Medication-related osteonecrosis of the jaw: prevention and medical-surgical management through low-level laser therapy with different wavelengths

Medication-related osteonecrosis of the jaw (MRONJ) is on the rise among patients taking long-term antiresorptive drugs. The primary goal of treatment in osteonecrosis of the jaws (ONJ) should be to improve the patient's quality of life by managing pain and infections, preventing the development of new lesions and slowing the progression of the disease. In recent years, the use of the laser for MRONJ treatment has spread, thanks to the practical administration and the widely reported beneficial effects on tissue healing. This literature overview sought to clarify whether low-level laser therapy (LLLT) has positive effects on the treatment of osteonecrosis of the jaw. Our results show that treatment modalities, including LLLT, were associated with superior outcomes in terms of cure or improvement of antiresorptive drugs-related osteonecrosis of jaw lesions compared to conventional surgical and / or conservative drug therapy alone. It can be concluded that combined treatment with antibiotics, minimally invasive surgery (including laser surgery) and LLLT in the early stages of the disease should be the gold standard for management to MRONJ.

Medication-related osteonecrosis of the jaws (MRONJ) is defined as a drug-related adverse reaction, with the progressive destruction and necrosis of the mandibular and / or maxillary bone associated with the use of an antiresorptive agents (bisphosphonate or denosumab) and anti-angiogenetic ones, without history of radiation therapy for the craniofacial region.
In fact, ONJ associated with the use of these drug classes constitutes one of the most important complications.
The main goal of treatment of ONJ should be to improve the patient's quality of life by managing pain and infections, preventing the development of new lesions and slowing the progression of the disease. In recent years, the use of laser for ONJ treatment has become more widespread, thanks to the widely reported beneficial effects on tissue healing. Currently, antibiotic therapy, minimally invasive surgery and the low level laser therapy (LLLT) during the early stages, have been considered the gold standard treatment to prevent MRONJ.

Materials and Methods:
We reviewed the literature and guidelines to try to clarify whether the LLLT has positive effects on the ONJ treatment.

Results:
By inserting the keywords "LLLT", "Osteonecrosis of the jaws", "MRONJ", "low level laser therapy", "ONJ" 959 results were obtained. Data were extracted by two reviewers independently (GM and MMS). Any disagreement between the authors regarding the inclusion of a particular article and the extraction of the data was resolved by discussion. The PRISMA flow diagram shows the flow of information through the different phases of the review process ( Figure 2).
After the exclusion of duplicates, 655 articles were evaluated, then 108 studies were left for full-text assessment. At last, 9 studies were included in the qualitative and in the quantitative analysis (Table 2).
LLLT can provide significant improvement in signs of inflammation (mainly swelling and pain), xerostomia, bacterial control and chemotherapy-induced oral mucositis. Therefore, it's effective in patients with MRONJ, preventing oral or cutaneous fistulas and healing the mucosa on the bone tissue and improving the patient's quality of life.
In addition, LLLT prevents evolution di ONJ from stage 2 (exposed and necrotic bone or a fistula with evidence of infection, typically asymptomatic and symptomatic) to stage 3 (exposed and necrotic bone or fistulas with evidence of infection and with pathological fracture or exposed necrotic bone, extraoral or oral antral or oral-nasal communication

Conclusions.
Biostimulation could represent an adjunct therapy in the treatment of the "initial" forms of drug-related ONJ, in patients with both oncological and osteometabolic pathology, as a safe, minimally invasive and well tolerated technique. [