Osteonecrosi dei mascellari associata a bisfosfonati, denosumab e farmaci anti-angiogenetici nei pazienti oncologici e osteoporotici: prevenzione dentale e sicurezza dei trattamenti odontoiatrici

Abstract

RIASSUNTOObiettivi. Proporre protocolli di gestione odontoiatrica per il paziente che assume o che assumerà farmaci (per esempio bisfosfonati, denosumab e anti-angiogenetici) correlati all'insorgenza di osteonecrosi dei mascellari (OsteoNecrosis of the Jaws, ONJ). Materiali e metodi. Gli autori del lavoro, recentemente estensori e collaboratori -su mandato della Società Italiana di Chirurgia Maxillo-Facciale (SICMF) e della Società Italiana di Patologia e Medicina Orale (SIPMO), delle Raccomandazioni clinicoterapeutiche sull'osteonecrosi delle ossa mascellari associata a bisfosfonati e sua prevenzione -hanno esaminato le informazioni in rapporto con le procedure odontoiatriche. Risultati e conclusioni. La ONJ da bisfosfonati, ma anche, negli ultimi anni, da denosumab e anti-angiogenetici, si può considerare la più emergente delle patologie odontoiatriche severe: negli ultimi 10 anni si sono registrati migliaia di casi in letteratura, con importanti implicazioni sulla qualità di vita del paziente. La comunità medica e odontoiatrica ha percepito la severità della patologia, ma anche la necessità di darsi regole, di ridisegnare il percorso preventivo e assistenziale di tale malattia: in tutte le nazioni industrializzate e parimenti in Italia sono state stilate linee guida o raccomandazioni per la prevenzione e cura della ONJ, malattia inizialmente solo associata ai bisfosfonati per via endovenosa, in pazienti oncologici, ma poi rilevata, sebbene con frequenza inferiore, anche nei pazienti non oncologici, principalmente osteoporotici, in terapia con

Medication-Related Osteonecrosis of Jaws (MRONJ) Prevention and Diagnosis: Italian Consensus Update 2020

“…Intriguingly, these infections are often the main reason for surgical procedures of dental extraction or implant removal during or after therapy. It is advisable to consult the newest recommendations (2020) on MRONJ published by the two Italian scientific societies SICMF/SIPMO for a complete list of systemic and local risk factors [ 14 ] ( Table 1 ).…”

“…Assume that the Consensus Conference has now adopted the new protocols for dental management in patients at risk of MRONJ, published in the recommendations on MRONJ by the two scientific societies SICMF/SIPMO [ 14 ], in which it re-evaluated its opinion on the following hot points: (a) implants in cancer and osteometabolic patients; (b) antibiotic prophylaxis; and (c) healing for first vs. second intention.…”

“…The half-life of BPs in circulation is short (ranging from 30 min to 2 h); however, once they have been incorporated into bone tissue, they can persist more than 10 years, depending on the skeletal turnover time [ 11 , 45 ]. Usually, BPs (i.e., alendronate) is administered orally (e.g., 150 mg/every 4 week); in a few patients BPs are administered intramuscularly (e.g., neridronate 2 mg/kg every 3 months) or intravenously (e.g., zoledronate 5 mg/every 12 months) [ 6 , 14 , 45 ]. Denosumab (Prolia ® ), a monoclonal human IgG2 antibody that highly binds the receptor activator of nuclear factor-kB ligand (RANK-L), blocks the osteoclast maturation, function and survival.…”

“…The present report was considered by the experts as convenient and worthwhile in the light of the new findings [ 10 , 12 , 13 ] and the publication, in June 2020, of the new recommendations (2020) on MRONJ by SICMF/SIPMO [ 14 ], written on the inputs of the experts of the Italian Consensus group on ONJ (IAC-ONJ). Some good practices were confirmed, while others were partially or fully updated (e.g., a drug holiday in osteometabolic patients, see Section 2.5 ); additionally, figures and tables have been added to some issues to emphasize some of the good practices.…”

“…It is matter for the cancer (principally) and osteometabolic patients, since they are exposed to an increasing number of drugs with antiresorptive (i.e., bisphosphonates and denosumab) or antiangiogenic activities (e.g., bevacizumab; aflibercept; inhibitors of Tyrosine Kinases, TKIs; and mTOR inhibitors) [ 6 , 8 , 11 , 15 , 16 , 17 , 18 ]. At the same time, the authors updated the easy applicable indications and procedures for dentists and oral surgeons, in order to reduce MRONJ onset risk and to diagnose it early [ 14 , 19 ].…”