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Table of Contents
Year : 2020  |  Volume : 3  |  Issue : 2  |  Page : 412

Authors' reply to Tandon et al., Kudva et al., and Krishnan et al.

Department of Radiodiagnosis and Imaging, Tata Memorial Hospital, Mumbai, Maharashtra, India

Date of Submission15-Apr-2020
Date of Decision17-Apr-2020
Date of Acceptance20-Apr-2020
Date of Web Publication19-Jun-2020

Correspondence Address:
Abhishek Mahajan
Department of Radiodiagnosis and Imaging, Tata Memorial Centre, Tata Memorial Hospital, Mumbai - 400 012, Maharashtra
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/CRST.CRST_157_20

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How to cite this article:
Ahuja A, Mahajan A. Authors' reply to Tandon et al., Kudva et al., and Krishnan et al. Cancer Res Stat Treat 2020;3:412

How to cite this URL:
Ahuja A, Mahajan A. Authors' reply to Tandon et al., Kudva et al., and Krishnan et al. Cancer Res Stat Treat [serial online] 2020 [cited 2020 Sep 19];3:412. Available from: http://www.crstonline.com/text.asp?2020/3/2/412/287210

We thank Tandon et al., Kudva and Kumar, and Krishnan et al. for their interest in our article.[1],[2],[3] As aptly pointed out by Tandon et al. and Krishnan et al., osteonecrosis of the jaw could be caused by various medications, including denosumab. In the present case, the risk versus benefit ratio was assessed by the clinical team in view of the metastatic disease, and denosumab was administered with monitoring and local examination of the jaw.[4] With reference to Chiu et al.'s comment, the use of long-term steroids is associated with an increased risk of osteonecrosis; however, our patient received only a single epidural injection for the degenerative disease, which is unlikely to be associated with osteonecrosis.[5],[6] In our article, “above mentioned systemic therapy” referred to fulvestrant, letrozole, and zolendronate, with the bisphosphonate being the crux of the discussion. As aptly pointed out by Kudva and Kumar when performing tooth extraction in patients who receive oral bisphosphonates, factors such as the age, extraction site, and duration of administration must be taken into consideration, and close postoperative follow-up should be carried out to facilitate effective and early management.[6] We completely agree with Krishnan et al. on the fact that even after 17 years of existence, the diagnosis of medication-related osteonecrosis of the jaw (MRONJ) is a surprise in many cases; in our case, the patient underwent tooth extraction in an outside clinic and was not advised proper care. This could be possibly due to either a lack of elucidation of the bisphosphonate medication history by the dental specialists or an insufficient awareness about the existence of this oral entity among them.[5] Hence, even today, several case reports on the surprise diagnosis of MRONJ or cases masquerading as jaw metastasis are seen in the literature; we attribute this 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 orthopantomogram (OPG) may fail to show the early changes of MRONJ; however, for a full-blown disease and follow-up of MRONJ, an OPG is an adequate investigation tool. In suspicious cases that are negative on OPG, a computed tomography (CT) scan or magnetic resonance imaging (MRI) of the jaw must be advised.[7] MRI and contrast-enhanced positron-emission tomography/CT are helpful imaging tools in differentiating local recurrence in a previously treated oral cancer versus treatment-induced osteoradionecrosis.[7],[8]

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There are no conflicts of interest.

  References Top

Tandon S, Faraz F, Datta A. Bisphosphonate-related osteonecrosis of the jaw – An ounce of prevention is worth a pound of cure. Cancer Res Stat Treat 2020;3:409-10.  Back to cited text no. 1
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Kudva A, Kumar M. Clinical aspects and considerations in patients with medication-induced osteonecrosis of the jaw: A commentary. Cancer Res Stat Treat 2020;3:408-9.  Back to cited text no. 2
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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.  Back to cited text no. 3
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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. 4
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Chiu CT, Chiang WF, Chuang CY, Chang SW. Resolution of oral bisphosphonate and steroid-related osteonecrosis of the jaw — A serial case analysis. J Oral Maxillofac Surg 2010;68:1055-63.  Back to cited text no. 5
Jeong HG, Hwang JJ, Lee JH, Kim YH, Na JY, Han SS. Risk factors of osteonecrosis of the jaw after tooth extraction in osteoporotic patients on oral bisphosphonates. Imaging Sci Dent 2017;47:45-50.  Back to cited text no. 6
Deshpande SS, Thakur MH, Dholam K, Mahajan A, Arya S, Juvekar S. Osteoradionecrosis of the mandible: Through a radiologist's eyes. Clin Radiol 2015;70:197-205.  Back to cited text no. 7
Dholam KP, Singh GP, Agarwal JP, Mahajan A. 18F FDG uptake due to late-onset osteoradionecrosis for tongue base carcinoma. Clin Nucl Med 2019;44:e345-6.  Back to cited text no. 8


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