Introduction First described in 2002, osteonecrosis of the jaw (ONJ, or avascular necrosis of the jaw) is an uncommon but potentially serious side effect of treatment with bisphosphonates. Although typically identified in patients with multiple myeloma and other malignancies, a few cases have been reported in patients taking bisphosphonates - a potent drug class used in the treatment of osteoclast-mediated bone resorption issues, including postmenopausal osteoporosis, Paget's disease, multiple myeloma, and malignant hypercalcemia. The clinical diagnosis of ONJ can be obscured by jaw pain, abscess, swelling, and fistulas, but exposed bone is a distinctive sign. This reports a case of ONJ secondary to bisphosphonate use in a 65-year-old woman and clinical management complications. Case Presentation A 65-year-old lady with history of age-related osteoporosis and compression fractures on alendronate for 4 years, squamous cell carcinoma of neck status post excision and radiotherapy 11-years prior, Sjogren's syndrome and discoid lupus on hydroxychloroquine, diabetes, hypertension, stroke and multiple dental abscesses presents with persistent neck pain. Initial CT neck with contrast showed diffuse fat stranding. Subsequently, alendronate was discontinued due to jaw necrosis suspicion. Eight months later, repeat CT scan showed new non-mass-like soft tissue thickening in the subcutaneous fat abutting the right anterior mandible with mandibular teeth cavities and periapical lucencies, likely to be periodontal cellulitis versus radiation osteonecrosis. Later, patient complained of a piece of bone penetrating the skin of her chin and presented with continuous drainage from sinus tract in her mandible, which was diagnosed as osteonecrosis attributed to bisphosphonates, previous radiation therapy, and dental abscesses. Patient was started on abaloparatide, an osteo-anabolic medication for osteoporosis and enrolled in hyperbaric oxygen therapy which immensely helped in controlling sinus drainage. Patient is currently awaiting mandibular reconstruction surgery. Discussion ONJ, often associated with pain, swelling, exposed bone, local infection, and pathologic fracture of the jaw, is a rare complication of bisphosphonate therapy. Currently, no prospective data exists to advise the benefits of therapy discontinuation however most clinical practices tend to discontinue at least temporarily. The incidence increases with longer treatment duration, particularly when therapy exceeds four years. Risk factors for developing ONJ while taking bisphosphonates include IV administration, anticancer therapy, dose and duration of exposure, dental extractions/implants, glucocorticoids, smoking, diabetes, and preexisting dental disease. Case reports and series suggest benefit from hyperbaric oxygen therapy in wound healing, pain, and quality of life at three months, however no significant differences exist with outcomes beyond three months. Patients being considered for therapy with a bisphosphonate should be thoroughly evaluated for dental issues, prior to initiating therapy. Conservative management with limited debridement, antibiotic therapy as needed, and topical mouth rinses rather than aggressive surgical resection are recommended. Conservative therapy may result in healing in a significant proportion of patients. Surgical resection of necrotic bone should be reserved for refractory or advanced cases. Providers should remain cautious while prescribing high doses of bisphosphonates in patients with increased risk factors to prevent, timely diagnose and treat this condition. References Edwards BJ, Gounder M, McKoy JM, et al. Pharmacovigilance and reporting oversight in US FDA fast-track process: bisphosphonates and osteonecrosis of the jaw. Lancet Oncol 2008; 9:1166. Khosla S, Burr D, Cauley J, et al. Bisphosphonate-associated osteonecrosis of the jaw: report of a task force of the American Society for Bone and Mineral Research. J Bone Miner Res 2007; 22:1479. Hoff AO, Toth BB, Altundag K, et al. Frequency and risk factors associated with osteonecrosis of the jaw in cancer patients treated with intravenous bisphosphonates. J Bone Miner Res 2008; 23:826.

Osteogenesis imperfecta (OI) is a heterogeneous disease of connective tissue, the cardinal symptom being fractures and severity ranging from mild to lethal. Dominant mutations in collagen I, encoded by COL1A1 and COL1A2, cause >90% of cases. To delineate genotype-phenotype correlations and pharmaco-genetic response, collagen I was sequenced in 150 unrelated Swedish families and clinical data were collected in Paper I. Mutation type, gene affected, and N- to C-terminal location correlated with phenotype and severity. Bisphosphonate response assessed by calculated yearly change in lumbar spine bone mineral density (BMD) was inversely related to age and BMD at treatment initiation. Mutations associated with a more severe phenotype exhibited an increased response after 2 years; however, all types of OI responded well. To investigate the effect of naturally occurring variations in collagen I, the only common coding single nucleotide polymorphism (rs42524 in COL1A2) was genotyped in 2004 healthy men in Paper II. Heterozygous genotype was associated with decreased BMD and an increased risk of stroke. An adolescent with repeated fractures despite a markedly high BMD harbored a unique C-terminal procollagen cleavage-site mutation in COL1A1, which motivated extensive investigations in concert with a similar COL1A2 case in Paper III. The probands were found to have impaired procollagen processing, incorporation of collagen with retained C-propeptide in matrix and increased mineral to matrix ratio, which demonstrates that C-propeptide cleavage is crucial to normal bone mineralization and structure. Bisphosphonate therapy has insufficient effect in OI, and as classical OI is a dominant disorder severe cases would benefit from silencing of the mutated allele. In Paper IV and V small interfering RNAs (siRNAs) were used to allele-specifically target primary human bone cells heterozygous for I) a coding polymorphism in COL1A2 and II) insertion/deletions in the 3’UTR of COL1A1 and COL1A2. Results were promising with altered allele ratios and decreased mRNA levels in the predicted fashion. To summarize, this thesis found that collagen I is crucial to bone and connective tissue and that collagen I mutations create markedly diverse phenotypes. Age, BMD and pharmaco-genetic effects influence the response to bisphosphonate therapy in individuals with OI; however, novel approaches are needed. Utilizing allele-specific siRNAs may be a way forward in the treatment of severe OI.

No description available.

Notre travail de thèse porte sur la réactivité de phosphates de calcium biomimétiques vis-à-vis d'un agent thérapeutique de la famille des bisphosphonates : le risédronate. Ce médicament actuellement commercialisé sous le nom de " Actonel ", est préconisé pour le traitement de certaines affections du tissu osseux telle que l'ostéoporose. Nous nous proposons dans cette contribution d'élucider les mécanismes d'interaction se produisant à l'interface entre des matériaux apatitiques de choix et le risédronate; pour cela les propriétés physico-chimiques des supports examinés ainsi que les caractéristiques de la solution d'incubation ont été prises comme variables expérimentales. L'étude d'adsorption nous a amené dans un premier temps à élaborer des phosphates de calcium présentant différentes caractéristiques physico-chimiques. Pour cela nous avons fait varier les conditions de synthèse (taux de saturation, température, durée de maturation, vitesse d'adition des réactifs...). Nous avons ensuite préparé des sels de risédronate de calcium, et ce afin de spécifier la nature des interactions entre molécules de risédronate et ions calcium en solution. Pour préciser les caractéristiques physicochimiques des précipités (index de cristallinité, modifications structurales, altérations morphologiques...), nous avons fait appel à diverses techniques physico-chimiques complémentaires (DRX, FTIR, Raman, RMN de l'état solide, MEB, MET, ATD/ATG, BET, complexométrie et analyses chimiques). Les solides précipités sont des apatites phosphocalciques qui présentent des compositions chimiques variables (rapport atomique Ca/P de 1,33 à 1,65) ainsi que des propriétés structurales et microstructurales différentes. Leur surface spécifique couvre la gamme de 49 à 201 m²/g. Les solides élaborés dans des conditions physiologiques de pH et de température sont des apatites nanocristallines de basse cristallinité, analogues au minéral osseux; ils sont dotés à leur surface d'une couche hydratée riche en environnements non apatitiques. Ces espèces labiles sont absentes pour l'hydroxyapatite bien cristallisée. L'étude d'adsorption des molécules de risédronate dans tous les cas examinés montre que la fixation de ces espèces par les supports apatitiques se fait selon une cinétique rapide, ce qui atteste de la grande réactivité de ces matériaux vis-à-vis de leur environnement. L'allure des isothermes d'adsorption obtenues dans un domaine de faibles concentrations sont de type Langmuir. La réactivité des solides examinés vis-à-vis des molécules d'adsorbat a été discutée sur la base des caractéristiques physico-chimiques du système. Ainsi divers facteurs sont à prendre en considération pour expliquer la différence de comportement de ces matériaux (composition chimique du support et de la solution, état de surface et présence d'environnement labiles en particulier, microstructure...). L'analyse globale des résultats d'adsorption issus des effets de la composition de la solution sur la fixation des molécules de risédronate et de l'adsorption sur les proportions des ions en solution met en évidence une corrélation entre les groupements phosphonate de la solution et les ions phosphate de la surface des supports. Cette observation traduit l'existence d'un processus d'échange impliquant ces espèces à l'interface minéral-milieu environnant. L'étude menée avec des apatites de basse cristallinité à différents stades de maturation confirme l'implication de cette force motrice. Toutefois, l'évolution des proportions en ions calcium échangées lors de l'adsorption laisse penser que d'autres phénomènes peuvent intervenir. Ainsi l'étude menée dans une gamme de concentration élevée en adsorbat montre des isothermes à plateaux, traduisant l'existence de processus complexes à la surface du solide. En outre, l'étude approfondie réalisée par spectroscopies Infrarouge et Raman et par RMN, sur des supports après contact avec les molécules d'adsorbat, atteste de la présence de fortes interactions impliquant les groupements fonctionnels de l'adsorbat et les sites calcium de la surface des apatites. L'étude comparée avec les sels de risédronate de calcium précipités confirme la formation de phase amorphe typique du composé Ca2BP. L'évolution des nanocristaux apatitiques en présence des molécules de risédronate affecte très peu la composition de la couche hydratée à leur surface et inhibe, par conséquent leur processus de maturation. Sur le plan biologique, la localisation de ces principes actifs à la surface du minéral osseux pourrait être bénéfique dans la mesure où ces espèces peuvent bloquer le processus de vieillissement du tissu osseux et préserver sa réactivité. Afin de limiter les effets secondaires des molécules de bisphosphonates, d'une part, et d'améliorer leur biodisponibilité locale en vue d'élargir leur champ d'application thérapeutique, d'autre part, une approche par diffusion locale semble une voie intéressante. L'ensemble des résultats issus de ce travail constitue une plate forme pour la mise au point d'un dispositif de vectorisation locale du risédronate par des substituts osseux phosphocalciques.

Abstract Bone remodelling occurs in humans throughout life, therefore bone is continuously renewed to better respond to changes in weightbearing circumstances. Bone remodelling is extremely vulnerable during fracture healing and integration of prostheses into the surrounding bone. Bone remodelling is a complex system in which many growth factors, cytokines and enzymes, which are essential for the differentiation of osteoblasts and osteoclasts, are involved. Some widely used drugs can affect this sensitive system of remodellation in unexpected manner. Painkillers such as cyclooxygenase (COX) inhibitors have been demonstrated in animal studies to interfere with fracture healing and a few retrospective clinical studies confirm these observations. Bisphosphonates (BP), main target of which is the bone resorbing osteoclast, have been suggested to be the drug of choice to improve periprosthetic bone density and thus prevent aseptic loosening of implants. The exact mechanism of action of clodronate (CLO), a non-amino-BP, which was selected for the study, has not been clarified thus far. In order to gain a deeper understanding of the role of the COX enzyme in the differentiation of osteoblasts we studied human mesenchymal stem cell (hMSC) cultures in the presence of different COX-inhibitors; indomethacine, parecoxib and NS398, a specific COX-2 inhibitor. We used the liposome encapsulated CLO metabolite (AppCCl2p) to study in detail the mechanism of BP induced apoptosis in osteoclast. The effects of different BPs CLO, pamidronate (PAM) and zoledronic acid (ZOL), on the differentiation of osteoblasts and osteoclasts were tested in vitro. The optimal concentration for in situ CLO rinsing in clinical study was found. Finally, the effects of in situ and per oral CLO on the periimplant bone density and integration of prostheses were studied in vivo. All tested COX-inhibitors significantly inhibited osteoblast differentiation from hMSCs and stimulated the differentiation of adipocytes. It was also demonstrated that AppCCl2p inhibits mitochondrial function by a mechanism that involves competitive inhibition of ADP/ATP translocase. In the comparison of BPs, ZOL seemed to posses the properties of both non-amino- and amino-BPs and it thus belongs to a new class of BPs. Peroral and in situ CLO seemed to have different mechanisms of action. Peroral CLO delayed the integration of prosthesis to the bone and increased peri-implant osteolysis while is situ CLO accelerated integration. In conclusion, we can alter normal bone remodellation during fracture healing and prosthesis integration. On the other hand, we can also improve the circumstances for the integration of implant to the surrounding bone by in situ BP rinsing, thus creating a better environment for bone ingrowth. / Tiivistelmä Läpi elämän luustossa tapahtuu uudelleenmuotoutumista, remodelaatiota, jonka seurauksena luu pystyy paremmin vastaamaan muuttuneisiin kuormitusolosuhteisiin. Remodelaatioprosessi on hyvin haavoittuvainen murtuman luutumisen aikana sekä proteesin kiinnittyessä ympäröivään luuhun. Luun remodelaatioon osallistuvat kasvutekijät, sytokiinit ja entsyymit, jotka puolestaan ovat välttämättömiä osteoblastien ja osteoklastien erilaistumiselle. Monet lääkeaineet voivat yllättävällä tavalla vahingoittaa tätä herkkää remodelaatiosysteemiä. Kipulääkkeet, kuten syklo-oksygenaasi (COX) estäjät, voivat häiritä murtuman luutumista aikaisempien eläintöiden ja muutamien retrospektiivisten potilastutkimusten mukaan. Lisäksi bisfosfonaatit, joiden päävaikutuskohde on luuta hajoittava osteoklasti, voisivat olla lupaavia lääkkeitä myös parantamaan proteesia ympäröivän luun laatua ja siten estämään aseptista implantin irtoamista. Tutkimuksen yhtenä tarkoituksena oli selvittää klodronaatin, ensimmäisen polven typpi-ryhmää sisältämättömän bisfosfonaatin tarkka vaikutusmekanismi. Viljelemällä ihmisen luuytimen kantasoluja indometasiinia, parekoksibia tai spesifistä COX-2 estäjää NS 398:a, sisältävässä kasvatusliuoksessa selvitettiin COX-entsyymin merkitys osteoblastien erilaistumiselle. Liposomien sisälle pakattua klodronaatin metaboliittia (AppCCl2p) käytettiin tutkittaessa millä vaikutusmekanismilla klodronaatti aiheuttaa osteoklastien apoptoosin. Bisfosfonaattien; klodronaatin, pamidronaatin ja tsoledronaatin vaikutusta osteoklastien ja osteoblastien erilaistumiseen tutkittiin soluviljelmämallissa ja määritettiin kliinisessä potilastyössä paikallisesti käytettävän klodronaattiliuoksen pitoisuus. Lopuksi potilastyössä selvitettiin paikallisen klodronaattihuuhtelun ja suun kautta annostellun klodronaatin vaikutus proteesia ympäröivän luun tiheyteen ja proteesin kiinnittymiseen ympäristöönsä. Tutkimukseen valitut COX-estäjät vähensivät ihmisen kantasolujen erilaistumista osteoblasteiksi ja lisäsivät erilaistumista rasvasoluiksi. Lisäksi todettiin, että AppCCl2p estää mitokondrioissa tapahtuvaa hengitystä estämällä ADP/ATP-vaihtajan toiminnan, saaden aikaan solukuoleman. Vertailtaessa bisfosfonaatteja, tsoledronaatilla vaikutti olevan sekä ensimmäisen, että kolmannen polven (sisältää typpi-ryhmän) bispfosfonaattien vaikutuksia, joten tsoledronaatti kuuluu aivan uuteen bisfosfonaattiryhmään. Potilastutkimuksessa suun kautta ja paikallisesti reisiluun ytimeen annostellulla klodronaatilla oli täysin erilainen vaikutus. Suun kautta syötynä klodronaatti hidasti proteesin kiinnittymistä ja aiheutti osteolyysiä. Sen sijaan paikallinen klodronaatti nopeutti merkittävästi proteesin kiinnittymistä ympäröivään luuhun. Näiden tutkimustulosten perusteella voidaan olettaa, että COX-estäjät, samoin kuin peroraalinen bisfosfonaatti, voivat tahattomasti häiritä luun remodelaatiota.

No description available.

Bone is a remarkable multifunctional tissue with the ability to regenerate and remodel without generating any scar tissue. However, bone loss due to injury or diseases can be a great challenge and affect the patient significantly. Autologous bone grafting is commonly used throughout the world. Autograft both fills the void and is bone inductive, housing the particular cells that are needed for bone regeneration. However, a regenerative complement to autograft is of great interest as the use of biomaterials loaded with bioactive molecules can avoid donor site morbidity and the problem of a limited volume of material. Two such regenerative products that utilise bone morphogenetic protein (BMP)-7 and -2 have been used for more than a decade clinically. Unfortunately, several side effects have been reported, such as severe swelling due to inflammation and ectopic bone formation. Additionally, the products require open surgery and use of supra physiological doses of the BMPs due to poor localisation and retention of the growth factor. The purpose of this thesis was to harness the strong inductive capacity of the BMP-2 by optimising the carrier of this bioactive protein, thereby minimising the side effects that are associated with the clinical products and facilitating safe and localised bone regeneration. We focused on an injectable hyaluronan-based carrier developed through polymer chemistry at the University of Uppsala. The strategy was to use the body’s own regenerative pathway to stimulate and enhance bone healing in a manner similar to the natural bone-healing process. The hyaluronan-based carrier has a similar composition to the natural extracellular matrix and is degraded by resident enzymes. Earlier studies have shown improved properties when adding hydroxyapatite, a calcium phosphate that constitutes the inorganic part of the bone matrix. In Paper I, the aim was to improve the carrier by adding other forms of calcium phosphate. The results indicated that bone formation was enhanced when using nano-sized hydroxyapatite. In Paper II, we discovered the importance of crushing the material, thus enhancing permeability and enlarging the surface area. We wished to further develop the carrier system, but were lacking an animal model with relatively high throughput, facilitated access, paired data, and we were also committed to the 3Rs of refinement, reduction, and replacement. To meet these challenges, we developed and refined an animal model, and this is described in Paper III. In Paper IV, we sought to further optimise the biomaterial properties of the hydrogel through covalent bonding of bisphosphonates to the hyaluronan hydrogel. This resulted in exceptional retention of the growth factor BMP-2. In Paper V, SPECT/PET/µCT was combined as a tri-modal imaging method to allow visualisation of the biomaterial’s in situ action, in terms of drug retention, osteoblast activity and mineralisation. Finally, in Paper VI the correlation between existing in vitro results with in vivo outcomes was observed for an array of biomaterials. The study identified a surprisingly poor correlation between in vitro and in vivo assessment of biomaterials for osteogenesis.

Os bisfosfonatos são medicamentos amplamente e efetivamente utilizados para o tratamento de doenças osteolíticas. Entretanto, na cavidade oral, é de particular relevância, pois possuem como efeito adverso a osteonecrose dos maxilares induzida pelo uso de bisfosfonatos. Sua etiopatogenia ainda não é bem estabelecida, os métodos de detecção são insatisfatórios e as terapias recomendadas são por vezes, medidas paliativas e ineficazes. Pouco ainda é sabido sobre o efeito do Ácido Zoledrônico na microestrutura óssea, portanto, propusemo-nos a realizar um estudo em modelo animal que analisasse o trabeculado ósseo da mandíbula através da Micro-CT. Foram utilizados 24 ratos machos (Rattus novergicus, albinus, Wistar), com 12 semanas de vida, divididos em 2 grupos: grupo controle (cloreto de sódio 0,9%) e grupo ácido zoledrônico (ácido zoledrônico 0,6mg/kg). As substâncias foram administradas via intraperitoneal a cada 28 dias em um total de 5 doses. Após 150 dias do início do experimento, foi realizada a eutanásia dos animais e então as amostras foram preparadas e escaneadas (Skyscan 1174) para análise da microestrutura óssea através da Micro- CT. O teste t-student demonstrou diferença estatisticamente significativa (p<0,05) em todos os fatores: volume ósseo, densidade óssea, fator de padrão trabecular, índice de modelo estrutural, espessura trabecular, separação trabecular, porosidade total exceção de número de trabéculas e volume tecidual, demonstrando que há alterações significativas na estrutura trabecular pelo uso de bisfosfonatos. O grupo medicado com ácido zoledrônico comparado ao grupo controle demonstrou trabéculas mais espessas, menos separadas e com menores ligações. / Bisphosphonates are widely and effectively drugs used for the treatment of osteolytic disorders. However, in the oral cavity, this situation is of particular relevance as it can lead to bisphosphonate related osteonecrosis of the jaws. Its etiopathogenesis is still not established, detection methods are unsatisfactory and recommended therapies are sometimes palliative and often ineffective. Little is known about the effect of zoledronic acid on the quality of trabecular bone, therefore, we proposed to conduct a study in an animal model to examine the trabecular bone of the jaw through the Micro-CT. 24 male rats were used (Rattus norvegicus, Albinus, Wistar), with 12 weeks old, divided into 2 groups: control group (sodium chloride 0.9%) and group with zoledronic acid (zoledronic acid 0.6 mg / kg). The substances were administered intraperitoneally every 28 days for a total of 5 doses. After 150 days from the beginning of the experiment, the animals were sacrificed and then the samples were prepared and scanned (Skyscan 1174) for analysis of the bone microstructure through Micro-CT. The \"t-student\" test demonstrated statistically significant differences (p<0.05) in all factors: bone volume, osseous density, trabecular pattern, structure model index, trabecular thickness, trabecular separation, total porosity except trabecular number and tissue volume, demonstrating that there are significant changes in the trabecular structure of the bisphosphonates. Zoledronic Acid compared to control group shows thicker, less separate and lower connected trabeculae.

Os bisfosfonatos são medicamentos amplamente e efetivamente utilizados para o tratamento de doenças osteolíticas. Entretanto, na cavidade oral, é de particular relevância, pois possuem como efeito adverso a osteonecrose dos maxilares induzida pelo uso de bisfosfonatos. Sua etiopatogenia ainda não é bem estabelecida, os métodos de detecção são insatisfatórios e as terapias recomendadas são por vezes, medidas paliativas e ineficazes. Pouco ainda é sabido sobre o efeito do Ácido Zoledrônico na microestrutura óssea, portanto, propusemo-nos a realizar um estudo em modelo animal que analisasse o trabeculado ósseo da mandíbula através da Micro-CT. Foram utilizados 24 ratos machos (Rattus novergicus, albinus, Wistar), com 12 semanas de vida, divididos em 2 grupos: grupo controle (cloreto de sódio 0,9%) e grupo ácido zoledrônico (ácido zoledrônico 0,6mg/kg). As substâncias foram administradas via intraperitoneal a cada 28 dias em um total de 5 doses. Após 150 dias do início do experimento, foi realizada a eutanásia dos animais e então as amostras foram preparadas e escaneadas (Skyscan 1174) para análise da microestrutura óssea através da Micro- CT. O teste t-student demonstrou diferença estatisticamente significativa (p<0,05) em todos os fatores: volume ósseo, densidade óssea, fator de padrão trabecular, índice de modelo estrutural, espessura trabecular, separação trabecular, porosidade total exceção de número de trabéculas e volume tecidual, demonstrando que há alterações significativas na estrutura trabecular pelo uso de bisfosfonatos. O grupo medicado com ácido zoledrônico comparado ao grupo controle demonstrou trabéculas mais espessas, menos separadas e com menores ligações. / Bisphosphonates are widely and effectively drugs used for the treatment of osteolytic disorders. However, in the oral cavity, this situation is of particular relevance as it can lead to bisphosphonate related osteonecrosis of the jaws. Its etiopathogenesis is still not established, detection methods are unsatisfactory and recommended therapies are sometimes palliative and often ineffective. Little is known about the effect of zoledronic acid on the quality of trabecular bone, therefore, we proposed to conduct a study in an animal model to examine the trabecular bone of the jaw through the Micro-CT. 24 male rats were used (Rattus norvegicus, Albinus, Wistar), with 12 weeks old, divided into 2 groups: control group (sodium chloride 0.9%) and group with zoledronic acid (zoledronic acid 0.6 mg / kg). The substances were administered intraperitoneally every 28 days for a total of 5 doses. After 150 days from the beginning of the experiment, the animals were sacrificed and then the samples were prepared and scanned (Skyscan 1174) for analysis of the bone microstructure through Micro-CT. The \"t-student\" test demonstrated statistically significant differences (p<0.05) in all factors: bone volume, osseous density, trabecular pattern, structure model index, trabecular thickness, trabecular separation, total porosity except trabecular number and tissue volume, demonstrating that there are significant changes in the trabecular structure of the bisphosphonates. Zoledronic Acid compared to control group shows thicker, less separate and lower connected trabeculae.

A osteonecrose dos maxilares associada aos bisfosfonatos (OMAB) é reconhecidamente uma complicação tardia dos bisfosfonatos, que são empregados para tratar desordens esqueléticas marcadas pela perda de massa óssea. Hoje, o reconhecimento da variante clínica sem exposição óssea e de outras classes de drogas associadas à osteonecrose dos maxilares (inibidores de RANK-L, VEGF, m- TOR e TNF-a) integram um novo aspecto do conceito dessa entidade patológica. Vários fatores de risco para o desenvolvimento de OMAB foram identificados, incluindo procedimentos odontológicos invasivos, má higiene oral, o uso de bisfosfonatos (particularmente, os bisfosfonatos nitrogenados como o pamidronato e o zoledronato), infusões frequentes e tempo prolongado de exposição aos bisfosfonatos. A saúde bucal é um fator significativo que afeta o risco de OMAB e, juntamente com a predisposição genética, pode explicar algumas das diferenças de incidência encontrada na literatura. Fatores genéticos parecem influenciar o risco de desenvolvimento da OMAB. Os polimorfismos de nucleotídeo único dos genes CYP2C8 e RBMS3 foram significativamente associados com um risco mais elevado. Enquanto o gene CYP2C8 está envolvido na inibição dos osteoclastos, diferenciação dos osteoblastos e regulação do tônus vascular, RBMS3 é um gene envolvido no metabolismo ósseo e foi associado à massa óssea reduzida e a fraturas osteoporóticas. Contudo, houve limitações metodológicas nesses estudos, dos quais apenas um abordou a diferença da frequência de polimorfismos associados à OMAB em grupos étnicos distintos. Até o momento faltam estudos genéticos sobre polimorfismos associados com OMAB que tenham sido replicados e validados com evidências convincentes, particularmente, envolvendo populações não caucasianas. Ainda hoje permanece um grande desafio: estratificar o risco para desenvolvimento da OMAB no contexto clínico. Assim, o objetivo do presente estudo é investigar a associação de fatores clínicos (saúde bucal) e genéticos com a ocorrência da OMAB. Realizou-se um estudo transversal com pacientes oncológicos expostos ao zoledronato e/ou pamidronato por pelo menos 7 meses, com ou sem OMAB. Submeteram-se os participantes à avaliação odontológica. Avaliou-se a condição de cárie dentária e doença periodontal através do índice de dentes cariados perdidos e obturados (CPOD) e índice periodontal comunitário. O índice gengival e o índice de higiene oral simplificado (IHOS) também constaram nessa avaliação. Para a discriminação dos genótipos dos genes CYP2C8 e RBMS3, 2 ml de saliva foram coletados e processados para a técnica de PCR quantitativa. A amostra consistiu de 80 pacientes (69 mulheres e 11 homens). O índice geral de OMAB foi 11,2% (câncer de mama: 11,3%; câncer de próstata: 22,2%). Houve forte correlação positiva entre o estadiamento clínico da OMAB e CPOD (rho=0.9189, p=0.001). Inflamação gengival moderada e cálculo dentário alcançaram, respectivamente, 72% e 50% dos indivíduos com OMAB. Bolsa periodontal de 4 mm ou mais envolveu 37,5% desse grupo. IHOS revelou aproximadamente 25% dos indivíduos desse grupo com higiene oral regular. O polimorfismo do gene CYP2C8 estava presente em 50% dos pacientes com OMAB, enquanto 12% apresentou mutação para o gene RBMS3. Em conclusão, a saúde bucal da população oncológica foi bastante precária e o polimorfismo do gene CYP2C8 pareceu se associar à OMAB em população oncológica. / Bisphosphonate-related osteonecrosis of the jaw (BRONJ) is recognized as a late complication of bisphosphonates, which are used to treat skeletal disorders characterized by loss of bone mass. The recognition of clinical variation without bone exposure and other classes of drugs associated with osteonecrosis of the jaws (RANK-L, VEGF, m-TOR and TNF-inhibitors) are part of a new aspect of the pathological concept. Several risk factors for the development of BRONJ have been identified, including invasive dental procedures, poor oral hygiene, use of bisphosphonate (particularly, nitrogen-containing bisphosphonate such as pamidronate and zoledronate), frequent infusions and prolonged exposure to bisphosphonate. Oral health is a significant factor that affects the risk of BRONJ and, along with a genetic predisposition, it might explain epidemiological differences found in literature. Genetic factors seem to impact the risk of developing BRONJ. Single nucleotide polymorphisms of the CYP2C8 and RBMS3 genes were significantly associated with a higher risk. While the CYP2C8 gene is involved in osteoclast inhibition, osteoblast differentiation and regulation of vascular tone, RBMS3 is a gene involved in bone metabolism and has been associated with reduced bone mass and osteoporotic fractures. However, methodological limitations are present in these studies, of which only one addressed the difference in the frequency of polymorphisms associated with BRONJ in different ethnic groups. So far genetic studies have been lacking on polymorphisms associated with BRONJ that have been replicated and validated with convincing evidence, particularly involving non- Caucasian populations. In clinical context, a great challenge remains: classify patients in high risk for the development of BRONJ. Thus, the present study aims to investigate an association of clinical (oral health) and genetic factors with the occurrence of BRONJ. A cross-sectional study was performed with oncologic patients exposed to zoledronate and/or pamidronate for at least 7 months, with or without BRONJ. Participants were submitted to dental evaluation. Dental caries and periodontal disease were evaluated through the index of missing and filled teeth (DMFT) and community periodontal index. The gingival index and the simplified oral hygiene index (SOHI) were also included in this evaluation. For the discrimination of genotypes of the CYP2C8 and RBMS3 genes, 2 ml of saliva were collected and processed for the quantitative PCR technique. The sample consisted of 80 patients (69 women and 11 men). The overall BRONJ index was 11.2% (breast cancer: 11.3%, prostate cancer 22.2%). There was a strong positive correlation between the clinical staging of BRONJ and DMFT (rho=0.9189, p=0.001). Moderate gingival inflammation and dental calculus comprised, respectively, 72% and 50% of individuals with OMAB. Periodontal pocket of 4 mm or more involved 37.5% of this group. SOHI revealed approximately 25% of individuals in this group with regular oral hygiene. The polymorphism of the CYP2C8 gene was present in 50% of patients with BRONJ, while 12% had a mutation for the RBMS3 gene. In conclusion, the oral health of the cancer population was very precarious and CYP2C8 gene polymorphism is apparently associated with BRONJ in cancer population.