Multiple rebound-associated vertebral fractures after denosumab discontinuation: is prompt antiresorptive therapy always recommended, even when the risk of fracture seems low? A case report

Background: Non-osteoporotic patients with endocrine-sensitive breast cancer are often treated with denosumab only during the anti-aromatase treatment, and when the anti-aromatase therapy is discontinued, no antiresorptive drug is prescribed. This case report clearly shows how even a patient with a low risk of fractures could have multiple rebound vertebral fractures after denosumab discontinuation. Case Presentation: We report the case of a 60-year-old woman who suffered from multiple vertebral fractures only seven months after discontinuation of denosumab that had been administered to prevent bone loss related to three years of aromatase inhibitors as adjuvant therapy for breast cancer. No antiresorptive therapy was prescribed at the time of denosumab discontinuation, assuming that the patient had a low absolute risk of fracture after the withdrawal of the aromatase inhibitor. Conclusion: This case underlines the relative irrelevance of bone mineral density and clinical algorithms in predicting the risk of rebound-associated vertebral fractures after denosumab discontinuation and the strong recommendation to always switch to another antiresorptive therapy (such as zoledronic acid) immediately at the time of denosumab discontinuation.

Effectiveness of different therapies for drug-related osteonecrosis of the jaw

Background. Antiresorptive drug-related osteonecrosis of the jaw (ADRONJ) is a serious complication of cancer patients or osteoporosis, under treatment with antiresorptive drugs. At present, there is no scientific evidence or consensus on the most appropriate treatment approach depending on the stages of the ADRONJ. Objective. To assess the effectiveness of the different therapeutic options in the treatment of ADRONJ. Search methods. The following electronic databases were searched: PubMed (MEDLINE, Cochrane Library), Web of Science (WoS) and Spanish Medical Index (IME). Selection criteria. Studies with results on treatment of ADRONJ. Data analysis. Descriptive statistics were carried out considering means and percentages. Results. 52 studies on treatment of ADRONJ were included in this review. The complete resolution of ADRONJ cases was observed in 205 of 257 patients (79.8%) treated with surgery plus flaps; 202 of 253 (another 79.8%) with the suspension of the antiresorptive drug (“drug holiday”); 512 of 648 (79.0%) with extensive surgery; 41 of 59 (69.5%) with adjuvant hyperbaric oxygen therapy; 462 of 680 (67.9%) with conservative surgery; 55 of 119 (46.2%) with laser therapy and, finally, 100 of the 346 patients (28.9%) achieved complete resolution with medical treatment (antibiotics + antiseptics). Conclusions. Depending on the severity of bone exposures, surgical treatment combined with flaps appears to be the best therapeutic option for the treatment of ADRONJ.

Antiresorptive drug-related changes of the mandibular bone densitiy in medication-related osteonecrosis of the jaw patients

Objectives: Medication-related osteonecrosis of the jaw (MRONJ) is a well known side-effect of anti-resorptive drugs. Changes in bone density might potentially constitute the development of ONJ. This study aimed to investigate, to which degree bisphosphonates (bp) and denosumab (db) induce changes in bone density that can be determined from routine diagnostic CT. Methods: CT scans of 101 patients were investigated. MRONJ was present in 61 patients (n = 26: db-treated; n = 35 bp-treated). 40 patients were included as a reference group. Bone density was measured at two distinct locations in the mandible (M1: anterior of the mental foramen; M2: retromolar), each on the contralateral side to the necrosis. Results: The bone density values measured at both locations were found to be significantly higher in the bp-group compared to the db-group (p = 0.027) and to the reference-group (p = 0.016). Almost no difference (p = 0.84) in bone density value was found between the db- and reference-groups.Investigating the effect of duration of treatment, none of the measured values showed significant differences in both locations of db- and bp-group. Conclusion: The findings from this study suggest that that bisphosphonates change the microarchitecture of the alveolar bone by being embedded in the mandible, which may subsequently lead to a bp-specific corticalization, and a decrease in vascularization of the lower jaw. This process may be distinctive for bp-treatment and seems to induce the congestion of cancellous bone rather rapidly after the first administrations. This effect could not be determined in denosumab-treated patients.

Biochemical Changes under the Influence of Comprehensive Treatment of Patients with Generalized Periodontitis and Osteopenia

The issue of surgical treatment of patients with generalized periodontitis and osteopenia is particularly topical. Numerous studies have confirmed the benefits of surgical treatment procedures using osteoplastic material to stimulate repair process of periodontal tissues.The objective of the research was to improve the effectiveness of surgical treatment of patients with generalized periodontitis and osteopenia through the combined use of osteoplastic material and antiresorptive drugs. Materials and methods. Ninety-three patients underwent treatment and clinical observation. The patients were divided into 3 groups. Group I included 20 patients who underwent surgical treatment according to conventional procedure. Group II included 25 patients who underwent surgical treatment with topical application of osteoplastic material “Easy Graft”. Surgical treatment in Group III (26 patients) was conducted using osteoplastic material “Easy Graft” and antiresorptive drug “Bonviva”. The control group consisted of 22 apparently healthy individuals.Conclusions. The obtained results indicated that surgical treatment with the combined use of osteoplastic material “Easy Graft” and antiresorptive drug “Bonviva” leads to process stabilization being confirmed by clinical study indices both in early and in remote postoperative period.