Bisphosphonate-related osteonecrosis: laser-assisted surgical treatment or conventional surgery?

Abstract

Bisphosphonates (BSPs) are used for the treatment of multiple myeloma, metastatic breast and lung cancer, Paget's disease, osteoporosis, hypercalcemia due to malignancy, and many other skeletal diseases. BSPs reduce osteoclastic functions, which result in bone resorption. Bisphosphonates-related osteonecrosis of jaws (BRONJ) is a newly developed term that is used to describe the significant complication in patients receiving bisphosphonates. BSPs are known to exhibit an anti-angiogenetic effect that initiates tissue necrosis of the hard tissue. There is currently no consensus on the correct approach to this issue. The aim of this retrospective study is to compare the effects of laser surgery with biostimulation to conventional surgery in the treatment of BSP-induced avascular bone necrosis on 20 patients who have been treated in our clinic. BRONJ was evaluated in patients with lung, prostate, and breast cancer under intravenous BSP treatment. Twenty patients in this study developed mandibular or maxillary avascular necrosis after a minor tooth extraction surgery or spontaneously. Bone turnover rates were evaluated by serum terminal C-telopeptide levels (CTX) using the electrochemiluminescence immunoassay technique and patients were treated with laser or conventional surgical treatments and medical therapy. Ten patients were treated with laser surgery and biostimulation. An Er:YAG laser (Fotona Fidelis Plus II® Combine laser equipment, Slovenia) very long pulse (VLP) mode (200 mJ, 20 Hz) using a fiber tip 1.3 mm in diameter and 12 mm in length was used to remove the necrotic and granulation tissues from the area of avascular necrosis. Biostimulation was applied postoperatively using an Nd:YAG laser. Low-level laser therapy (LLLT) was applied to the tissues for 1 min from 4 cm distance using an Nd:YAG laser (Fotona-Slovenia) with a R24 950-µm fiber handpiece long-pulse (LP) mode, 0.25-W, 10 Hz power/cm(2) from the mentioned distance the spot size was 0.4 cm(2), and power output was 2.5 J. Energy density from the mentioned distance was calculated to be 6.25 J/cm(2). The other ten patients were treated with conventional surgery. Treatment outcomes were noted as either complete healing or incomplete healing. There were no statistically significant differences between laser surgery and conventional surgery (p > 0.05). CTX values also did not affect the prognosis of the patients. Treatment outcomes were significantly better in patients with stage II osteonecrosis than in patients with stage I osteonecrosis. Our findings suggest that dental evaluation of the patients prior to medication is an important factor in the prevention of BRONJ. Laser surgery is a beneficial alternative in the treatment of patients with this situation. Further randomized studies with larger patient numbers may also improve our understanding of treatment protocols for this situation.

Therapy for bisphosphonate-related osteonecrosis of the jaw: a systematic review

“…The use of laser therapy [7][8] and hyperbaric oxygen 9 were suggested as adjuvant therapies. Laser therapy can remove the necrotic and infected tissue, decontaminate the area and provide biostimulation, thus accelerating the healing process and stimulating alkaline phosphatase and osteoblasts.…”

“…[1][2][3] Once BRONJ is developing, its management is a dilemma. 8 To this day, no effective treatment was found and discontinuing bisphosphonates has not proven to be beneficial. 3,8 The temporary discontinuation of bisphosphonates does not seem to provide any short -term advantage, while the long -term discontinuation, if systemic conditions allow, may benefit the stabilization of ONJ sites and reduce clinical symptoms.…”

“…8 To this day, no effective treatment was found and discontinuing bisphosphonates has not proven to be beneficial. 3,8 The temporary discontinuation of bisphosphonates does not seem to provide any short -term advantage, while the long -term discontinuation, if systemic conditions allow, may benefit the stabilization of ONJ sites and reduce clinical symptoms. [1][2][3][4][5][6][7] Local and systemic antimicrobial drugs have been used independently or along with surgery, and sometimes associated with therapies that accelerate healing, such as laser therapy, hyperbaric oxygen, and platelet -rich plasma.…”

“…[1][2][3][4][5][6][7] Local and systemic antimicrobial drugs have been used independently or along with surgery, and sometimes associated with therapies that accelerate healing, such as laser therapy, hyperbaric oxygen, and platelet -rich plasma. [8][9][10][11][12][13][14] This systematic review aimed to assess the treatments available for BRONJ.…”

Surgical management in patients with bisphosphonate-related osteonecrosis of the jaw: four cases

“…7,12 Moreover, ozone therapy and laser applications (Low Level Laser Therapy -LLLT) have been also reported in the literature for the treatment of BRONJ. [15][16][17][18] However it must be recognized that interindividual variability, gender, age, physical activity, and seasonal and circadian variation exist that can result in difficulty in interpreting the treatment and more research is needed.…”