Medical treatment of MR-ONJ: getting out of the box

In 2014 the AAOMS updated its considerations about medication-related osteonecrosis of the jaws (MRONJ), considering as treatment goal for those patients the maintenance and improvement of the oral health related quality of life (Qol). In other words the goal of MRONJ treatment (non-surgical and surgical) is symptomatic relief rather than complete healing and the prevention of its significant morbidity which may lead to compromising patient’s well being up to necessary cancer therapy suspension. The impact of exposed bone super-infection on the severity of MRONJ has been evaluated and therefore the potential treatment strategies. According to the Italian Society of Oral Medicine and Pathology (SIPMO) approach the presence/absence of suppuration is a fundamental feature for correct staging of the disease. therefore conventionally when we refer to medical treatment we mean a wide range of antibiotics in combination with antiseptic mouth rinses administered with different dosage and schedule until either full recovery or substantial improvement is reached or as a complement to surgical treatment. Non-surgical treatment options entail the use of antimicrobials such as chlorhexidine 0.12% or 2% rinse and antibiotics. common antibiotics employed include amoxicillin, amoxicillin with clavulanic acid, clindamycin and/or metronidazole, other non surgical treatments are hyperbaric oxigen (HBo), medical ozone therapy (Mot) and low-level laser therapy (lllt); nevertheless even if stage- specific therapy has reached general agreement, clear treatment guidelines are not available for the non surgical approach by specifying what medications should be preferred and the optimal duration of pharmacological therapy. On the side of the much debated role of targeted vs empiric antibiotic therapy new pharmacological treatments have appeared. The research is focusing on testing the efficacy of innovative molecules in reversing the effect of anti-resorptive and anti-angiogenic drugs in order to identify a novel pharmacological approach to MRONJ medical treatment. Teriparatide as an osteo-anabolic agent has shown encouraging results in MRONJ osteoporotic patients. More recently the efficacy and safety of pentoxifylline and tocopherol (PeNt-e) in the management of MRONJ has been demonstrated, also suggesting the use of PeNt-e prophylactically in patients at increased risk with concomitant oral diseaseas for osteo-radionecrosis. Furthermore the hypothesis that systemic or local treatment with anti-angiogenic inhibitors could lead to new therapeutic strategies for Mr-oNJ has been investigated bringing to the attention agents such as geranylgeraniol (ggoH). Our mission as health providers is to reach positive results in improving quality of life of our patients leading to the research of safe effective and efficient care solutions. In the light of these considerations we are committed to investigate on novel medical biotechnologies for treatment of MRONJ disease, getting out of the box, identifying among emerging agents the best option for non surgical MRONJ treatment, reiterating the need for an individualized treatment plan with the aim to reduce skeletal related adverse effects and improve quality of life.