Osteonecrosis de los maxilares asociada a medicamentos: revisión de la literatura y propuesta para la prevención y manejo

Abstract

Medication-related osteonecrosis of the jaw is a disease where there is necrotic bone exposed or that can be explored by means of a fistula in the maxillofacial region. It has been associated with the use Biphosphonates and denosumab for osteoporosis. Although its etiology is unclear, it may be related to a decrease in bone turnover produced by these drugs, rendering the bone more prone to generate cell necrosis during invasive dental procedures, especially in the posterior region of the jaw. There is no consensus about the prevention and treatment of this condition. The aim of this paper is to present a review of the literature with the main characteristics of osteonecrosis of the jaws associated with drugs, together with a proposal for prevention and treatment for these patients.

The clinical case of an oncological patient affected by mandibular osteonecrosis and literature review about therapeutic alternatives

“…Mandibular osteonecrosis is defined as a potentially serious side effect of drugs that modify bone metabolism and inhibit angiogenesis, generally manifesting as an infection of the jaw (mainly in the lingual area of the alveolar border of lower premolars and molars, site most exposed to mechanical trauma of chewing and reduced bone turnover with a high rate of remodeling) [3] in people of advanced age. Its incidence varies from approximately 1% to 10% of cases and, as major triggers have been identified for invasive dental procedures (especially in patients with a history of periodontal or periapical disease), injection of intravenous drugs, the duration, frequency of administration and their use in the context of multiple myeloma and metastatic breast cancer [1]. It is essential to make a differential diagnosis, especially in cases where the lesions are not clinically visible; in fact, periodontal disease, osteomyelitis, sinusitis, radiological osteonecrosis, primary bone neoplasms and metastases can cause the same symptoms as pharmacological mandibular osteonecrosis (pain, dental motility, gingival swelling, erythema and ulceration), that in about 30% of cases it is asymptomatic [1,3].…”

“…Mandibular osteonecrosis is an infrequent complication but with a gradual increasing incidence (phenomenon linked to the increase in neoplastic diseases, the higher survival rate of patients and induced by antineoplastic treatment) related to the use of antiresorptive drugs (especially zoledronic acid), RANK ligand inhibitors (i.e., denosumab) and/or antiangiogenics (i.e., bevacizumab), particularly if administered intravenously [1,2]. It is not excluded that one of the triggering causes may be poor bone turnover and remodeling, insufficient blood supply and constant microtraumas; necrosis can occur in an exposed area of the bone or through a fistula in correspondence with the maxillofacial region [3].…”

Prevalencia de osteonecrosis de los maxilares asociada a medicamentos en pacientes tratados con bifosfonatos intravenosos: análisis epidemiológico en Centro del Cáncer - Red de Salud UC-CHRISTUS

“…(2018) concluyeron que las bajas tasas de frecuencia (1,3% para pacientes bajo ácido zoledrónico) de OMAM se deben a un riguroso protocolo previo al inicio de la terapia antirresortiva 18 . Si bien la OMAM se puede producir de forma espontánea, la mayoría de los casos presenta como factor desencadenante común una exodoncia y/o procedimientos dentales invasivos 22,23 . Es fundamental que todo paciente reciba una rigurosa evaluación de su salud oral previo a que se inicie el tratamiento con fármacos antirresortivos 23,24 .…”

“…Si bien la OMAM se puede producir de forma espontánea, la mayoría de los casos presenta como factor desencadenante común una exodoncia y/o procedimientos dentales invasivos 22,23 . Es fundamental que todo paciente reciba una rigurosa evaluación de su salud oral previo a que se inicie el tratamiento con fármacos antirresortivos 23,24 . Por lo anteriormente planteado, sumado a nuestra experiencia y la literatura relacionada, todo paciente que requiere iniciar tratamiento con BFIV en nuestra institución debe ser evaluado previamente de forma interdisciplinaria.…”

“…Por lo anteriormente planteado, sumado a nuestra experiencia y la literatura relacionada, todo paciente que requiere iniciar tratamiento con BFIV en nuestra institución debe ser evaluado previamente de forma interdisciplinaria. En conjunto a los equipos de Cirugía Oncológica y Maxilofacial, y Oncología Médica de la Red de Salud UC-CHRISTUS, se desarrolló un protocolo para la prevención y manejo de esta patología, el cual se detalla en la Figura 4 23 .…”