1

….because evidence based therapy protocolsfor complete remodelling of bone defect arestill missing prevention in bisphosphonate-

treated patients seems to be of utmostimportance.

A close interdisciplinarycollaboration is required.

Dannemann C, Gratz KW, Reiner MO, Zwahlen RA: Jaw osteonecrosis related to bisphosphonate therapy: asevere secondary disorders. Bone 2007 Apr;40(4):828-34

TERAPIA BRONJ

PREVENZIONE Ematologia

Medicina Interna

Radiologia

Oncologia

Odontostomatologia (PC)

Chirurgia Maxillo-Facciale

Anatomia Patologica

Farmacia

ANDI

Ordine dei Medici

Ambulatorio di Patologia e ChirurgiaOrale Laser Assistita

La Repubblica 16 maggio 2009

Metà italiani mai dal dentista, solo 8% in strutture pubbliche-Roma, 23 apr.2009 (Adnkronos Salute)

La metà degli italiani non è mai stata dal dentista e, fra coloro cheinvece curano la salute della loro bocca, solo l'8% si rivolge a strutturepubbliche, contro il 92% che sceglie un privato. "E' colpa soprattuttodella scarsa informazione, perché le persone che si recano in ospedaleper curare i denti non sono necessariamente le meno abbienti, masoprattutto le più informate sulla possibilità di avere assistenza dalServizio sanitario nazionale (Ssn)".

• Pazienti oncologici:- Visita odontoiatrica con rx panoramica arcate dentarie- Terapie odontoiatriche invasive- Rimandare terapie odontoiatriche non urgenti (sospensione della BPT)- Igiene orale professionale e domiciliare- Controllo delle protesi- Visite odontoiatriche periodiche : ogni 4 mesi

PRIMA DELL’INIZIO DELLA BPT

STOPPING SMOKING, LIMITING ALCOHOL INTAKE,MAINTAINING ORAL HYGIENE, DENTAL FOLLOW-UP

should be emphasized for all patients receiving BPT

Bagan J, Blade J, Cozar JM, Constela M et al: Recommendations for the prevention, diagnosis and treatmentof osteonecrosis of the jaw (ONJ) in cancer patients treated with bisphosphonates. Med Oral Pat Oral ChirBucal 2007;12:E336-40

Khan AA, Sàndor GK, Dore E, Morrison AD et al: Canadian consensus pratical guidelines for bisphosphonateassociated osteonecrosis of the jaw. J Rheumatol 2008 Jul;35(7):1391-7

PREVENZIONETERAPIA BRONJ

2

APPLICAZIONE DELLE MISURE ODONTOIATRICHEPREVENTIVE nei pazienti oncologici :

RIDUZIONE DI INCIDENZA DI ONJ

• MILANO 966 pazienti 28 ONJ (2,9%): 7,8% (PRE-) 1,7% (POST-)• ATENE 128 pazienti ONJ (26,3%) (PRE-) 6,7% (POST-)

Ripamonti CI, Maniezzo M, Canpa T, Fagnoni E et al: Decreased occurrence of osteonecrosis of the jaw afterimplementation of dental preventive measures in solid tumor patients with bone metastases treated withbisphosphonates. The experience of the National Cancer Institute of Milan. Ann Oncol 2009 Jan;20(1):137-45.

Dimopoulos MA, Kastritis E, Bamia C, Melakopoulos I et al: Reduction of osteonecrosis of the jaw (ONJ) afterimplementation of preventive measures in patients with multiple myeloma treated with zoledronic acid. AnnOncol 2009 Jan;20(1):117-20.

IN CONCLUSION : the risk of developing ONJ after treatment withzoledronic acid is reduced , BUT NOT DELETED by the

implementation of preventive measures

TERAPIA BRONJPREVENZIONE

“… the cessation ofintravenousbisphosphonatetreatment in ourexperience has not hada major impact onthe progression ortreatment of thisprocess …”

Ruggiero SL, Fantasia J, Carlson E: Bisphosphonate-related osteonecrosis of the jaw: background andguidelines for diagnosis, staging and management. Oral Surg Oral Med Oral Pathol Oral Radiol and Endod2006,102(4):433-441

INTERRUZIONE della BPT

2005

2006

TERAPIA BRONJ

VehicleVehicle ZOL ZOL (single)(single)

Adapted :Daubine F, et al. J Natl Cancer Inst. 2007;99(4

INTERRUZIONE della BPTTERAPIA BRONJ

• PARMA- 98 siti di BRONJ trattati (chirurgia / non chirurgia)- 387 estrazioni dentarie durante BPT (pazienti oncologici e

non oncologici affetti o meno da ONJ)

ASSENZA DI CORRELAZIONE STATISTICA (P = 0,65)

Vescovi P, Manfredi M, Merigo E, Meleti M, Fornaini C, Rocca JP, Nammour S: Surgical approach withEr:YAG laser on Osteonecrosis of the Jaws (ONJ) in patients under Bisphosphonate Therapy (BPT).Lasers in Medical Science 2009 June(eupub)

Vescovi P, Meleti M, Guidotti R, Manfredi M, Merigo E, Fornaini C, Nammour S: 281 Dental Extractions inpatients in long-term Bisphosphonate Therapy (BPT) affected or not by Osteonecrosis of the Jaws (ONJ).Useful of Nd:YAG laser biostimulation. J Oral Maxillofac Surg (submitted)

INTERRUZIONE della BPT

TERAPIA BRONJ

3

OSSIGENOTERAPIA IPERBARICA

TERAPIA BRONJ

INCERTA L’UTILITA’EFFETTIVA:

- Associazione con terapiamedica e chirurgica

- ControindicazioniSolieau KM: Oral post-surgical complications following the administration of bisphosphonates given forosteopenia related to malignancy. J Periodontol 2006;77(4):738-743

Ruggiero S., Gralow J, Marx RE, Hoff AO et al: Pratical Guidelines for the prevention, diagnosis andtreatment of osteonecrosis of the jaw in patients with cancer. Journal of Oncology Practice 2006;Vol2Issue 1;7-13

Freiberger JJ, Padilla-Burgos R, Chhoeu AH, Kraft KH et al: Hyperbaric oxygen treatment andbisphosphonate-induced osteonecrosis of the jaw: a case series. J Oral Maxillofac Surg 2007;65:1321-27

Freiberger JJ: Utility of Hyperbaric Oxygen in treatment of bisphosphonate-related osteonecrosis of thejaws. J Oral Maxillofac Surg 2009;suppl1,67:96-106

•PENICILLINA (2 gr/die) + •METRONIDAZOLO (1 gr/die)

•ANTIBATTERICI TOPICI STAGE 1

STAGE 2

TERAPIA MEDICA

AAOMS (American Association of Oral and Maxillofacial Surgeons): Position Paper on Bisphosphonate-Related Osteonecrosis of the Jaws – 2009 update J Oral Maxillofac Surg 2009, 67:2-12

TERAPIA BRONJ

Limiti della terapia medica:

- Risultato immediato positivo:(riduzione sintomi e segniclinici) ma frequenti recidivedopo 3 settimane disospensione- Possibili effetti LOCALI eSISTEMICI di terapie troppoprolungate in pazienti anzianie defedati

Vescovi P, Merigo E, Meleti M, Manfredi M: Early surgical approach preferable to medical therapy forbisphosphonates related osteonecrosis of the jaw. J Oral Maxillofac Surg 2008, 66:931-933

August 2006

March 2007

STAGE 3

STAGE 1 STAGE 2

December 2006

C.R.- F- Anni 74 - Ca mammario

TERAPIA MEDICA + BIOSTIMOLAZIONE LASER

24.03.2006

26.06.2006

Limiti dellaterapia medica:

4

•Debridement•Rimozione dei sequestri ossei e di porzioni mobili di osso•Resezione mandibolare

STAGE 3

AAOMS (American Association of Oral and Maxillofacial Surgeons): Position Paper on Bisphosphonate-Related Osteonecrosis of the Jaws – 2009 update J Oral Maxillofac Surg 2009, 67:2-12

STAGE 2

TERAPIA CHIRURGICA

TERAPIA BRONJ

Vescovi P, Merigo E, Meleti M, Manfredi M: Bisphosphonate-associated osteonecrosis (BON) of the jaws:a possibile treatment? J Oral Maxillofac Surg 2006; 64: 1460-146

Vescovi P, Merigo E, Manfredi M, Meleti M, Fornaini C, Bonanini M, Rocca JP, Namour S: Usefulness ofNd:YAG laser biostimulation with or without conventional surgical appoach in the treatment ofBisphosphonate-associated jawbone ostenecrosis. Br J Oral Maxillofac Surg 2007 Dec;45(8);628-32

STAGE 1

STAGE 2

STAGE 3

TERAPIA LASER

TERAPIA CHIRURGICA

TERAPIA MEDICA

TERAPIA BRONJ

BIOSTIMOLAZIONE laser (LLLT)EFFETTI SUI TESSUTI MOLLI EOSSO

• ↑ ALP e attività osteoblastica• ↑ differenzazione osteoblasti e

fibroblasti• ↑ vasi sanguigni• ↑ prostaglandine• ↑ sintesi di DNA

Poon V KM, Huang L, Burd A: biostimulation of dermal fibroblast by sublethal Q-switched Nd:YAG 532 nmlaser: collagen remodelling and pigmentation. J Photochem Photobiol 2005,81:1-8

Stein A, Benayahu, Maltz L, Oron U: Low Level Laser irradiation promotes proliferation and differentiation ofhuman osteoblasts in vitro. Photomed Laser Surg 2005;23(2):161-166

Vescovi P, Merigo E, Manfredi M, Meleti M, Fornaini C, Bonanini M, Rocca JP, Nammour S: Nd:YAG laserbiostimulation in the treatment of Bisphosphonate-associated ostenecrosis of the jaws (BON): experience in26 cases. Photomed Laser Surg 2008 Feb;26(1):37-46

TERAPIA BRONJ

CHIRURGIAEr:YAG laser

Vescovi P, Merigo E, Manfredi M, Fornaini C, Rocca JP, Nammour S: Er:YAG and Nd:YAG laserapplications in Bisphosphonate-Related Jaws Osteonecrosis: our experience in 60 patients.Laser in Medical Sciences supplement Abstracts of the 17 th ISLSM (International Society LaserSurgery and Medicine) Congress – Laser Florence 2007

Stübinger S, Dissmann J-P, Pinho NC, Saldamli B et al: A preliminary report about treatment ofbisphosphonate related osteonecrosis of the jaw with Er:YAG ablation. Lasers Surg Med2009,41:26-30

TERAPIA BRONJ

• Tecnica poco invasiva• Possibilità di raggiungere siti poco

accessibili• Minima produzione di smear

layer, superfici chirurgichedeterse

• Minimo rialzo termico delle areelimitrofe

• Assenza di vibrazioni