Local radiographic risk factors for MRONJ in osteoporotic patients undergoing tooth extraction

Abstract

Objective: To identify local radiographic risk factors for Medication-Related Osteonecrosis of the Jaws (MRONJ) in osteoporotic patients treated with antiresorptive drugs (ARD) and undergoing tooth extraction. Material and Methods: Patients were included in this retrospective, longitudinal, case-control study, if having at least one administration of ARD, underwent tooth extraction(s), and had pre-and postoperative panoramic radiographs. Additionally, a matched control group was selected. Three calibrated, blinded, and independent observers assessed each tooth extraction site. Statistical analysis compared control against study group, and within the latter, sites MRONJ+ and MRONJ-.Results: In total 120 patients (99 females/21 males) with 354 tooth extractions were included, from which nine patients (7.5%) and eleven tooth extraction sites (3.1%) developed MRONJ. When comparing control with study group, the latter showed significantly more thickened lamina dura, persistence of the alveolar socket, heterogeneous bone patterns, and sequestrum formation. In the study group, MRONJ developed significantly more in males (19%,p=0.049), smokers (25%,p=0.008), in the mandible (82%,p=0.027), when identifying a radiolucent or sclerotic trabecular pattern (p=0.004) or when extracting teeth with furcation involvement (p<0.001), root remnants (p=0.017), or unrestored caries lesions (p=0.005).Conclusions: Tooth extraction sites showing radiographic signs of chronic dental infection are prone to MRONJ.

Key insights into antiresorptive drug use and osteonecrosis in osteoporotic patients undergoing tooth extractions: A clinical and CBCT assessment

“…One of the novel aspects of the present investigation is the comprehensive assessment of bony changes seen on CBCT images, which has been studied in oncologic patients treated with high doses of ARDs [21,29] but to a lesser extent in patients treated with low doses. In osteoporotic patients under ARDs, no significant differences in the trabecular bone pattern have been demonstrated in two- [12] or three-dimensional examinations [16] when compared to a control group. Nevertheless, even low doses of ARD demonstrated significantly more thickening of the lamina dura in panoramic radiographs [12].…”

“…This control group was matched with the study group in terms of age, sex, and extracted tooth, and also complied with the same exclusion criteria. Tooth extractions followed the methodology outlined by Moreno-Rabié et al 2023 [12]. Specifically, patients in the study group who were on active ARD therapy did not undergo a drug holiday at the time of tooth extractions.…”

“…Factors such as the duration of ARD treatment [10], corticosteroid use, and diabetes mellitus [3] have been associated with MRONJ. Additionally, concerning dental extractions, local risk factors for this condition, such as osteosclerosis or osteolysis, teeth with furcation involvement or untreated dentinal caries, multi-rooted teeth, and mandibular extraction sites, have been recognized [12].…”

“…Several studies have employed diagnostic imaging to investigate the effects of ARDs on the jaw and their potential contribution to osteonecrosis development [13]. While some investigations have utilized panoramic radiographs [12,14], the utilization of cone beam computed tomography (CBCT) images for this purpose in osteoporotic patients has been relatively uncommon. Existing CBCT studies have primarily focused on the mandibular cortical area [15,16], resulting in a gap in the comprehensive evaluation of broad-spectrum changes in this patient population.…”

Risk factors for dental findings of the development of medication-related osteonecrosis of the jaw: Investigation of 3734 teeth in cancer patients receiving high dose antiresorptive agents

“…If everything is to be treated within a short period, tooth extraction may be an option; however, there is no evidence that tooth extraction prevents the development of MRONJ, and some reports suggest that tooth extraction at sites of chronic inflammation may actually predispose patients to MRONJ. 20 In addition, if multiple tooth extractions are necessary, the invasiveness of the procedure may be significant and reduce the quality of life. While dental treatment should be performed on a small number of teeth if there is time to do so, treatment methods for patients who need treatment for multiple teeth should be considered in the future.…”