RESUMO

La osteonecrosis maxilar relacionada con medicamentos (ONMM) es una patología de características clínicas objetivas con signo-sintomatología patogno-mónica. El criterio clínico aceptado es la presencia de hueso necrótico expuesto y visible sobre el reborde óseo maxilar que no ha cicatrizado luego de 8 sema-nas, en pacientes con antecedentes de tratamiento antirresortivo. La denominación relacionada con medicamentos se utiliza por el creciente número de casos asociados con otros fármacos antirresortivos como denosumab y con terapias antiangiogénicas, más allá de la conocida relación con bifosfonatos. Si bien la incidencia de ONMM en pacientes tratados por osteopatías metabólicas es muy baja, la situa-ción se torna más compleja en pacientes oncológicos con altas dosis de antirresortivos para tratamiento de metástasis ósea. Varios informes de casos des-criben cuadros de ONMM en pacientes con cáncer que reciben terapias dirigidas, específicamente TKI (inhibidores de tirosina kinasa) y anticuerpos mo-noclonales-VEGF (anticuerpos dirigidos al factor de crecimiento del endotelio vascular). La ONMM afecta negativamente la calidad de vida del paciente onco-lógico y produce comorbilidad significativa. Resulta imperioso identificar los pacientes en riesgo y dise-ñar un protocolo de atención odontológica específico para estos casos. En este artículo, se presenta un caso de ONMM asociado con altas dosis de Deno-sumab y administración simultánea de anticuerpos monoclonales específicos. El caso sorprende por la magnitud de la necrosis y su cuadro insidioso. El pro-tocolo de tratamiento descripto permitió controlar el cuadro inicial, limitar el avance de la lesión, asegurar el control del dolor y la infección, y finalmente, la cu-ración total de la lesión (AU)

Medication-related osteonecrosis of the jaws (MRONJ) is a pathology with objective clinical characteristics with pathognomonic signs and symp-toms. The accepted clinical criterion is the presence of exposed and visible necrotic bone on the maxillofacial region that has not healed after 8 weeks, in patients with history of antiresorptive treatment. The name medication-related is justified by the growing number of cases associated with other antiresorptive drugs such as denosumab and antiangiogenic therapies, beyond the known relationship with bisphosphonates. Although the incidence of MRONJ in patients treated for metabolic osteopathies is very low, the situation becomes more complex in cancer patients who re-ceive high doses of antiresorptives for the treatment of skeletal metastases. Several case reports describe the presence of MRONJ in cancer patients receiving targeted therapies, specifically TKI (tyrosine kinase inhibitors) and monoclonal antibodies-targeting VEGF (vascular endothelial growth factor). MRONJ nega-tively affects the quality of life in cancer patients and produces significant comorbidity. It is imperative to identify patients at risk and design a specific den-tal care strategy for these cases. In this article, we present a case of MRONJ associated with high doses of Denosumab and simultaneous administration of specific monoclonal antibodies. The case is surpris-ing due to magnitude of the necrosis. The described treatment strategies made it possible to control the initial symptoms, limit the lesion progression, ensure pain and infection control, and finally, the total heal-ing of the lesion (AU)

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RESUMO

he bisphosphonates are synthetic substances of inorganic pyrophosphate that havebeen the basis of treatment of patients with osteolytic diseases, such as multiple myeloma, malignanthypercalcemia, Paget's disease, or patients with bone metastases. Its main pharmacological effect is inhibitionof bone resorption caused by osteoclasts, which have a reduced function. Their adverse effects are infrequentbut include pyrexia, impaired renal function, hypocalcemia, and more recently, maxillo-mandibular ostenecroseinduced bofosfonatos. In this report we describe a clinical case of jaw osteonecrosis induced by bisphosphonatesin patient with chronic kidney disease and the treatment protocol performed

Los bisfosfonatos son sustancias sintéticas de pirofosfato inorgánico que han sido la base del tratamiento de pacientes con enfermedades osteolíticas, como mieloma múltiple, hipercalcemia maligna, enfermedad de Paget o pacientes con metástasis ósea. Su principal efecto farmacológico es la inhibición dela resorción ósea causada por osteoclastos, que tienen una función reducida. Sus efectos adversos son infrecuentes, pero incluyen pirexia, deterioro de la función renal, hipocalcemia y, más recientemente, indujo inducido por bicosfonatos maxilomandibular. En este informe se describe un caso clínico de osteonecrosis mandibular inducida por bifosfonatos en pacientes con enfermedad renal crónica y el protocolo de trata-miento realizado.

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O objetivo do presente estudo foi avaliar a progressão da periodontite experimental (PE) e a resposta tecidual periodontal frente à raspagem e alisamento radicular (RAR) durante tratamento com dose oncológica de zoledronato. Foram utilizados 100 ratos (6 meses de idade) distribuídos aleatoriamente em 4 grupos experimentais: SAL (n=30), ZOL (n=30), SAL-RAR (n=20) e ZOL-RAR (n=20). O plano de tratamento medicamentoso teve duração de 8 semanas. Os ratos receberam injeções intraperitoneais de 0,45 ml de solução de cloreto de sódio 0,9% (Grupos SAL e SALRAR) ou 0,45 ml da mesma solução acrescida de 100 µg/Kg de zoledronato (ZOL e ZOL-RAR) com um intervalo de três dias entre as aplicações. Decorridas duas semanas de tratamento medicamentoso, foi instalada uma ligadura de algodão ao redor do primeiro molar inferior esquerdo. Nos grupos SAL e ZOL essa ligadura permaneceu até o final do experimento. Nos grupos SAL-RAR e ZOL-RAR após outras duas semanas a ligadura foi removida, e foi efetuada a RAR. A eutanásia foi efetuada nos grupos SAL e ZOL aos 14, 21 e 42 dias pós instalação da ligadura e nos grupos SAL-RAR e ZOL-RAR aos 7 e 28 dias pós tratamento local com RAR. Foi executado o processamento histológico das hemi-mandíbulas e os cortes histológicos foram submetidos à coloração pela hematoxilina-eosina (HE). Na região de furca do primeiro molar inferior foram efetuadas: análise histopatológica dos tecidos peridontais e análise histométrica da porcentagem de osso na região de furca (POF) e da porcentagem de osso necrótico na região de furca (PON). Os resultados foram submetidos a análise estatística. O grupo ZOL apresentou uma resposta inflamatória local mais exacerbada, maior POF e maior PON aos 14d, 21d e 42 pós instalação da ligadura em relação ao grupo SAL. Em ZOL-RAR a resposta inflamatória se mostrou mais exacerbada, não houve alteração da POF, e a PON se mostrou maior ao longo do tempo e em relação ao grupo que não recebeu tratamento periodontal. Conclui-se que o tratamento com dose oncológica de zoledronato reduz a perda óssea alveolar induzida pela PE, todavia, aumenta a quantidade de tecido ósseo alveolar necrótico, exacerba e prolonga a resposta inflamatória local, tanto nos sítios sem tratamento periodontal quanto nos sítios submetidos à RAR, ou seja, a doença periodontal e o tratamento mecânico periodontal convencional são importantes fatores de risco local para a ONM-M(AU)

The present study aims to assess the progression of experimental periodontitis (EP) and the periodontal tissue response to scaling and root planing (SRP) during treatment with oncological dose of zoledronate. A total of 100 rats were used (6 months old) randomically distributed into 4 experimental groups: SAL (n=30), ZOL (n=30), SALSRP (n=20) e ZOL-SRP (n=20). Drug treatment plan lasted for 8 weeks. Intraperitoneal injections of 0,45 ml of sodium chloride solution 0,9% (Groups SAL and SAL-SRP) or 0,45 ml of the same solution adding 100 µg/Kg of zoledronate (ZOL and ZOL-SRP) were given to the rats within intervals of three days between injections. A cotton ligature was installed around the first left lower molar after two weeks of medicative treatment. At SAL and ZOL groups such ligature endured until the end of the experiment. At the groups SAL-SRP and ZOL-SRP ligature was removed two more weeks later and SRP was executed. Euthanasia was done at the groups SAL and ZOL after 14, 21 and 42 days from the ligature installation and at the groups SAL-SRP and ZOL-SRP after 7 and 28 days after local treatment with SRP. Hemimandibula was histological processing and executed and histological sections went under Hematoxylin and eosin staining (HE). At the furcal region of the first lower molar were executed: histopathological analysis of periodontal tissues and histometric analysis of bone percentage at the furcal region (BPF) and necrotic bone percentage at the furcal region (NPF). Results went under statistical analysis. ZOL group presented increased local inflammatory response, higther BPF and higher NPF at days 14, 21 and 42 after ligature installation in relation to SAL group. At ZOL-SRP, inflammatory response was increased, there was no BFP alteration, and NPF was higher throughout time in comparison to the group that had not received periodontal treatment. It can be concluded that treatment with oncological dose of zoledronate decreases alveolar bone loss induced by EP, on the other hand, it increases the amount of alveolar necrotic bone tissue, increases and extends local inflammatory response, either at sites with no periodontal treatment or the ones that went under SRP, in other words, periodontal disease and conventional mechanical periodontal treatment are important local risk factor for medication-related osteonecrosis of the jaw (MRONJ)(AU)

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El objetivo del trabajo es presentar la asociación de la osteonecrosis mandibular y el uso de bifosfonatos con fines terapéuticos. Los bifosfonatos son fármacos utilizados en el manejo de los desórdenes primarios y secundarios del hueso. Principalmente en la osteoporosis tanto local como general, enfermedades metabólicas óseas, calcificación de tejidos blandos y estados de hipercalcemia, entre otras. Asimismo también pueden actuar como antineoplásicos al inhibir la activación de proteínas vinculadas al cáncer. En los últimos años se ha incrementado su uso para la prevención de osteoporosis postmenopáusicas, gracias a que favorece el incremento en la densidad de minerales en huesos, lo que ha permitido la disminución fracturas. Se presenta un caso clínico de paciente femenina de 61 años de edad con el antecedente de cáncer de mama, ingesta de bifosfonato desde hace 3 años, la cual presentó exposición ósea espontánea, asintomática. Se muestra su manejo médico-quirúrgico y su evolución.

The aim of the present paper was to present the association between mandibular osteonecrosis and use of bisphosphonates for therapeutic purposes. Bisphosphonates are drugs used for the treatment of primary and secondary bone disorders. They are mainly used for local and general osteoporosis treatment, metabolic bone diseases, soft tissue calcification as well as hypercalcemia occurrence, among others. They can also act as antineoplastic agents through the inhibition of activation of cancer-linked proteins. In recent years, bisphosphonates have been used to prevent post-menopausae osteoporosis, since they enhance mineral density increase in bone and therefore contribute to a decrease in fractures. The clinical case here presented is that of a 61 year old female patient with previous history of breast cancer and ongoing 3 year bisphosphonate intake. The patient presented asymptomatic, spontaneous bone exposition. Surgical and medical handlings of the case are presented, as well as its evolution.