Medication-Related Osteonecrosis of Jaws (MRONJ) Prevention and Diagnosis: Italian Consensus Update 2020

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Abstract

The Medication-Related Osteonecrosis of Jaws (MRONJ) diagnosis process and its prevention play a role of great and rising importance, not only on the Quality of Life (QoL) of patients, but also on the decision-making process by the majority of dentists and oral surgeons involved in MRONJ prevention (primary and secondary). The present paper reports the update of the conclusions from the Consensus Conference—held at the Symposium of the Italian Society of Oral Pathology and Medicine (SIPMO) (20 October 2018, Ancona, Italy)—after the newest recommendations (2020) on MRONJ were published by two scientific societies (Italian Societies of Maxillofacial Surgery and Oral Pathology and Medicine, SICMF and SIPMO), written on the inputs of the experts of the Italian Allied Committee on ONJ (IAC-ONJ). The conference focused on the topic of MRONJ, and in particular on the common practices at risk of inappropriateness in MRONJ diagnosis and therapy, as well as on MRONJ prevention and the dental management of patients at risk of MRONJ. It is a matter of cancer and osteometabolic patients that are at risk since being exposed to several drugs with antiresorptive (i.e., bisphosphonates and denosumab) or, more recently, antiangiogenic activities. At the same time, the Conference traced for dentists and oral surgeons some easy applicable indications and procedures to reduce MRONJ onset risk and to diagnose it early. Continuous updating on these issues, so important for the patient community, is recommended.

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Bisphosphonate-associated osteonecrosis of the jaw: report of a task force of the American Society for Bone and Mineral Research.

Sundeep Khosla, David Burr, Jane Cauley … (2007)

ONJ has been increasingly suspected to be a potential complication of bisphosphonate therapy in recent years. Thus, the ASBMR leadership appointed a multidisciplinary task force to address key questions related to case definition, epidemiology, risk factors, diagnostic imaging, clinical management, and future areas for research related to the disorder. This report summarizes the findings and recommendations of the task force. The increasing recognition that use of bisphosphonates may be associated with osteonecrosis of the jaw (ONJ) led the leadership of the American Society for Bone and Mineral Research (ASBMR) to appoint a task force to address a number of key questions related to this disorder. A multidisciplinary expert group reviewed all pertinent published data on bisphosphonate-associated ONJ. Food and Drug Administration drug adverse event reports were also reviewed. A case definition was developed so that subsequent studies could report on the same condition. The task force defined ONJ as the presence of exposed bone in the maxillofacial region that did not heal within 8 wk after identification by a health care provider. Based on review of both published and unpublished data, the risk of ONJ associated with oral bisphosphonate therapy for osteoporosis seems to be low, estimated between 1 in 10,000 and <1 in 100,000 patient-treatment years. However, the task force recognized that information on incidence of ONJ is rapidly evolving and that the true incidence may be higher. The risk of ONJ in patients with cancer treated with high doses of intravenous bisphosphonates is clearly higher, in the range of 1-10 per 100 patients (depending on duration of therapy). In the future, improved diagnostic imaging modalities, such as optical coherence tomography or MRI combined with contrast agents and the manipulation of image planes, may identify patients at preclinical or early stages of the disease. Management is largely supportive. A research agenda aimed at filling the considerable gaps in knowledge regarding this disorder was also outlined.

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Is bisphosphonate-associated osteonecrosis of the jaw caused by soft tissue toxicity?

Mark J. Bolland, Charlotte Grey, Robert J. Reid (2007)

Osteonecrosis of the jaw (ONJ) is a complication of high-dose bisphosphonate use, characterized by the finding of exposed bone in the oral cavity. It has been assumed that the primary lesion lies in bone and is related to over-suppression of bone turnover, but it is unclear why such a lesion should present with loss of the soft tissue covering of the mandible or maxilla as the primary clinical feature. A possible explanation of this paradox is that bisphosphonate is accumulated in bone in concentrations sufficient to be directly toxic to the oral epithelium. This would result in the failure of healing of soft tissue lesions (such as those caused by invasive dental procedures or by subclinical trauma from dentures) leading to secondary infection of the underlying bone. This model would explain why bone resection is unhelpful in managing this problem, suggests that low bone turnover caused by non-bisphosphonate drugs should not cause the same problem, and raises the possibility that agents which reverse bisphosphonate effects in vitro might have a role in the management of ONJ.

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Managing the care of patients receiving antiresorptive therapy for prevention and treatment of osteoporosis: executive summary of recommendations from the American Dental Association Council on Scientific Affairs.

P. Jacobsen, John Hellstein, H Ristic … (2011)

This narrative review of osteonecrosis of the jaw in patients with low bone mass receiving treatment with antiresorptive agents is based on an appraisal of the literature by an advisory committee of the American Dental Association Council on Scientific Affairs. It updates the committee's 2008 advisory statement. The authors searched MEDLINE for literature published between May 2008 (the end date of the last search) and February 2011. This report contains recommendations based on the findings of the literature search and on expert opinion that relate to general dentistry; periodontal disease management; implant placement and maintenance; oral and maxillofacial surgery; endodontics; restorative dentistry and prosthodontics; orthodontics; and C-terminal telopeptide testing and drug holidays. The highest reliable estimate of antiresorptive agent-induced osteonecrosis of the jaw (ARONJ) prevalence is approximately 0.10 percent. Osteoporosis is responsible for considerable morbidity and mortality. Therefore, the benefit provided by antiresorptive therapy outweighs the low risk of developing osteonecrosis of the jaw. An oral health program consisting of sound hygiene practices and regular dental care may be the optimal approach for lowering ARONJ risk. No validated diagnostic technique exists to determine which patients are at increased risk of developing ARONJ. Discontinuing bisphosphonate therapy may not lower the risk but may have a negative effect on low-bone-mass-treatment outcomes.

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Journal

Journal ID (nlm-ta): Int J Environ Res Public Health

Journal ID (iso-abbrev): Int J Environ Res Public Health

Journal ID (publisher-id): ijerph

Title: International Journal of Environmental Research and Public Health

Publisher: MDPI

ISSN (Print): 1661-7827

ISSN (Electronic): 1660-4601

Publication date (Electronic): 18 August 2020

Publication date (Print): August 2020

Volume: 17

Issue: 16

Electronic Location Identifier: 5998

Affiliations

[1 ]Department of Surgical, Oncological, and Oral Sciences, University of Palermo, 90127 Palermo, Italy; campisi@ 123456odonto.unipa.it (G.C.); odifede@ 123456odonto.unipa.it (O.D.F.); antonio.locasto@ 123456unipa.it (A.L.C.); panzarella@ 123456odonto.unipa.it (V.P.)

[2 ]IAC-ONJ (Italian Allied Committee on ONJ), Temporary Chair at University of Palermo, 90100 Piazza Marina, Italy; francesco.bertoldo@ 123456univr.it (F.B.); giordanabettini@ 123456gmail.com (G.B.); fusco.dott.vittorio@ 123456gmail.com (V.F.); paolo.vescovi@ 123456unipr.it (P.V.); claudio.marchetti@ 123456unibo.it (C.M.); alberto.bedogni@ 123456unipd.it (A.B.)

[3 ]Department of Biomedical and Dental Sciences and Morphofunctional Imaging, University of Messina, 98124 Messina, Italy; antoniam@ 123456hotmail.it (A.M.); oterig@ 123456unime.it (G.O.)

[4 ]Department of Medicine, University of Verona, 37134 Verona, Italy

[5 ]Regional Center for Prevention, Diagnosis and Treatment of Medication and Radiation-Related Bone Diseases of the Head and Neck, University of Padova, 35128 Padova, Italy

[6 ]Department of Medical, Surgical and Health Sciences, University of Trieste, 34129 Trieste, Italy; m.biasotto@ 123456fmc.units.it

[7 ]Department of Medical, Surgical and Dental Speciality, University of Campania “Luigi Vanvitelli”, 80138 Naples, Italy; giuseppe.colella@ 123456unicampania.it

[8 ]Department of Surgery, Medicine, Dentistry and Morphological Sciences with Transplant Surgery, Oncology and Regenerative Medicine Relevance, University of Modena and Reggio Emilia, 41125 Modena, Italy; ugo.consolo@ 123456unimore.it

[9 ]Department of Interdisciplinary Medicine, University of Bari Aldo Moro, 70124 Bari, Italy; prof.gfavia@ 123456gmail.com

[10 ]Azienda Ospedaliera SS. Antonio e Biagio e Cesare Arrigo, Azienda Ospedaliera Nazionale SS. Antonio e Biagio e Cesare Arrigo, 15121 Alessandria, Italy

[11 ]Department of Surgical, Medical and Molecular Pathology and Critical Care Medicine, University of Pisa, 56126 Pisa, Italy; mario.gabriele@ 123456med.unipi.it

[12 ]Department of Clinical and Experimental Medicine, University of Foggia, 71121 Foggia, Italy; lorenzo.lomuzio@ 123456unifg.it

[13 ]Department of Clinical Specialistic and Dental Sciences, Marche Polytechnic University, 60126 Ancona, Italy; MarcoMascitti86@ 123456hotmail.it (M.M.); andrea.santarelli@ 123456staff.univpm.it (A.S.)

[14 ]Department of Medicine and Surgery, University of Parma, 43125 Parma, Italy; marco.meleti@ 123456unipr.it

[15 ]Department of Neuroscience, Reproductive and Odontostomatological Sciences, University of Naples Federico II, 80131 Napoli, Italy; mignogna@ 123456unina.it

[16 ]Department of Oral and Maxillofacial Sciences, Sapienza University of Rome, 00161 Roma, Italy; umberto.romeo@ 123456uniroma1.it

[17 ]Department of Biomedical and Neuromotor Sciences, University of Bologna, 40125 Bologna, Italy

Author notes

[* ]Correspondence: rodolfo.mauceri@ 123456unipa.it

Author information

Giuseppina Campisi https://orcid.org/0000-0002-9443-0495

Rodolfo Mauceri https://orcid.org/0000-0002-4008-6502

Francesco Bertoldo https://orcid.org/0000-0002-5175-7340

Giordana Bettini https://orcid.org/0000-0002-4314-3277

Ugo Consolo https://orcid.org/0000-0001-5557-3285

Olga Di Fede https://orcid.org/0000-0002-5562-7420

Lorenzo Lo Muzio https://orcid.org/0000-0003-4633-4893

Marco Mascitti https://orcid.org/0000-0002-7304-3752

Giacomo Oteri https://orcid.org/0000-0002-0941-1645

Vera Panzarella https://orcid.org/0000-0001-6339-6020

Umberto Romeo https://orcid.org/0000-0003-2439-2187

Andrea Santarelli https://orcid.org/0000-0003-4218-3354

Claudio Marchetti https://orcid.org/0000-0002-4178-4257

Alberto Bedogni https://orcid.org/0000-0003-4742-4508

Article

Publisher ID: ijerph-17-05998

DOI: 10.3390/ijerph17165998

PMC ID: 7460511

PubMed ID: 32824826

SO-VID: 971cf241-3742-4026-93ea-6b3f055dce31

License:

Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license ( http://creativecommons.org/licenses/by/4.0/).

Medication-Related Osteonecrosis of Jaws (MRONJ) Prevention and Diagnosis: Italian Consensus Update 2020

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Most cited references 41

Bisphosphonate-associated osteonecrosis of the jaw: report of a task force of the American Society for Bone and Mineral Research.

Is bisphosphonate-associated osteonecrosis of the jaw caused by soft tissue toxicity?

Managing the care of patients receiving antiresorptive therapy for prevention and treatment of osteoporosis: executive summary of recommendations from the American Dental Association Council on Scientific Affairs.

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