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Table of Contents
LETTER TO EDITOR
Year : 2020  |  Volume : 3  |  Issue : 2  |  Page : 410-411

Medication-related osteonecrosis of the jaw: An unfamiliar guest at your doorstep?


1 Department of Oral and Maxillofacial Surgery, A. B. Shetty Memorial Institute of Dental Sciences, NITTE Deemed to be University, Mangalore, Karnataka, India
2 Department of Oral Medicine and Maxillofacial Radiology, A. B. Shetty Memorial Institute of Dental Sciences, NITTE Deemed to be University, Mangalore, Karnataka, India
3 Department of Urology, K. S. Hegde Medical Academy, NITTE Deemed to be University, Mangalore, Karnataka, India

Date of Submission18-Mar-2020
Date of Decision19-Mar-2020
Date of Acceptance21-Mar-2020
Date of Web Publication19-Jun-2020

Correspondence Address:
Thekke Puthalath Rajeev
Department of Urology, K. S. Hegde Medical Academy, NITTE Deemed to be University, Mangalore . 575 018, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/CRST.CRST_90_20

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How to cite this article:
Shalini K, Babu GS, Rajeev TP. Medication-related osteonecrosis of the jaw: An unfamiliar guest at your doorstep?. Cancer Res Stat Treat 2020;3:410-1

How to cite this URL:
Shalini K, Babu GS, Rajeev TP. Medication-related osteonecrosis of the jaw: An unfamiliar guest at your doorstep?. Cancer Res Stat Treat [serial online] 2020 [cited 2020 Jul 5];3:410-1. Available from: http://www.crstonline.com/text.asp?2020/3/2/410/287288



The article titled, “The mystery of the jaw pain” under the “Image Challenge” section was quite unique as Waghmare et al. tried to figure out medication-related osteonecrosis of the jaw (MRONJ), a clinical entity of the recent times.[1] I would like to comment that although MRONJ is a rare complication of the bone resorption inhibitor (BRI) therapy, it should be familiar to those involved in cancer care, as its incidence has enormously increased with the use of a wide spectrum of agents, such as bisphosphonates, receptor activator of nuclear factor kappa-B ligand inhibitors (denosumab), and antiangiogenic agents.

The tremendous advancement in drug therapy for malignancies has enhanced the life span of even Stage IV patients. The BRIs used in metastatic bone disease, myeloma, and other osteopenic conditions have a significant impact on curtailing the disease progression and improving the quality of life. In addition to assessing the oncological outcome, such patients require regular monitoring to determine the adverse effects of therapy. Marx reported bisphosphonate-related osteonecrosis of the jaw in 2003, followed by reports of other entities, such as atypical femoral fractures and low energy fractures of the humeral shaft, with bisphosphonate use.[2] Differentiating these “cluster diseases” from new metastatic lesions is a challenge in clinical practice.[3] It has been proven that metastasis to the bone has a predictable pattern, and knowledge of this pattern can help in the early detection of metastasis.[4]

Interestingly, to date, even after 17 years of existence, the diagnosis of MRONJ is delayed. This could be possibly due to either a lack of elucidation of BRI medication history by the dental specialists or an insufficient awareness about the existence of this oral entity among medical specialists.[5] Hence, even today, a propensity of case reports on surprise diagnosis of MRONJ or cases masquerading as jaw metastasis are seen in the literature, which we attribute to our sheer unfamiliarity with this condition. The diagnosis and staging of MRONJ are primarily clinical, and hence, the presence of an open, nonhealing socket or exposed bone within 1 month of extraction had to be specifically looked for in this case. An orthopantamogram is an adequate investigation tool to support the diagnosis of MRONJ; if required, the extent of the lesion can be defined easily by a computed tomographic scan. A magnetic resonance imaging in this case scenario was unnecessary. Further, initiating denosumab, a medication known to cause MRONJ, after confirmation of the diagnosis was unacceptable.

As there are no well-defined corrective therapeutic options for the advanced stage of MRONJ, prevention and early detection are crucial to the management of this debilitating condition. Therefore, availability of a dedicated dental unit in tertiary oncology centers to address dental hygiene, oral prophylactic measures including atraumatic extraction when required, and oral and maxillofacial surgical intervention in advanced cases of MRONJ should be considered.

With these collective efforts, early detection of MRONJ shall be prompt and accurate without any ambiguity, unfamiliarity, or surprise.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Waghmare M, Ahuja A, Pande P, Mahajan A. The mystery of the jaw pain. Cancer Res Stat Treat 2020;3:93-6.  Back to cited text no. 1
  [Full text]  
2.
Marx RE. Pamidronate (Aredia) and zoledronate (Zometa) induced avascular necrosis of the jaws: A growing epidemic. J Oral Maxillofac Surg 2003;61:1115-7.  Back to cited text no. 2
    
3.
Rajeev T. Editorial comment to case of atypical femoral fractures that mimicked the typical imaging findings of prostate cancer-induced bone metastasis. IJU Case Reports 2019;2:306-307.  Back to cited text no. 3
    
4.
Krishnan S, Shetty J, Babu GS, Rajeev TP. Pattern of metastatic bone disease: An observational study. J Evolution Med Dent Sci 2018;7:1204-8.  Back to cited text no. 4
    
5.
Krishnan S, Shetty V, Shetty J, Rajeev TP. Bisphosphonate-related osteonecrosis of the jaw: An enigma among medical practitioners. Indian J Med Paediatr Oncol 2019;40:257-64.  Back to cited text no. 5
  [Full text]  




 

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