Angela Tempesta

New Dimensional Staging of Bisphosphonate-Related Osteonecrosis of the Jaw Allowing a Guided Surgical Treatment Protocol: Long-Term Follow-Up of 266 Lesions in Neoplastic and Osteoporotic Patients from the University of Bari

Bisphosphonate-related osteonecrosis of the jaw (BRONJ) is the most serious side effect in patients receiving bisphosphonates (BPs) for neoplastic disease and osteoporosis. The aim of this study is to propose a new dimensional stage classification, guiding the surgical treatment of BRONJ patients, and to evaluate the success rate of this new management. From 2004 to 2013, 203 neoplastic and osteoporotic patients with 266 BRONJ lesions were referred to the Odontostomatology Unit of the University of Bari. All patients underwent surgery after suspension of BPs therapy and antibiotic treatment. The surgical procedure was complemented by piezosurgery and followed by the application of hyaluronate and amino acids. The new dimensional staging suggests the choice of the surgical approach, and allows the prediction of postoperative complications and soft and hard tissues healing time, guiding the surgical treatment protocol. This protocol could be a successful management strategy for BRONJ, considering the low recurrences rate and the good stabilisation of the surgical sites observed after a long-term follow-up.

Medication-Related Osteonecrosis of the Jaws: Considerations on a New Antiresorptive Therapy (Denosumab) and Treatment Outcome after a 13-Year Experience

Medication-related osteonecrosis of the jaw (MRONJ) is a serious complication in patients receiving antiresorptive therapies for bone neoplastic localizations and osteoporosis. The aim of this study was to evaluate the clinicopathological features of MRONJ in a cohort of patients treated by new antiresorptive drugs (denosumab) and the corresponding outcome after 13-year maximum follow-up. Overall, 244 patients affected by MRONJ were treated from 2003 to 2015. After clinical and radiological examinations, all lesions were staged according to a dimensional staging system and then surgically treated. All the denosumab-related lesions were classified as stage II or III, thus requiring a more or less invasive surgical approach, despite the results of many recent studies, which suggested a conservative medical approach with early resolution for MRONJ in patients on denosumab. In the current series, 86.9% of treated lesions showed complete clinical and radiological healing, while 13.1% recurred; all recurrences were detected in patients who could not interrupt chemotherapy, steroids, and/or antiresorptive drugs administration due to their general conditions. In conclusion, all oral specialists should be aware of the MRONJ risk among patients taking new antiresorptive drugs; moreover, our protocol based on surgical treatment guided by dimensional staging could be considered effective in view of the low recurrence rate.

Metastatic Breast Cancer in Medication-Related Osteonecrosis Around Mandibular Implants

Patient: Female, 66 Final Diagnosis: Breast cancer metastasis in medication-related osteonecrosis of the jaw Symptoms: — Medication: — Clinical Procedure: Clinical and radiological examination • surgical treatment Specialty: Dentistry Objective: Rare co-existance of disease or pathology Background: Many authors have considered dental implants to be unrelated to increased risk of medication-related osteonecrosis of the jaw (MRONJ). Nevertheless, more recently, more cases of peri-implant MRONJ (PI-MRONJ) have been described, thus becoming a challenging health problem. Also, metastatic cancer deposits are not infrequently found at peri-implant sites and this may represent an additional complication for such treatments. We present the case of a breast cancer patient with PI-MRONJ, presenting a clinically and radiologically undetected metastasis within the necrotic bone, and highlight the necessity of an accurate histopathological analysis. Case Report: A 66-year-old female patient, who had received intravenous bisphosphonates for bone breast cancer metastases, came to our attention for a non-implant surgery-triggered PI-MRONJ. After surgical resection of the necrotic bone, conventional and immunohistochemical examinations were performed, which showed breast cancer deposits within the necrotic bone. Conclusions: Cancer patients with metastatic disease, who are undergoing bisphosphonate treatment, may develop unusual complications, including MRONJ, which is a site at risk for hosting additional metastatic deposits that may be clinically and radiologically overlooked. Such risk is increased by previous or concomitant implant procedures. Consequently, clinicians should be prudent when performing implant surgery in cancer patients with advanced-stage disease and consider the possible occurrence of peri-implant metastases while planning adequate treatments in such patients.

Rhinocerebral Mucormycosis with Orosinusal Involvement: Diagnostic and Surgical Treatment Guidelines

BACKGROUND Rhinocerebral mucormycosis is a rare, rapidly progressive and potentially lethal disease almost exclusively affecting immunocompromised hosts or patients with metabolic disorders, such as poorly controlled diabetes mellitus. METHODS This work is aimed to describe five cases of rhinocerebral mucormycosis to review and possibly define diagnostic and surgical treatment guidelines. In all the patients, surgical debridement, systemic and local antifungal therapy, and oral rehabilitation using filling prostheses were performed. RESULTS None of the patients revealed recurrence of the infection, as confirmed by radiological and clinical long term follow up. CONCLUSION Given the lethal nature of the disease, the authors underline the importance of early diagnosis and of a multidisciplinary approach in order to undertake correct surgical and medical treatments, while keeping the underlying disease under control.

Hyperphosphatemic Familial Tumoral Calcinosis: Odontostomatologic Management and Pathological Features

Patient: Male, 9 Final Diagnosis: Hyperphosphatemic familial tumoral calcinosis Symptoms: — Medication: — Clinical Procedure: Ortopantomography Specialty: Dentistry Objective: Rare disease Background: Hyperphosphatemic familial tumoral calcinosis (HFTC) is to a rare autosomal recessive disorder characterized by cutaneous and sub-cutaneous calcified masses, usually adjacent to large joints. The aim of the current study was to report on the clinico-pathological features of a patient with HFCT, with emphasis on alterations in the jawbones and teeth and the subsequent therapeutic interventions. Case Report: A 13-year-old male patient with HFTC diagnosis came to our attention for dental anomalies and maxillary and mandibular hypoplasia. OPT highlighted multiple impacted teeth, short and bulbous teeth, and pulp chamber and canal obliterations. Lateral cephalometric radiograms pointed out retrusion of both jaws, skeletal class II malocclusion, and deep-bite. He underwent orthopedic, orthodontic, conservative, and surgical treatments, allowing the correction of maxillo-facial and dental abnormalities and dysmorphisms without adverse effects. The surgical samples were sent for conventional and confocal laser scanning microscope (CLSM) histopathological examination, which highlighted several metaplastic micro- and macro-calcifications in the soft tissues, and typical islands of homogenous, non-tubular, dentino-osteoid calcified structures in dentinal tissues. Conclusions: The management of maxillo-facial abnormalities in patients affected by HFTC is very difficult and, requires a combined therapeutic approach. To date, very few indications have been published in the literature.

Medication-related osteonecrosis of the jaw after once-a-year intravenous zoledronic acid infusion for osteoporosis: Report of eight cases.

OBJECTIVE Medication-related osteonecrosis of the jaw (MRONJ) is a commonly reported side effect of antiresorptive drugs prescribed for osteoporosis. Oral bisphosphonates (BPs) are the most frequently administered antiresorptive drugs for osteoporosis, but because of low compliance of the patients with this treatment, which may require weekly or monthly administration, a new formulation (once a year) of zoledronic acid for intravenous infusion has been recently introduced. Although MRONJ has been repeatedly reported in oncologic patients treated with multiple infusions of zoledronic acid, to date MRONJ occurring in patients undergoing once-a-year infusion of zoledronic acid for osteoporosis has been described very rarely. The aim of this study was to report our experience with eight such patients. METHOD AND MATERIALS Eight osteoporotic female patients came to our attention for intraoral necrotic bone exposures with subsequent diagnosis of MRONJ; they had a history of long-term oral antiresorptive therapy but soon developed MRONJ after the shift to once-a-year infusion of zoledronic acid. Consequently, the patients firstly underwent prolonged antibiotic therapy, then surgical removal of the necrotic bone was performed. RESULTS Following antibiotic and surgical treatments, all the patients healed without complications or recurrence. CONCLUSION These cases suggest that, although rare and not yet well documented, MRONJ related to yearly infusion of zoledronic acid may occur in association with significant morbidity and should not be overlooked by either medical or dental clinicians.

Massive Lingual and Sublingual Haematoma following Postextractive Flapless Implant Placement in the Anterior Mandible

Dental implants placement in the anterior mandible with flap or flapless technique is a routine procedure and is considered to be safe. However, serious life-threatening complications may occur. We report the first case of massive lingual and sublingual haematoma following postextractive implant placement in the anterior mandible with flapless technique. A 45-year-old female patient underwent placement of four immediately postextractive implants in the anterior mandible using flapless technique. During the procedure, the patient referred intense acute pain and worsening sign of airway obstruction, dysphagia, dyspnea, and speech difficulties. Bimanual compression of the mouth floor, lingual surface of the mandible, and submental skin was maintained for approximately 25 minutes in order to stop the bleeding. Computerized tomography highlighted the massive lingual and sublingual haematoma. The symptoms and signs had almost completely resolved in the next 48 hours. The prevention of these complications is mandatory with clinical and CT analyses, in order to highlight mandibular atrophy and to select carefully the correct length and angulation of bone drilling and to keep more attention to the flapless technique considering the elevation of a lingual mucoperiosteal flap to access the mandibular contour intraoperatively and to protect the sublingual soft tissues and vasculature in high risk cases.

Orofacial Manifestations and Temporomandibular Disorders of Sjögren Syndrome: An Observational Study

AIMS: Sjӧgren Syndrome is a disorder involving oral tissues, with xerostomia, dysgeusia, dysphagia, tooth decay, gingivitis, angular cheilitis and glossitis. Temporomandibular disorders are a generic term referred to clinical conditions involving the jaw muscles and temporomandibular joint. The aim of this study was to investigate the prevalence of oral manifestations and temporomandibular disorders (TMD) in Sjӧgren Syndrome (SS) patients compared with healthy people. METHODS: The study group included 72 SS patients (2 men, 70 women) diagnosed according to the American-European Consensus Group (AECG) Criteria. A randomly selected group of 72 patients, matched by sex and age, served as control group. The examination for TMD signs and symptoms was based on the standardized Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD) through a questionnaire and clinical examination. RESULTS: SS patients complained more frequently (95.8%) of oral symptoms (xerostomia, dysgeusia, dysphagia) than controls (22.2%) (χ2= 80.66 p< 0.001). TMD symptoms (muscle pain on chewing, difficulty in mouth opening, arthralgia, headaches, tinnitus) were complained by 91.7% of SS patients and by 84.7% of controls (χ2= 1,667 p= 0,196). At the clinical examination, 91,7% of SS had at least one oral sign respect to 75 % of controls. The salivary flow measurements showed high statistical significance between the two groups (Unpaired test, p< 0,0001). Myofascial pain (caused by muscular contracture) was significantly higher in the study group than in the control one (p≤ 0,05). Furthermore 18,05% of SS patients showed deflection versus 5,5% of controls (χ2=5,402 p=0,020). CONCLUSIONS: Sjӧgrens Syndrome seems to play a role in temporomandibular joint disorders.

Diode laser treatment and clinical management of multiple oral lesions in patients with hereditary haemorrhagic telangiectasia

Hereditary haemorrhagic telangiectasia (HHT) is rare, and characterised by vascular dysplasia that leads to various symptoms including visceral arteriovenous malformations and mucocutaneous telangiectatic lesions. Our aim was to describe the clinical features and options for the treatment of multiple oral lesions, and to illustrate the efficacy of the diode laser in the treatment of early (<2mm) and advanced lesions (2mm or more). We report 24 patients with 1200 oral telangiectatic lesions, which were often associated with regular bleeding (from monthly to daily), superinfection, pain, and swelling, and treated with multiple sessions of laser according to the number and size of the lesions. Early lesions were treated with a single laser impulse in ultrapulsed mode, and advanced lesions with repeated laser impulses in pulsed mode (t-on 200ms/t-off 500ms), at a power of 8W. Early lesions healed completely after laser photocoagulation with no operative or postoperative complications, while advanced lesions improved with a remarkable reduction in size but more discomfort. Protective occlusal plates were sometimes used to reduce the incidence of new lesions caused by dental trauma. The treatment of oral telangiectatic lesions is still being debated, and it is important to improve quality of life for patients. Diode laser surgery could be an effective treatment for oral lesions in those with hereditary haemorrhagic telangiectasia.

PHACES syndrome: Diode laser photocoagulation of intraoral hemangiomas in six young patients

Highlights • This study well defines the oral clinical aspects of PHACES oral hemangiomas, poorly noticed in current English literature, and their laser therapy.• Diode laser photocoagulation techniques have been proved to be very effective and minimally invasive surgical treatment for IH in syndromic patient considering the presence of numerous lesions and the necessity of several interventions.• This study shows the two main laser technique used for the treatment of oral hemangiomas highlighting the differences between these ones and their main recommendations.