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Oral bisphosphonate-related osteonecrosis of the jaws in rheumatoid arthritis patients: a critical discussion and two case reports.

Conte-Neto N, Bastos AS, Spolidorio LC, Marcantonio RA, Marcantonio E - Head Face Med (2011)

Bottom Line: Complete healing of the lesions was achieved.This paper brings to light the necessity for rheumatologists to be aware of the potential risk to their patients of developing BRONJ and to work together with dentists for the prevention and early detection of the lesions.Although some features seem to link RA with oral BRONJ and act as synergistic effects, more studies should be developed to support the scientific bases for this hypothesis.

View Article: PubMed Central - HTML - PubMed

Affiliation: UNESP-Univ, Estadual Paulista, School of Dentistry, Department of Diagnosis and Surgery, Division of Periodontology, Rua Humaitá 1680, 14801-903 Araraquara, SP/Brazil. ncn1@ibest.com.br

ABSTRACT

Background: Bisphosphonate-related osteonecrosis of the jaw (BRONJ) is a clinical condition characterized by the presence of exposed bone in the maxillofacial region. Its pathogenesis is still undetermined, but may be associated with risk factors such as rheumatoid arthritis (RA). The aim of this paper is to report two unpublished cases of BRONJ in patients with RA and to conduct a literature review of similar clinical cases with a view to describe the main issues concerning these patients, including demographic characteristics and therapeutic approaches applied.

Methods: Two case reports of BRONJ involving RA patients were discussed

Results: Both patients were aging female taking alendronate for more than 3 years. Lesions were detected in stage II in posterior mandible with no clear trigger agent. The treatment applied consisted of antibiotics, oral rinses with chlorhexidine, drug discontinuation and surgical procedures. Complete healing of the lesions was achieved.

Conclusions: This paper brings to light the necessity for rheumatologists to be aware of the potential risk to their patients of developing BRONJ and to work together with dentists for the prevention and early detection of the lesions. Although some features seem to link RA with oral BRONJ and act as synergistic effects, more studies should be developed to support the scientific bases for this hypothesis.

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Surgical approach of the BRONJ lesion. A) Surgical exposition of the distally right implant showing a large bone sequestrum around the dental implant; B) Sequestrectomy of the bone necrosis around the dental implant; C) Surgical area after the debridement showing a bone bleeding surface associated with the dental implant removal.
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Figure 3: Surgical approach of the BRONJ lesion. A) Surgical exposition of the distally right implant showing a large bone sequestrum around the dental implant; B) Sequestrectomy of the bone necrosis around the dental implant; C) Surgical area after the debridement showing a bone bleeding surface associated with the dental implant removal.

Mentions: Periimplantitis was the primary hypothesis considered at that time, but BRONJ was also considered. The initial treatment plan was mouth-rinsing with chlorhexidine 0.12% four times a day and antibiotic therapy with Clindamycin 300 mg twice a day for 10 days, since the patient had allergy for β-lactam antibiotics. Surgical decontamination of the implant surface was also planned; however, upon mucosal flap incision, there was no indication of any exposition of implant threads, but there was a large zone of necrotic bone forming a sequestrum area (Figure 3a). Therefore, it was opted to removal of the implant with sequestrectomy and debridement (Figure 3b) until a bleeding bone was observed (Figure 3c). An interrupted suture was made with 4-0 silk in an attempt to close the wound primarily without tension. After medical consensus, alendronate was suspended.


Oral bisphosphonate-related osteonecrosis of the jaws in rheumatoid arthritis patients: a critical discussion and two case reports.

Conte-Neto N, Bastos AS, Spolidorio LC, Marcantonio RA, Marcantonio E - Head Face Med (2011)

Surgical approach of the BRONJ lesion. A) Surgical exposition of the distally right implant showing a large bone sequestrum around the dental implant; B) Sequestrectomy of the bone necrosis around the dental implant; C) Surgical area after the debridement showing a bone bleeding surface associated with the dental implant removal.
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC3111349&req=5

Figure 3: Surgical approach of the BRONJ lesion. A) Surgical exposition of the distally right implant showing a large bone sequestrum around the dental implant; B) Sequestrectomy of the bone necrosis around the dental implant; C) Surgical area after the debridement showing a bone bleeding surface associated with the dental implant removal.
Mentions: Periimplantitis was the primary hypothesis considered at that time, but BRONJ was also considered. The initial treatment plan was mouth-rinsing with chlorhexidine 0.12% four times a day and antibiotic therapy with Clindamycin 300 mg twice a day for 10 days, since the patient had allergy for β-lactam antibiotics. Surgical decontamination of the implant surface was also planned; however, upon mucosal flap incision, there was no indication of any exposition of implant threads, but there was a large zone of necrotic bone forming a sequestrum area (Figure 3a). Therefore, it was opted to removal of the implant with sequestrectomy and debridement (Figure 3b) until a bleeding bone was observed (Figure 3c). An interrupted suture was made with 4-0 silk in an attempt to close the wound primarily without tension. After medical consensus, alendronate was suspended.

Bottom Line: Complete healing of the lesions was achieved.This paper brings to light the necessity for rheumatologists to be aware of the potential risk to their patients of developing BRONJ and to work together with dentists for the prevention and early detection of the lesions.Although some features seem to link RA with oral BRONJ and act as synergistic effects, more studies should be developed to support the scientific bases for this hypothesis.

View Article: PubMed Central - HTML - PubMed

Affiliation: UNESP-Univ, Estadual Paulista, School of Dentistry, Department of Diagnosis and Surgery, Division of Periodontology, Rua Humaitá 1680, 14801-903 Araraquara, SP/Brazil. ncn1@ibest.com.br

ABSTRACT

Background: Bisphosphonate-related osteonecrosis of the jaw (BRONJ) is a clinical condition characterized by the presence of exposed bone in the maxillofacial region. Its pathogenesis is still undetermined, but may be associated with risk factors such as rheumatoid arthritis (RA). The aim of this paper is to report two unpublished cases of BRONJ in patients with RA and to conduct a literature review of similar clinical cases with a view to describe the main issues concerning these patients, including demographic characteristics and therapeutic approaches applied.

Methods: Two case reports of BRONJ involving RA patients were discussed

Results: Both patients were aging female taking alendronate for more than 3 years. Lesions were detected in stage II in posterior mandible with no clear trigger agent. The treatment applied consisted of antibiotics, oral rinses with chlorhexidine, drug discontinuation and surgical procedures. Complete healing of the lesions was achieved.

Conclusions: This paper brings to light the necessity for rheumatologists to be aware of the potential risk to their patients of developing BRONJ and to work together with dentists for the prevention and early detection of the lesions. Although some features seem to link RA with oral BRONJ and act as synergistic effects, more studies should be developed to support the scientific bases for this hypothesis.

Show MeSH
Related in: MedlinePlus