Minimizing MRONJ after Tooth Extraction in Cancer Patients Receiving Bone-Modifying Agents

Abstract

Background: Medication-related osteonecrosis of the jaws (MRONJ) is a mucosal lesion of the maxillofacial region with necrotic bone exposure. MRONJ is believed to be multifactorial. Tooth extraction is debatably a risk factor for MRONJ. The targets of the present study were to examine MRONJ occurrence in patients using bone modifying agents (BMAs) for oncology indications and undergoing a dental extraction, and to assess whether suspected predisposing factors can predict MRONJ. Materials and Methods: This retrospective, cohort study included all patients fitting the inclusion criteria and a large tertiary medical center. Data were obtained from the hospital’s medical records using a structured questionnaire. Results: We performed 103 extractions on 93 patients. Local inflammation/infection of the extraction site was most associated with a complication (p = 0.001) OR = 13.46, 95% CI = (1.71, 105.41), OR = 13.5. When the indication for extraction was periodontal disease, vertical root fracture, or periapical pathosis, the odds of developing MRONJ were 4.29 times higher than for all other indications (p = 0.1), OR = 4.29, 95% CI = (1.16, 15.85). A significant association was found between the time of onset of BMA treatment and time of extraction and the development of MRONJ, OR = 3.34, 95% CI = (1.01, 10.18). Other variables did not correlate with the development of MRONJ. Conclusion: Local inflammation/infection and onset of BMA treatment prior to extraction yield a 10.23 times higher chance of developing MRONJ following tooth extraction. Future protocols should use this information to minimize MRONJ incidence.

Incidence and risk factors for medication‐related osteonecrosis after tooth extraction in cancer patients—A systematic review

“…Five of the included studies in this review reported that teeth with signs of inflammation, such as severe periodontal disease, osteomyelitis, or other symptoms of infection, before the treatment showed an increased risk of MRONJ after extraction (Hasegawa et al, 2019;Manfredi et al, 2017;Saia et al, 2010;Soutome et al, 2018;Yamazaki et al, 2012). The results therefore suggest that nonrestorable teeth and those with poor Also, two recently published studies performed in Japan (Hasegawa et al, 2021) and Israel (Avishai et al, 2022) confirm that local inflammation processes present even before tooth extraction increase the risk of MRONJ. These findings can support the hypothesis that a periodontal infection in combination with antiresorptive treatment initiates osteonecrosis and not tooth extraction itself.…”

“…However, in a Swedish prospective study with a 4‐year follow‐up, Hallmer et al (2018) indicated that pre‐existing inflammatory dental disease such as periodontal disease or periapical pathology is a well‐recognized risk factor, assessed as the initiating factor for the development of MRONJ in 18% and 4% of the cases, respectively. Also, two recently published studies performed in Japan (Hasegawa et al, 2021) and Israel (Avishai et al, 2022) confirm that local inflammation processes present even before tooth extraction increase the risk of MRONJ. These findings can support the hypothesis that a periodontal infection in combination with antiresorptive treatment initiates osteonecrosis and not tooth extraction itself.…”

“…Two studies published after the search for this review was completed report a consistent incidence of MRONJ after tooth extractions of 28%-29% (Avishai et al, 2022;Hasegawa et al, 2021). The wide range in this review could partially…”

“…An increased prevalence of MRONJ was noted in association with sequential therapy for pamidronate‐zoledronate and BP‐DS administration as compared to single therapy (Srivastava et al, 2021 ). Previous studies have shown that a longer duration appears to be associated with an increased risk (Avishai et al, 2022 ; Hasegawa et al, 2021 ). As reported by Ruggiero et al ( 2014 ), regardless of indications for therapy, the duration of antiresorptive therapy continues to be considered a risk factor for developing MRONJ.…”

“…The incidence rates for MRONJ vary widely in this review from 11.4% to 50%. Two studies published after the search for this review was completed report a consistent incidence of MRONJ after tooth extractions of 28%–29% (Avishai et al, 2022 ; Hasegawa et al, 2021 ). The wide range in this review could partially be affected by the variation in follow‐up time.…”