OSTEONECROSI DELLA MANDIBOLA

Transcription

1 OSTEONECROSI DELLA MANDIBOLA OSTEONECROSIS OF THE JAWS (ONJ) Paolo Vescovi DDS, MSc Professore Associato di Clinica Odontostomatologica Direttore EMDOLA (European Master Degree on Oral Laser Applications) Università degli Studi di Parma BISPHOSPHONATE THERAPY (BPT) ONJ - BPT ONJ 250 ONJ july ONJ AND Osteonecrosis AND Osteonacrosis of the jaws AND july Osteonecrosis of the jaws 1

2 WIKIPEDIA wiki - vocabolo hawaiano = veloce pedia - suffisso di enciclopedia salute VERO Novembre 2007 Febbraio 2008 L Espresso Marzo 2008 Radio Dee Jay Maggio 2008????? ANCORA MOLTI DUBBI 2

3 Non omogeneità di denominazione:? osteochemonecrosis bisphosphonate osteochemonecrosis of the jaws Bis-Phossy Jaw avascular osteonecrosis bisphosphonate-induced osteopetrosis OSTEONECROSI DELLA MANDIBOLA ONJ-BP (osteonecrosis of the jaws and bisphosphonate) ONJ-BPT (osteonecrosis of the jaws bisphosphonate treatment related) BON (bisphosphonate associated osteonecrosis) BAJO (bisphosphonate associated jaw osteonecrosis) BRON (bisphosphonate-related ostenecrosis) BRONJ (bisphosphonate-related ostenecrosis of the jaw) BONJ (bisphosphonate-associated osteonecrosis of the jaw ) ESPERIENZA DELL AMBULATORIO DI PATOLOGIA E CHIRURGIA ORALE LASER ASSISTITA DELL UNIVERSITA DI PARMA Gennaio 2004 Agosto PAZIENTI AFFETTI DA BRONJ: SEDI MANDIBOLARE 73 (66,4%) MASCELLARE 27 (24,5 %) CONTEMPORANEE 10 (9%) OSTEONECROSI DEI MASCELLARI BRONJ 3

4 BRONJ: Bisphosphonate-Related Osteonecrosis of the Jaws MULTIFACTORIAL PATHOGENESIS STORIA EPIDEMIOLOGIA ASPETTI CLINICI ASPETTI RADIOLOGICI A critical review of the literature reveals that the etiology of ONJ remains unknown and to date no direct causal link to bisphosphonates has been established. Multifactorial pathogenesis FATTORI DI RISCHIO Migliorati CA: Lancet Oncol 2006;7: TERAPIA BRONJ Silverman SL, Landesberg R: Osteonecrosis of the jaw and role of bisphosphonates: a critical review. The American Journal of Medicine 2009 Feb122(24): Migliorati CA, Siegel MA, Elting LS: Bisphosphonate-associated osteonecrosis: a long term complication of bisphosphonate treatment. Lancet Oncol 2006 June (7) BONE REMODELLING SUPRESSION In humans intracortical remodelling rates of the jaw are times higher than inside the cortex of the iliac creste Daily oral alendronate significantly suppressed the intracortical bone formation rate of the mandible in particular in the alveolar region Allen MR. and Burr DB: J Oral Maxillfac Surg 67, 2009 suppl 1. EFFECTS ON THE OSTEOCYTES BPs accumulate in the osteocyte lacunae Regions of non viable bone matrix : the osteocyte network filled with minerals Most often observed in the alveolar portion of the jaws Han ZH, Palmikar S, Rao DS et al: Effects of ethnicicy and age of menopause on the remodeling and turnover of the iliac bone: implications of mechanisms of bone loss. J Bone Mineral Res 1997;12:498 Allen MR, Burr DB: Mandible matrix necrosis in beagle dogs after 3 years of daily oral bisphosphonate treatment. J Oral Maxillofac Surg 2008;66:987 Allen MR. and Burr DB: J Oral Maxillfac Surg 67, 2009 suppl 1. Allen MR, Burr DB: Mandible matrix necrosis in beagle dogs after 3 years of daily oral bisphosphonate treatment. J Oral Maxillofac Surg 2008;66:987 4

5 ANGIOGENESIS SUPRESSION Each bone remodelling unit (Basic Multicellular Units:BMU) receives its nutrients through vessels. Bone remodelling and angiogenesis are intimately linked Role of altered angiogenesis related to difficult wound healing of soft tissues Disruption of clot and provisional matrix formation in the post extractive sockets Reduction of blood flow in the mandible Allen MR, Burr DB: The pathogenesis of bisphosphonate-related osteonecrosis of the jaw: so many hypotheses, so few data. J Oral Maxillofac Surg 2009; suppl 1,67:61-70 ROLE OF BACTERIAL INFECTION TOXIC EFFECTS ON THE SOFT TISSUE BPs which accumulate in the bone have direct toxic effects on the oral epithelium and inhibit normal healing of soft tissue around the lesions caused by invasive dental interventions. BPs induces the death of fibroblasts and epithelial cells by combined intrinsic and extrinsic pathway of apoptosis Reid IR, Bolland MJ: Is bisphosphonate-associated osteonecrosis of the jaw caused by soft tissue toxicity? Bone 2007;41: Landesberg R, Cozin M, Cremers S, Woo V et val: Inhibition of oral mucosa cell wound healing by bisphosphonates. J Oral Maxillofac Surg 2008;66, Scheper MA, Badros A, Chaisuparat R et al: Effect of zoledronic acid on oral fibroblasts and epithelial cells: a potential mechanism of bisphosphonate-associated osteonecrosis. British Journal of Haematology 2008, Nov;144: STORIA Settembre descrizione di ONJ-BPT Biofilm on the bone/tooth/mucosal surfaces: Actinomyces Unclear if the infection is a primary or secondary event in BRONJ pathophysiology Sedghizadeh PP, Kumar SK, Gorur A et al: Identification of microbial biofilms in osteonecrosis of the jaws secondary to bisphosphonate therapy. J Oral Maxillofac Surg 2008;66,767 Marx RE: Pamidronate (aredia) and zoledronate (zometa) induced avascular necrosis of the jaws. A growing epidemic. J Oral Maxillofac Surg 2003,61: