Complementarity of Photo-Biomodulation, Surgical Treatment, and Antibiotherapy for Medication-Related Osteonecrosis of the Jaws (MRONJ)

Abstract

Background and Objectives: Antiresorptive or anti-angiogenic agents may induce medication-related osteonecrosis of the jaws (MRONJ), which represents a challenge for clinicians. The aim of this study is to design and apply a composed and stage-approach therapy combining antibiotherapy, surgical treatment, and photo-biomodulation (PBM) for the prevention or treatment of MRONJ lesions. Materials and Methods: The proposed treatment protocol was carried out in the Department of Oral & Maxillofacial Surgery of the “Victor Babes” University of Medicine and Farmacy of Timisoara, in 2018–2020. A total of 241 patients who were previously exposed to antiresorptive or anti-angiogenic therapy, as well as patients already diagnosed with MRONJ at different stages of the disease were treated. A preventive protocol was applied for patients in an “at risk” stage. Patients in more advanced stages received a complex treatment. Results: The healing proved to be complete, with spontaneous bone coverage in all the n = 84 cases placed in an “at risk” stage. For the n = 49 patients belonging to stage 0, pain reductions and decreases of mucosal inflammations were also obtained in all cases. For the n = 108 patients proposed for surgery (i.e., in stages 1, 2, or 3 of MRONJ), a total healing rate of 91.66% was obtained after the first surgery, while considering the downscaling to stage 1 as a treatment “success”, only one “failure” was reported. This brings the overall “success” rate to 96.68% for a complete healing, and to 99.59% when downscaling to stage 1 is included in the healing rate. Conclusions: Therefore, the clinical outcome of the present study indicates that patients with MRONJ in almost all stages of the disease can benefit from such a proposed association of methods, with superior clinical results compared to classical therapies.

The Role of the Laser Photobiomodulation (PBM) in the Management of Patients at Risk or Affected by MRONJ

“…A preventive administration of PBM in patients at-risk for MRONJ has been described by Nica et al too. In their 84-patient case series the authors applied the laser therapy immediately after the teeth extraction and, daily for the successive three weeks until the complete bone and mucosal healing, reporting no osteonecrotic lesions onset in all the studied cases [6].…”

“…Autologous hemoderivatives, as PRP, L-PRF, etc., have been introduced in oral surgery in the last twenty years, confirming their positive efficiency in the bone remodeling and healing processes. In many studies, they have been introduced in the post-surgical phase of MRONJ patients [6]. The association of surgical therapy, pharmacological therapy, PRP and PBM induced a complete response and a positive outcome for most of a case series analyzed by Martins et al [35].…”

“…In addition, many co-factors, such as comorbidities (e.g., diabetes), smoking, dental interventions, and concurrent medications (e.g., corticosteroids), have been reported to play a role in its pathogenesis [5]. Bone progressive exposure and pain are the most severe complications of MRONJ, and their onset was demonstrated to greatly reduce the Quality of Life (QoL) of patients [2,6,7].…”

“…There is no general consensus on the management of MRONJ in the literature, and its treatment is very difficult and debated [8][9][10][11]. The main target of all therapeutic protocols is to minimize the occurrence or the progression of bone necrosis, to eliminate pain, to control infection and suppuration, and to provide some relief to patients [6,[8][9][10][11].…”

“…As in many other pathologies, prevention is always the main focus in patients following at-risk MRONJ therapeutic protocols; conservative measures, such as good oral hygiene, 0.12% chlorhexidine mouthwashes, and the treatment of any early dental or periodontal lesions are fundamental. In fact, any surgical intervention should be avoided, though the prevention of this may lead to areas of exposed necrotic bone [6]. In the past, the onset of the lesions was thought to be related to minor oral surgery in at-risk patients being administered drugs for long periods; on the contrary, recently, periodontal and periimplant infections have been considered as crucial risk factors, being the sites that often need surgical dental or implant removal, and so leading to the onset of MRONJ lesions [2].…”