis, and Paget's disease. A late complication of this medication is osteonecrosis in the maxillary bones. It is defined as the development of necrotic bone in the oral cavity of a patient under current or with previous treatment with bisphosphonate and subjected to some invasive oral surgical procedure without radiotherapy. Objective: This study aimed to describe, through case reports, the option of a surgical technique for the treatment of osteonecrosis with bisphosphonates. Materials and Method: In all cases reported, surgical therapy included osteotomy and surgical removal of bone sequestration, debridement, irrigation with saline solution, and simple continuous suture. Results: The postoperative clinical control revealed satisfactory healing, considerable lesion improvement, and significant short- and long-term re-epithelialization. Conclusion: Patients should be subjected to a careful dental examination before using these medications. No invasive surgical treatment should be performed during therapy with these drugs. (AU)

Osteonecrosis maxilar asociada a tratamiento con denosumab en una paciente con mastocitosis sistémica / Maxillar osteonecrosis associated to denosumab in a patient with systemic mastocytosis

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Fístula oroantral en contexto de osteonecrosis maxilar y mandibular por bifosfonatos. Caso clínico / Oroantral fistula in maxillary and jaw osteonecrosis by bisphosphonates. Case report / Fístulao roantral em contexto de osteonecrose maxilar e mandibular por bifosfonatos. Caso clínico

La fístula oroantral es una comunicación patológica entre la cavidad oral y el seno maxilar. Están descritas varia causas, entre ellas la osteonecrosis maxilar y mandibular por bifosfonatos, descrita por primera vez en 2003. Este medicamento ha sido ampliamente utilizado y con gran eficacia en el tratamiento de diversas neoplasias con metástatización ósea, especialmente en el cáncer de mama, en el que la supervivencia ha aumentado considerablemente. Presentamos el caso paradigmático de una mujer de 58 años con historia de neoplasia maligna de mama y metátasis óseas, tratada con quimioterapia endovenosa asociada a bifosfonatos, que desarrolló osteonecrosis maxilar y mandibular en el contexto de una extracción dentaria y que desarrolló una fístula oroantral. Esto nos recuerda este importante factor de riesgo, considerando que dada la supervivencia actual entre la población con cáncer de mama, la prevalencia de la fístula oroantral irá en aumento

Oroantral fistula is a pathological communication between the oral cavity and the maxillary sinus. There are several causes, being the maxillary and jaw osteonecrosis by intravenous bisphosponates an important cause which was reportedby the first time in 2003. The bisphosphonates have been used with good results in treatment of several cancers and in bone metastases, especially in breast cancer, where the survival rate has increased in the recent years. We report a representative case of a 58-year-old female with previous history of breast cancer and bone metastases. She had been treated with chemotherapy and intravenous bisphosphonates and had developed maxillary and jaw osteonecrosis. After that, she underwent surgery with extraction of first molar and acquired an oroantral fistula. The present case reminds us of an important risk factor for oroantral fistula in patients treated with intravenous bisphosphonates. Thus, due to the increasing survival rate in breast cancer patients, the oroantral fistula prevalence is going to increase exponentially

A fístula oroantral é uma comunicação patológica A entre a cavidade oral e o seio maxilar. Estão descritas várias causas, sendo que a osteonecrose maxilar e mandibular por bifosfonatos foi descrita pela primeira vez em 2003. Esta terapêutica tem sido largamente utilizada e com grande eficácia no tratamento de várias neoplasias com metastização óssea, em especial no cancro da mama, onde a sobrevida tem aumentado consideravelmente. Os autores reportam um caso paradigmático de uma mulher de 58 anos de idade com história de neoplasia maligna da mama e metastização óssea, tendo efectuado quimioterapia associada a bifosfonatos por via endovenosa. A doente desenvolveu posteriormente osteonecrose maxilar e mandibular e, em contexto de extracção dentária, condicionou fístula oroantral. O caso apresentado relembra um importante factor de risco para o desenvolvimento de fístula oroantral nos doentes em quimioterapia associada a bifosfonatos. Devido ao aumento da sobrevida da população com cancro da mama, a prevalência de fístula oroantral irá aunmentar exponencialmente