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Case Report | DOI: https://doi.org/10.31579/2690-4861/058
*Corresponding Author: Picardo Silvana Noemi, Head of Practical Works Chair in Oral and Maxillofacial Surgery II School of Dentistry University of Buenos Aires and Department of Dentistry Favaloro Foundation University Hospital.
Citation: P S Noemi, R G Sergio, R Eduardo. (2020) Dental management in Oncology patient: osteonecrosis related osteonecrosis of the Jaw (MRONJ). International Journal of Clinical Case Reports and Reviews. 4(1); DOI: 10.31579/2690-4861/058
Copyright: © 2020 Picardo Silvana Noemi, This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Received: 14 September 2020 | Accepted: 28 September 2020 | Published: 03 November 2020
Keywords: antiresorptive (AR); bisphosphonates (BPS); denosumab (DS); antiangiogenic drugs; medication related osteonecrosis of the jaw (MRONJ); oncology
It is essential that oncological patients treated with antiresorptives or antiangiogenic drugs diagnosed Medication Related Osteonecrosis of the Jaw (MRONJ) must be treated in an interdisciplinary fashion. The patient’s stomatognathic system should be examined preventatively prior to the initiation of antiresorptive drugs in order to avoid pathological buccal manifestations, following the same healthcare clinical protocols used for patients receiving head and neck radiotherapy. Additionally, patients should be informed of the precautions to be taken, including regular dental appointments for oral health assessment. The risk of developing MRONJ should be evaluated according to the type of antiresorptives or antiangiogenic drugs administered and treatment duration.
In the case of MRONJ, its fundamental characteristic is positioned in the biochemical particularity of the pharmacokinetic expression of antiresorptive drugs, reversibly (DS) or irreversibly (BPs) inhibiting the functionality of the osteoclast. Therefore, the consideration of invading bone tissue as little as possible and performing resective therapies in cases of systemic infectious spread follows, since its long-term resolution would not be effective because the drug (BPs) has frank accumulation at a distance, a characteristic used by treating doctors and it would not have clinical relevance to suggest its suspension.
According to the recommendations of AAOMS; Task Force and AOCMF coincide with the sharing of consensus on minimally invasive manipulations once the necrotic foci have been installed and the preventive attitude prevails of eliminating all septic foci prophylactically before starting therapy with antiresorptive drugs. There are positions with a trend more committed to frank bone manipulation with the aim of evacuating the infectious problem and other more conservative positions in order not to expand drug necrosis volumetrically due to bone accumulation of BPs or DS.
The American Surgery of Bone Mineral Research (ASBMR) in 2007 defined MRONJ as “necrotic bone area exposed to the oral environment with more than eight weeks of permanence, in the presence of chronic treatment with BPs, in the absence of radiation therapy to the head and neck”. In 2014 the American Association of Oral and Maxillofacial Surgeons (AAOMS) divided the MRONJ into 4 stages from 0 to 3, according to the clinical and radiological aspect of the osteonecrotic lesion: stage 0: Osteonecrotic lesion without sign-pathognomonic evidence of osteonecrosis: stage 1: osteonecrotic lesion with clinical signs and absence of clinical symptoms; Stage 2: Osteonecrotic lesion with sign and evident clinical symptoms; Stage 3: Osteonecrotic lesion with signs and evident symptoms that involve noble structures: pathological fractures, anesthesia of the lower dental nerve, oral-nasal communication, oral-sinus communication, skin fistulas [4].
Prophylactic antibiotic is not necessary to clinical attention depend on MRONJ so, patients with MRONJ have no risk of bacterial endocarditis, except patients like oncology comorbidity requires. [8].
It is known that MRONJ present a distinctive anatomopathological pattern that characterizes them, both in prescribed patients with BPs: “Pagetoid bone-like histological pattern, with signs of mosaic remodeling and trabecular appearance, areas of necrosis and bacterial colonies in surface and between medullary spaces” [9].
Discussion
It is necessary to stablish a differential diagnosis about different infectious pathologies that involve bone tissue with respect to their etiology, since from the radiological clinical point of view the pathologies described below have similar characteristics. [10] It is known that, in the osteomyelitis, that the cause is microbiological, therefore: with the culture the antibiogram emerges, performing the correct resection maneuver, the evolution is favorable since the osteoblast-osteoclast cell coupling is not involved in bone healing.
In the case of osteoradionecrosis, the etiological factor is physical, which causes damage to the cellular genetic material, both of the osteoblast and of the osteoclast temporarily according to the potential of radiation, but, even so, when the time elapses, the resolution therapeutic is identical to the treatment of osteomyelitis [11].
Analyzing the meta-analysis of Limones et.al. No significant clinical differences were found in relation to bone necrosis associated with BPs versus DS, coinciding with our experience [10].
Given the aforementioned, both osteoporotic and oncological pathologies require the accumulation of the drug due to the need to use antiresorptive protocols that present higher relative potencies, such as the case of treatment in oncological patients [12].
Some reversibility benefit of MRONJ has been seen in the administration of Teriparatide 20 mg / day in osteoporotic patients taking into account the prescription of treatments no longer than 6 months due to the appearance of sarcomas [5]; The use of PRP and / or the application of laser has not shown any benefit. Access to the hyperbaric chamber only has an effect on angiogenic recovery, but therapeutic success has not been proven in patients with MRONJ. There are not enough studies to support such therapies [5-13].
Conclusion
It is known the favorable action which antiresorptive (Bisphosphonates BPs, Denosumab: DS) and Antiangiogenic drugs produce in bone tissue. High concentrations are primarily used as an effective treatment in the management of cancer-related disorders, including hypercalcemia of malignant [14].
From the results found and from those published in the bibliography, it appears that the interaction between health professionals is essential since the prevention of MRONJ is better than the treatment. In this sense, prior dental evaluation of patients is recommended, in order to carry out dental interventions before establishing chronic treatment with antiresorptive drugs [15].
It is clear from the suggested treatments that before the diagnosis of MRONJ the therapeutic attitude is consolidated in non-invasive maneuvers regarding the manipulation of bone tissue, performing the pertinent clinical controls in order to avoid systemic spread to deep planes, due to its pharmacokinetics of bone accumulation that could condition a septicemia picture in affected patients, interacting with the attending physician in the event of a certain event of exacerbation of injuries that affect the patient's general health [16].
There is a need not to suspend antiresorptive medication, necessary according to medical criteria to compensate for the morbidity of the pathology, both in osteoporotic and oncological patients, since in that sense, according to the pharmacokinetics of BPs due to their accumulation, it would not provide greater dental therapeutic benefit. In the case of DS, despite the fact that its pharmacodynamics is reversible, upon request for suspension of said drug by osteoporotic prescription, our patients would present a picture of abrupt bone mass decrease with the consequent morbidity of their osteoporotic pathology. It is known that in cancer patients the suspension of antiresorptives would instigate metastatic spread [17].
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