Passaretti A1, Zuccarini F2, Tordiglione P2, Araimo Morselli FSM2, Imperiale C2, Petroni G1, Miracolo G1 and Cicconetti A1*
1Department of Odontostomathology and Maxillo-Facial Sciences, Policlinico Umberto I, Rome
2Department of Anesthesiology and Critical Care Medicine, Policlinico Umberto I, Rome, Italy
Received: 22 September, 2016; Accepted: 15 October, 2016; Published: 17 October, 2016
Andrea Cicconetti, MD, Department of Odontostomathology and Maxillo-Facial Sciences, Policlinico Umberto I, Via Caserta 6 – 00161, Rome, Italy, E-mail:
Passaretti A, Zuccarini F, Tordiglione P, Araimo Morselli FSM, Imperiale C, et al. (2016) Oxygen-Ozone Treatment in Bisphosphonate Related Osteonecrosis of the Jaw: A Case Report. Glob J Anesthesiol 3(1): 014-017. DOI: 10.17352/2455-3476.000024
© 2016 Passaretti A, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Bisphosphonate; Jaw osteonecrosis; Ozone therapy
The bisphosphonate related osteonecrosis of the jaws (BRONJ) is defined as a drug-adverse reaction that involves the maxillary bones.
It develops during or after a long-term bisphosphonate therapy in absence of radiotherapy .
The clinical pattern was described for the first time by Marx RE in 2003, who observed the development of jaws osteonecrosis in patients underwent to Multiple Myeloma and Mammary Cancer therapy . Bisphosphonates (BF) pharmacokinetics consist in the osteoclast function interruption, angiogenesis inhibition, as well as blocking any cancer cell line activity together with the interruption of signal transduction . In this way the bone regeneration is interrupted and osteonecrosis is more probable.
Although BF are administered to prevent secondary diseases linked to tumors and to manage osteoporosis and metabolic diseases of the bone , several reports connect BF administration with intraoral lesions [2,5-15].
A review shows that the incidence of BRONJ is between 1% and 15% in oncological population, between 0,001% and 0,01% in osteoporosis population and <0,001 in the general population .
Patients treated with BF therapy have more chances to develop BRONJ, depending on the doses, the bioavailability of the drug and the comorbidity .
The pathogenesis of BRONJ is caused by the BF selectivity for tissues with elevated turn-over , in particular for the alveolar bone which is in constant regeneration .
Osteonecrosis is, in many cases, subsequent to a dental extraction [7,18] or to other conditions which implicate bone remodeling. Only in few cases, it is a spontaneous process . Particular attention is recommended in dental management of these patients .
BRONJ is characterizes by a wide range bone exposure with a great deal of variables. The lesions are often anticipated by inflammation of the mucosa together with reddening and/or pain. The bone exposure is often associated with bacterial infection and abscess. The most common complications are: nerves involvement, abscesses in the nasal cavity or in paranasal sinuses and pathological bones fractures.
Considering the pathogenesis and the clinical outcome, the therapeutic strategy is oriented to face the infective complications (antibiotic, antiseptic, antifungal) and to remove the necrotic bone (minimally-invasive surgery). Bio-stimulation of involved tissue is also recommended.
At the present state two different methods are proposed for biostimulation: Low Level Laser Therapy, the efficacy of which is shown by many works [21-24], and Oxygen/Ozone therapy.
The use of Oxygen/Ozone in BRONJ therapy was introduced by Agrillo et al. in 2007 . Some of its therapeutic properties are: bactericide and virustatic effects, anti-oxidant power and bio-stimulation [26,27]. The efficacy on wound healing, blood circulation, immunological response, and microbicide power make this molecule an interesting therapeutic aid for many diseases, including BRONJ .
Studies lead by several authors [3,19,25,29-31] showed how Ozone could induce bone sequestrum and revascularization; in some cases, the removal of bone sequestrum lead to the complete healing without the necessity of any other treatment (including surgery).
To evaluate the efficacy of local Oxygen/Ozone applications in the treatment of BRONJ.
L.M., a 69 female patient, arrived to Oral Surgical Ward of Policlinico Umberto I, Sapienza, University of Rome, Rome, Italy in November 2014.
Anamnesis referred breast cancer with bone metastasis diagnosed in 2013 treated by bilateral mastectomy and adjuvant chemotherapy. Because of occurring osteoporosis, the patient underwent to bisphosphonates administration. All the needed treatments were carried out by her dentist before the administration of intravenous Zolendronic Acid (Zometa Novartis).
The therapy was interrupted in August 2014 when jaw bone exposure was diagnosed.
Objective examination showed three different injuries: a lesion of 5 cm on the right side of the superior arch and two lesions of 1 and 0,5 cm in the left side of the superior arch (Table 1, Figure 1)