Elsevier

Dental Abstracts

Volume 61, Issue 3, May–June 2016, Pages 143-144
Dental Abstracts

Hands On
Cancer treatments and osteonecrosis

https://doi.org/10.1016/j.denabs.2016.02.025Get rights and content

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Background

Several new cancer treatments have a propensity to induce osteonecrosis, with a particular risk for causing jaw necrosis. The implications for dental practitioners were explored, looking at the facts regarding osteonecrosis and the specific actions of the new approaches to cancer therapy.

Osteonecrosis Characteristics

Osteonecrosis refers to an area of exposed avascular dead bone that is caused by several conditions. Radiation-induced osteonecrosis of the jaw produces fibrosis that leads to poor blood supply and vulnerability to infection. Management is achieved using pentoxifylline and vitamin E. Bisphosphonates (BPs) may also cause osteonecrosis of the jaw (BRONJ). The American Association of Oral and Maxillofacial Surgeons (AAOMS) has proposed the term medication-related osteonecrosis of the jaw (MRONJ)

Bone-Modulating Therapy

Bone-modulating therapy (BMT) is used in primary bone tumors and metastatic cancers, to control hypercalcemia, and in nonneoplastic conditions such as osteoporosis, Paget’s disease, and osteogenesis imperfecta. BMT uses drugs such as bisphosphonates (BPs), receptor activator of nuclear factor kappa b ligand (RANKL) inhibitors, strontium ranelate, calcitonin, and parathyroid hormone but only BPs and RANKL inhibitors appear to cause ONJ.

Denosumab (DB) is a human monoclonal IgG2 antibody that

Anti-Angiogenic Drug Therapy

Angiogenic growth factors such as vascular endothelial growth factor (VEGF) help tumors induce their own vascular supply. When VEGF is inhibited, tumor growth has been suppressed in animals, increasing the potential for this therapy to work in humans. Bevacizumab, sunitinib, and cabozantinib act primarily through VEGF inhibition. Both bevacizumab and sunitinib used alone or with BPs have been linked to ONJ. Cabozantinib is a new therapy for treating progressive, unresectable, locally advanced

Radiation Drug Therapy

Radium-223 and strontium-89 are used as intravenous infusions. Radium selectively binds to areas of increased bone turnover such as bone metastases and emits high-energy alpha particles that induce breaks in double-stranded DNA, releasing a potent, highly localized cytotoxic effect. Patients treated with radium-223 have had significantly prolonged overall survival in cases of prostate cancer and bone metastases. Strontium-89 is similar in its use as internal radiotherapy. The risk of ONJ is

Other Bone-Modulating Therapeutic Agents

Ondanacatib is a selective cathepsin K inhibitor that inhibits osteoclast function but preserves osteoclast viability. ONJ has not yet been reported with its use.

Implications for Dentists

As more patients survive cancer, the reservoir of those who are at risk of ONJ has increased. Many dental patients are likely to require significant efforts to avoid ONJ. Accessing this care is problematic because these patients will often require a novel approach to tooth care. Dental care practitioners will require appropriate training and experience to handle the requirements of this group of patients.

MRONJ prevention is being instituted. Patients are strongly encouraged to use interspace

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Patel V, Kelleher M, Sproat C, et al: New cancer therapies and jaw necrosis. Br Dent J 219:203-207, 2015

Reprints available from M McGurk, Dept of Oral and Maxillofacial Surgery, Atrium 3, 3rd Floor, Bermondsey Wing, Guy’s Hosp, London, SE1 9RT; e-mail: [email protected]

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