Ezher Hamza Dayisoylu

Does an alkaline environment prevent the development of bisphosphonate-related osteonecrosis of the jaw? An experimental study in rats

OBJECTIVE To investigate the preventive effect of locally applied sodium bicarbonate on bisphosphonate-related osteonecrosis of the jaw (BRONJ). STUDY DESIGN Thirty-six Sprague-Dawley rats were divided into 4 groups. Animals in group I received 0.1 mg/kg sterile saline 3 times per week for 8 weeks. Groups II, III, and IV received intraperitoneal zoledronate injection in the same manner with the same frequency and duration. The right first molar tooth was extracted in groups III and IV. One mL 8.4% sodium bicarbonate (SB) was applied to the extraction socket at the time of extraction in group IV. The effect of locally applied SB as an alkalizing agent was evaluated by histomorphometric analysis. RESULTS BRONJ was observed in none of the animals in the control groups, 67% of the animals in the tooth extraction group, and none of the animals in the local SB application group (P < .01). CONCLUSIONS Administration of locally applied SB had positive effects on the prevention of BRONJ in animals, but further studies are required to verify the effectiveness of this form of treatment before its use in humans.

The effects of adjunctive parathyroid hormone injection on bisphosphonate-related osteonecrosis of the jaws: an animal study

Bisphosphonate (BP)-related osteonecrosis of the jaw (BRONJ) is a serious and challenging complication of chronic BP uptake in patients with osteoporosis who require management of skeletal-related events. The efficiency of adjunctive parathyroid hormone (PTH) injection was evaluated after chronic BP administration that was followed by tooth extraction. BRONJ was not observed in any of the subjects in the control groups, while BRONJ was observed in 66% and 22% of the subjects in the tooth extraction group and the tooth extraction with PTH injection group, respectively. In addition the presence and severity of inflammation was lower in the PTH injected group than in the tooth extraction group, but the difference was not statistically significant (P>0.01). In conclusion, the administration of 30μg/kg/day PTH during a period of 8 weeks had positive effects on the resolution of BRONJ, but further studies are required to verify the effectiveness of PTH in the treatment of BRONJ.

Ultrasound-guided arthrocentesis of the temporomandibular joint

f g h t w w ysis and lavage of the upper joint space is a safe and effecive way of managing disorders of the temporomandibular oint (TMJ), and some studies have attempted to find ways f making arthrocentesis comfortable.1 Identification of the pper joint space is important for successful lysis and lavage, o reference points have been laid down.2 However, use of he “blind” technique to reach the upper joint space requires xperience, and carries a risk of damage to the collateral ligments of the disc and the adjacent soft tissue. In addition, xtra-articular or intra-articular injections affect the success f treatments such as prolotherapy, injection of autologous lood, and arthrocentesis. Although magnetic resonance imaging (MRI) is the gold tandard for clinical diagnostic criteria for disorders of the MJ, ultrasound (US) is also effective.3 In addition, USuided lysis and lavage of the TMJ may permit real-time ynamic arthrocentesis, which we describe here.

Comments on “Diagnosis and Management of Osteonecrosis of the Jaw: A Systematic Review and International Consensus”

This work provides a systematic review of the literature from January 2003 to April 2014 pertaining to the incidence, pathophysiology, diagnosis, and treatment of osteonecrosis of the jaw (ONJ), and offers recommendations for its management based on multidisciplinary international consensus. ONJ is associated with oncology-dose parenteral antiresorptive therapy of bisphosphonates (BP) and denosumab (Dmab). The incidence of ONJ is greatest in the oncology patient population (1% to 15%), where high doses of thesemedications are used at frequent intervals. In the osteoporosis patient population, the incidence of ONJ is estimated at 0.001% to 0.01%, marginally higher than the incidence in the general population (<0.001%). New insights into the pathophysiology of ONJ include antiresorptive effects of BPs and Dmab, effects of BPs on gamma delta T-cells and onmonocyte and macrophage function, as well as the role of local bacterial infection, inflammation, and necrosis. Advances in imaging include the use of cone beam computerized tomography assessing cortical and cancellous architecture with lower radiation exposure, magnetic resonance imaging, bone scanning, and positron emission tomography, although plain films often suffice. Other risk factors for ONJ include glucocorticoid use, maxillary or mandibular bone surgery, poor oral hygiene, chronic inflammation, diabetes mellitus, illfitting dentures, as well as other drugs, including antiangiogenic agents. Prevention strategies for ONJ include elimination or stabilization of oral disease prior to initiation of antiresorptive agents, as well as maintenance of good oral hygiene. In those patients at high risk for the development of ONJ, including cancer patients receiving high-dose BP or Dmab therapy, consideration should be given to withholding antiresorptive therapy following extensive oral surgery until the surgical site heals with mature mucosal coverage. Management of ONJ is based on the stage of the disease, size of the lesions, and the presence of contributing drug therapy and comorbidity. Conservative therapy includes topical antibiotic oral rinses and systemic antibiotic therapy. Localized surgical debridement is indicated in advanced nonresponsive disease and has been successful. Early data have suggested enhanced osseous wound healingwith teriparatide in thosewithout contraindications for its use. Experimental therapy includes bonemarrow stem cell intralesional transplantation, low-level laser therapy, local platelet-derived growth factor application, hyperbaric oxygen, and tissue grafting.

Short-term results of prolotherapy in the management of temporomandibular joint dislocation.

ObjectiveProlotherapy, the rehabilitation of ligaments or tendons by induced proliferation of cells by using dextrose, is a noninvasive and effective method for the treatment of temporomandibular joint (TMJ) dislocation. The aim of this study was to evaluate the efficacy of prolotherapy method for the management of acute or chronic dislocation of TMJ. Materials and MethodsIn this study, 10 patients with TMJ dislocation (2 acute, 8 chronic) were examined retrospectively. All patients consisted of female patients, with a mean age of 28.4, who were treated with prolotherapy procedure. Differences of visual analog scale scores in quality of life, pain on function, and chewing function efficacy between sessions were investigated using the Wilcoxon t test and median values of sessions were evaluated using the Kruskal-Wallis H test. The amount of change at the maximum mouth opening occurring between the preoperative and postoperative values and the frequency of locking episodes were calculated, with results considered statistically significant at P < 0.05. ResultsPain on function scores were significantly decreased in all patients, and TMJ locking were not observed during the follow-up period. Maximum mouth opening exhibited a tendency to decrease, but it was not statistically significant. Also, clicking sound on function presented no significant change (P > 0.05). On the other hand, the visual analog scale scores for quality of life showed significant improvement in all patients (P < 0.05). ConclusionsThe results of this study show that prolotherapy can be used as an efficient, simple, and conservative method to treat TMJ dislocation.

The effects of chronic zoledronate usage on the jaw and long bones evaluated using RANKL and osteoprotegerin levels in an animal model

The discovery of the receptor activator of nuclear factor kappaB (RANK), RANK ligand (RANKL), and osteoprotegerin (OPG) system (RANK/RANKL/OPG system) has been one of the most important advances in bone biology in the last decade. We investigated how the chronic application of bisphosphonate affects the RANKL and OPG levels in an animal model and whether this effect may be related to bisphosphonate-related osteonecrosis of the jaws (BRONJ). Thirty female Sprague-Dawley rats were used in this study. The rats were randomly divided into three groups (10 in each): Z, the zolendronate group, injected with zolendronate for 10 weeks; S, a control group, injected with saline solution for 10 weeks; and C, a control group, in which no injection was given. RANKL values in the tibia were increased in the Z group when compared with the two controls; however, the RANKL values in the mandible were decreased when compared with the controls. Although the differences did not reach statistical significance, the mandibular OPG values were increased in the Z group when compared with the C and S groups. The mechanism of RANKL negation and absence in osteoclastic activation could be a predisposing factor for the development of BRONJ.

Evaluation of sedation in oral and maxillofacial surgery in ambulatory patients: failure and complications

OBJECTIVES This study evaluated the failure and complication rates of sedation in ambulatory patients undergoing oral and maxillofacial surgery. MATERIALS AND METHODS This retrospective cohort study was carried out among 619 patients who had undergone maxillofacial surgical procedures under intravenous sedation with midazolam and fentanyl. Each patients age, American Society of Anesthesiologists (ASA) classification, systemic condition, surgical procedure, complications, and failures were recorded for evaluation. RESULTS A total of 400 patients with ASA I, 199 with ASA II, and 20 with ASA III between the ages of 9 months and 84 years were included in the study. The most common systemic disorders in our patients were mental retardation (35%), hypertension (19%), and epilepsy (15%). Evaluation of the cases revealed 9 complications (1.4%) and 9 sedation failures (1.4%). The complications were bradycardia, postoperative agitation and hallucination, drug reaction, vomiting and nausea, desaturation, and hypotension. CONCLUSIONS Our results in the oral and maxillofacial surgery clinic revealed low complication and failure rates.

Pathogenesis of Medication-Related Osteonecrosis of the Jaw

Since the first descriptions of bisphosphonate-related osteonecrosis (BRONJ) of the jaw, numerous studies and research articles have focused on the pathophysiology of the disease which has currently been renamed to medication-related osteonecrosis of the jaw (MRONJ). Several possible pathomechanisms including over-suppression of jawbone turnover, specific pathogens, antiangiogenic effects, and soft tissue toxicity have been proposed to be the main drivers of the disease. More recently, theories dealing with the role of local inflammations and consecutive pH changes have been introduced. While the precise aetiology is still under current investigation, it is now widely accepted that medication-related osteonecrosis of the jaw has a multifactorial aetiology. Besides, there is more and more evidence that local inflammations and dento-alveolar infections play a key role in the pathogenesis of the disease. Recently, osteonecrotic lesions in the jaw have been described under the treatment with denosumab as well, an antibody against RANK ligand. A better understanding of this entity and the involvement of the RANK-RANKL-OPG system might offer new insights towards a comprehensive understanding of medication-related osteonecrosis of the jaw (MRONJ).