Key Insights into Antiresorptive Drug Use and Osteonecrosis in Osteoporotic Patients Undergoing Tooth Extractions: A Clinical and CBCT Assessment

Overview

Journal Osteoporos Int

Specialties Endocrinology
Orthopedics

Date 2024 May 20

PMID 38767743

Authors

Catalina Moreno-Rabie

Rocharles Cavalcante Fontenele

Nicolly Oliveira-Santos

Fernanda Nogueira-Reis

Tim Van den Wyngaert

Reinhilde Jacobs

Affiliations

Soon will be listed here.

Abstract

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.

References

Kwack D, Park S . Prediction of medication-related osteonecrosis of the jaw (MRONJ) using automated machine learning in patients with osteoporosis associated with dental extraction and implantation: a retrospective study. J Korean Assoc Oral Maxillofac Surg. 2023; 49(3):135-141. PMC: 10318313. DOI: 10.5125/jkaoms.2023.49.3.135. View

Ruggiero S, Dodson T, Fantasia J, Goodday R, Aghaloo T, Mehrotra B . American Association of Oral and Maxillofacial Surgeons position paper on medication-related osteonecrosis of the jaw--2014 update. J Oral Maxillofac Surg. 2014; 72(10):1938-56. DOI: 10.1016/j.joms.2014.04.031. View

Shudo A, Kishimoto H, Takaoka K, Noguchi K . Long-term oral bisphosphonates delay healing after tooth extraction: a single institutional prospective study. Osteoporos Int. 2018; 29(10):2315-2321. DOI: 10.1007/s00198-018-4621-7. View

Hansen P, Knitschke M, Draenert F, Irle S, Neff A . Incidence of bisphosphonate-related osteonecrosis of the jaws (BRONJ) in patients taking bisphosphonates for osteoporosis treatment - a grossly underestimated risk?. Clin Oral Investig. 2012; 17(8):1829-37. DOI: 10.1007/s00784-012-0873-3. View

Taylor T, Bryant C, Popat S . A study of 225 patients on bisphosphonates presenting to the bisphosphonate clinic at King's College Hospital. Br Dent J. 2013; 214(7):E18. DOI: 10.1038/sj.bdj.2013.327. View

Seki K, Kaneko T, Kamimoto A, Wada M, Takeuchi Y, Furuchi M . Medication-related osteonecrosis of the jaw after tooth extraction in patients receiving pharmaceutical treatment for osteoporosis: A retrospective cohort study. J Dent Sci. 2022; 17(4):1619-1625. PMC: 9588785. DOI: 10.1016/j.jds.2022.03.014. View

Ruggiero S, Dodson T, Aghaloo T, Carlson E, Ward B, Kademani D . American Association of Oral and Maxillofacial Surgeons' Position Paper on Medication-Related Osteonecrosis of the Jaws-2022 Update. J Oral Maxillofac Surg. 2022; 80(5):920-943. DOI: 10.1016/j.joms.2022.02.008. View

Barngkgei I, Halboub E, Almashraqi A . Effect of bisphosphonate treatment on the jawbone: an exploratory study using periapical and panoramic radiographic evaluation. Oral Radiol. 2018; 35(2):159-170. DOI: 10.1007/s11282-018-0358-4. View

Moreno Rabie C, Fontenele R, Oliveira Santos N, Nogueira Reis F, Van den Wyngaert T, Jacobs R . Three-dimensional clinical assessment for MRONJ risk in oncologic patients following tooth extractions. Dentomaxillofac Radiol. 2023; 52(8):20230238. PMC: 10968756. DOI: 10.1259/dmfr.20230238. View

10.

Poxleitner P, Steybe D, Kroneberg P, Ermer M, Yalcin-Ulker G, Schmelzeisen R . Tooth extractions in patients under antiresorptive therapy for osteoporosis: Primary closure of the extraction socket with a mucoperiosteal flap versus application of platelet-rich fibrin for the prevention of antiresorptive agent-related.... J Craniomaxillofac Surg. 2020; 48(4):444-451. DOI: 10.1016/j.jcms.2020.02.006. View

11.

Yanaguizawa W, Barros F, Kobayashi-Velasco S, Salineiro F, Alves F, Cavalcanti M . Computed tomography bone density variations in oncological patients undergoing antiresorptive medication. Med Oral Patol Oral Cir Bucal. 2022; 27(6):e489-e496. PMC: 9648640. DOI: 10.4317/medoral.25191. View

12.

Couso-Queiruga E, Ahmad U, Elgendy H, Barwacz C, Gonzalez-Martin O, Avila-Ortiz G . Characterization of Extraction Sockets by Indirect Digital Root Analysis. Int J Periodontics Restorative Dent. 2021; 41(1):141-148. DOI: 10.11607/prd.4969. View

13.

Chiu W, Yang W, Chien J, Lee J, Tsai K . The influence of alendronate and tooth extraction on the incidence of osteonecrosis of the jaw among osteoporotic subjects. PLoS One. 2018; 13(4):e0196419. PMC: 5918995. DOI: 10.1371/journal.pone.0196419. View

14.

Barngkgei I, Khattab R . Detecting the effect of bisphosphonates during osteoporosis treatment on jawbones using multidetector computed tomography: The OSTEOSYR project. J Investig Clin Dent. 2018; 9(3):e12332. DOI: 10.1111/jicd.12332. View

15.

Moreno-Rabie C, Gaeta-Araujo H, Oliveira-Santos C, Politis C, Jacobs R . Early imaging signs of the use of antiresorptive medication and MRONJ: a systematic review. Clin Oral Investig. 2020; 24(9):2973-2989. DOI: 10.1007/s00784-020-03423-0. View

16.

Bedogni A, Fedele S, Bedogni G, Scoletta M, Favia G, Colella G . Staging of osteonecrosis of the jaw requires computed tomography for accurate definition of the extent of bony disease. Br J Oral Maxillofac Surg. 2014; 52(7):603-8. DOI: 10.1016/j.bjoms.2014.04.009. View

17.

Lesclous P, Cloitre A, Catros S, Devoize L, Louvet B, Chatel C . Alendronate or Zoledronic acid do not impair wound healing after tooth extraction in postmenopausal women with osteoporosis. Bone. 2020; 137:115412. DOI: 10.1016/j.bone.2020.115412. View

18.

Aljohani S, Fliefel R, Ihbe J, Kuhnisch J, Ehrenfeld M, Otto S . What is the effect of anti-resorptive drugs (ARDs) on the development of medication-related osteonecrosis of the jaw (MRONJ) in osteoporosis patients: A systematic review. J Craniomaxillofac Surg. 2017; 45(9):1493-1502. DOI: 10.1016/j.jcms.2017.05.028. View

19.

Diniz-Freitas M, Fernandez-Montenegro P, Fernandez-Feijoo J, Limeres-Posse J, Gonzalez-Mosquera A, Vazquez-Garcia E . Mandibular cortical indices on cone-beam computed tomography images in osteoporotic women on treatment with oral bisphosphonates. Gerodontology. 2014; 33(2):155-60. DOI: 10.1111/ger.12121. View

20.

Hamada H, Matsuo A, Koizumi T, Satomi T, Chikazu D . A simple evaluation method for early detection of bisphosphonate-related osteonecrosis of the mandible using computed tomography. J Craniomaxillofac Surg. 2014; 42(6):924-9. DOI: 10.1016/j.jcms.2014.01.012. View