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Removal of a sequestrum by a patient with medication-related osteonecrosis of the jaw
YBJOM-5255;
ARTICLE IN PRESS
No. of Pages 2
Available online at www.sciencedirect.com
ScienceDirect British Journal of Oral and Maxillofacial Surgery xxx (2017) xxx–xxx
Letter to the Editor
Removal of a sequestrum by a patient with medicationrelated osteonecrosis of the jaw Sir, Medication-related osteonecrosis of the jaw (MRONJ) is a rare complication of dentoalveolar surgery after treatment with antiresorptive or antiangiogenic agents.1 Patients are diagnosed with MRONJ if they have or have had: current or previous treatment with antiresorptive or antiangiogenic agents, exposed bone or bone that can be probed through an intraoral or extraoral fistula that has persisted for more than eight weeks, and no history of radiation to the jaws or metastatic disease to the jaws.2 The main risk factor is the underlying disease. Patients being treated for cancer are more likely to develop it than those being treated for osteoporosis alone. Other risk factors include: dentoalveolar surgery, duration of drug treatment, other medication such as steroids, and the route of delivery of the drug.3 The current management of MRONJ can be categorised into: conservative, surgical, and other treatment. Which management to choose is a challenge and should be done case by case, as there is no gold standard.4 We describe the case of a 75-year-old man who was referred with a non-healing socket after dental extractions in the right mandible. At the time of the extractions, he was being treated for multiple myeloma with infusions of zoledronic acid intravenously. He had developed a large (5 × 3 cm) bony sequestrum in the lower right quadrant extending from LR1 to LR5 (Fig. 1). This was causing discomfort, and he was keen to have debridement. In the meantime, he was prescribed metronidazole orally for two weeks, chlorhexidine mouthwash, and analgesia. One month later he reported that he had removed the sequestrum himself with a screwdriver. On examination, it was healing well with no signs of infection or remnants of exposed bone (Fig. 2). Patients being treated for MRONJ should be made dentally fit before starting any antiresorptive or antiangiogenic agents to reduce the risk of it progressing.1–3 Regardless of staging, any mobile bony sequestrum should be removed (though
Fig. 1. Clinical appearance of the necrotic bone at presentation.
Fig. 2. Clinical appearance of the right side of the mandible after removal of the necrotic bone by the patient.
preferably not at home with a screwdriver) to facilitate good healing of the soft tissue.
Conflict of interest We have no conflicts of interest.
Ethics statement/confirmation of patient’s permission N/A.
http://dx.doi.org/10.1016/j.bjoms.2017.06.019 0266-4356/© 2017 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
Please cite this article in press as: Davies M, et al. Removal of a sequestrum by a patient with medication-related osteonecrosis of the jaw. Br J Oral Maxillofac Surg (2017), http://dx.doi.org/10.1016/j.bjoms.2017.06.019
YBJOM-5255; 2
No. of Pages 2
ARTICLE IN PRESS Letter to the Editor / British Journal of Oral and Maxillofacial Surgery xxx (2017) xxx–xxx
References 1. Muthukrishnan A, Al-Ismail S, Bertelli G, et al. MRONJ risk reduction pathway −360 degree survey. Br Dent J 2017;222:386–90. 2. Ruggeiro SL, Dobson TB, Fantasia J, et al. American Association of Oral and Maxillofacial Surgeons position paper on medication-related osteonecrosis of the Jaw — 2014 update. J Oral Maxillofac Surg 2014;72:1938–56. 3. Scottish Dental Clinical Effectiveness Programme. Oral health management of patients at risk of medicine-related osteonecrosis of jaw. NHS Education for Scotland 2017. Available from URL: http://www.sdcep.org.uk/wp-content/uploads/2017/04/SDCEP-Oral -Health-Management-of-Patients-at-Risk-of-MRONJ-Guidance-full.pdf (last accessed 4th June 2017). 4. Rollason V, Laverriere A, MacDonald LC, et al. Interventions for treating bisphosphonate-related osteonecrosis of the jaw (BRONJ). Cochrane Database Syst Rev 2016;2. CD008455.
M. Davies A. Power A. Kanatas ∗ Leeds General Infirmary, Great George Street, Leeds, UK ∗ Corresponding author at: Leeds Teaching Hospitals and St James Institute of Oncology, Leeds Dental Institute and Leeds General Infirmary, LS1 3EX. Tel.: +44 7956603118. E-mail address: [email protected] (A. Kanatas)
Please cite this article in press as: Davies M, et al. Removal of a sequestrum by a patient with medication-related osteonecrosis of the jaw. Br J Oral Maxillofac Surg (2017), http://dx.doi.org/10.1016/j.bjoms.2017.06.019
ARTICLE IN PRESS
No. of Pages 2
Available online at www.sciencedirect.com
ScienceDirect British Journal of Oral and Maxillofacial Surgery xxx (2017) xxx–xxx
Letter to the Editor
Removal of a sequestrum by a patient with medicationrelated osteonecrosis of the jaw Sir, Medication-related osteonecrosis of the jaw (MRONJ) is a rare complication of dentoalveolar surgery after treatment with antiresorptive or antiangiogenic agents.1 Patients are diagnosed with MRONJ if they have or have had: current or previous treatment with antiresorptive or antiangiogenic agents, exposed bone or bone that can be probed through an intraoral or extraoral fistula that has persisted for more than eight weeks, and no history of radiation to the jaws or metastatic disease to the jaws.2 The main risk factor is the underlying disease. Patients being treated for cancer are more likely to develop it than those being treated for osteoporosis alone. Other risk factors include: dentoalveolar surgery, duration of drug treatment, other medication such as steroids, and the route of delivery of the drug.3 The current management of MRONJ can be categorised into: conservative, surgical, and other treatment. Which management to choose is a challenge and should be done case by case, as there is no gold standard.4 We describe the case of a 75-year-old man who was referred with a non-healing socket after dental extractions in the right mandible. At the time of the extractions, he was being treated for multiple myeloma with infusions of zoledronic acid intravenously. He had developed a large (5 × 3 cm) bony sequestrum in the lower right quadrant extending from LR1 to LR5 (Fig. 1). This was causing discomfort, and he was keen to have debridement. In the meantime, he was prescribed metronidazole orally for two weeks, chlorhexidine mouthwash, and analgesia. One month later he reported that he had removed the sequestrum himself with a screwdriver. On examination, it was healing well with no signs of infection or remnants of exposed bone (Fig. 2). Patients being treated for MRONJ should be made dentally fit before starting any antiresorptive or antiangiogenic agents to reduce the risk of it progressing.1–3 Regardless of staging, any mobile bony sequestrum should be removed (though
Fig. 1. Clinical appearance of the necrotic bone at presentation.
Fig. 2. Clinical appearance of the right side of the mandible after removal of the necrotic bone by the patient.
preferably not at home with a screwdriver) to facilitate good healing of the soft tissue.
Conflict of interest We have no conflicts of interest.
Ethics statement/confirmation of patient’s permission N/A.
http://dx.doi.org/10.1016/j.bjoms.2017.06.019 0266-4356/© 2017 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
Please cite this article in press as: Davies M, et al. Removal of a sequestrum by a patient with medication-related osteonecrosis of the jaw. Br J Oral Maxillofac Surg (2017), http://dx.doi.org/10.1016/j.bjoms.2017.06.019
YBJOM-5255; 2
No. of Pages 2
ARTICLE IN PRESS Letter to the Editor / British Journal of Oral and Maxillofacial Surgery xxx (2017) xxx–xxx
References 1. Muthukrishnan A, Al-Ismail S, Bertelli G, et al. MRONJ risk reduction pathway −360 degree survey. Br Dent J 2017;222:386–90. 2. Ruggeiro SL, Dobson TB, Fantasia J, et al. American Association of Oral and Maxillofacial Surgeons position paper on medication-related osteonecrosis of the Jaw — 2014 update. J Oral Maxillofac Surg 2014;72:1938–56. 3. Scottish Dental Clinical Effectiveness Programme. Oral health management of patients at risk of medicine-related osteonecrosis of jaw. NHS Education for Scotland 2017. Available from URL: http://www.sdcep.org.uk/wp-content/uploads/2017/04/SDCEP-Oral -Health-Management-of-Patients-at-Risk-of-MRONJ-Guidance-full.pdf (last accessed 4th June 2017). 4. Rollason V, Laverriere A, MacDonald LC, et al. Interventions for treating bisphosphonate-related osteonecrosis of the jaw (BRONJ). Cochrane Database Syst Rev 2016;2. CD008455.
M. Davies A. Power A. Kanatas ∗ Leeds General Infirmary, Great George Street, Leeds, UK ∗ Corresponding author at: Leeds Teaching Hospitals and St James Institute of Oncology, Leeds Dental Institute and Leeds General Infirmary, LS1 3EX. Tel.: +44 7956603118. E-mail address: [email protected] (A. Kanatas)
Please cite this article in press as: Davies M, et al. Removal of a sequestrum by a patient with medication-related osteonecrosis of the jaw. Br J Oral Maxillofac Surg (2017), http://dx.doi.org/10.1016/j.bjoms.2017.06.019