Complementarity of Photo-Biomodulation, Surgical Treatment, and Antibiotherapy for Medication-Related Osteonecrosis of the Jaws (MRONJ)

Abstract

Background and Objectives: Antiresorptive or anti-angiogenic agents may induce medication-related osteonecrosis of the jaws (MRONJ), which represents a challenge for clinicians. The aim of this study is to design and apply a composed and stage-approach therapy combining antibiotherapy, surgical treatment, and photo-biomodulation (PBM) for the prevention or treatment of MRONJ lesions. Materials and Methods: The proposed treatment protocol was carried out in the Department of Oral & Maxillofacial Surgery of the "Victor Babes" University of Medicine and Farmacy of Timisoara, in 2018-2020. A total of 241 patients who were previously exposed to antiresorptive or anti-angiogenic therapy, as well as patients already diagnosed with MRONJ at different stages of the disease were treated. A preventive protocol was applied for patients in an "at risk" stage. Patients in more advanced stages received a complex treatment. Results: The healing proved to be complete, with spontaneous bone coverage in all the n = 84 cases placed in an "at risk" stage. For the n = 49 patients belonging to stage 0, pain reductions and decreases of mucosal inflammations were also obtained in all cases. For the n = 108 patients proposed for surgery (i.e., in stages 1, 2, or 3 of MRONJ), a total healing rate of 91.66% was obtained after the first surgery, while considering the downscaling to stage 1 as a treatment "success", only one "failure" was reported. This brings the overall "success" rate to 96.68% for a complete healing, and to 99.59% when downscaling to stage 1 is included in the healing rate. Conclusions: Therefore, the clinical outcome of the present study indicates that patients with MRONJ in almost all stages of the disease can benefit from such a proposed association of methods, with superior clinical results compared to classical therapies.

Keywords: laser therapy; medication-related osteonecrosis of the jaws (MRONJ); photo-biomodulation (PBM); piezo-surgery; plasma rich fibrin (PRF); surgical therapy.

Figure 1

(a) Patient with the 1st upper premolar indicated for extraction; (b) 10 days after extraction; (c) complete healing after 8 weeks.

Figure 2

(a) Patient diagnosed with congestion and edema of oral mucosa (4th quadrant) in stage 0 of medication-related osteonecrosis of the jaws (MRONJ); (b) panoramic radiography showing no alveolus remodeling 5 months after the extraction performed in the 4th quadrant; (c) complete remission of pain, edema, and mucosal inflammation after antibiotics therapy and photo-biomodulation (PBM).

Figure 3

(a) Patient in stage 0 of MRONJ, initial presentation; (b) during the surgical healing, after the tooth extraction; (c) 3 months after the surgery.

Figure 4

(a) Posterior mandible of a patient with a stage 1 of MRONJ; (b) complete healing, 3 months after surgery, antibiotic therapy, and PBM.

Figure 5

(a) Patient in stage 2 of MRONJ at initial presentation; she was downscaled at stage 1 after PBM and antibiotherapy and was further on proposed for surgery; (b) performed surgery, with necrotic bone removal; (c) plasma rich fibrin (PRF) was applied in 2 layers; (d) complete bone coverage after the treatment.

Figure 6

(a) Patient in stage 3 of MRONJ with infection extended to the inferior border of mandible-extraoral view; (b) intraoral view at the initial presentation of the patient; (c) mandible bone showing a sclerotic structure; (d) performed surgery, with necrotic block resection; (e) PRF membranes covering completely the bone in 2 layers; (f) tension-free closure of the surgical wound; (g) complete healing achieved 6 months after the end of the treatment.