Bone necrosis (bisphosponate associated)

Inndication		Joule cm2	Frequency	Treeatments week
Bone necrosis		4 - 6	cw, A	2-3
	X	Apply the laser directly on the necrosis with dental applicator

Dr. S. Hafner, Germany, was the first who treated the bone necrosis successfully using the Physiolaser olympic with power of 200 mW/685 nm and as well 500 mW/810 nm.

The laser therapy according to Dr. Hafner is the only known method to cure the necrosis following the cancer therapy.

Osteology Monaco Poster Session 05/2007

A new effective treatment protocol for bisphosphonate associated osteonecrosis of the jaws by using Low-level-laser therapy combined with conservative dentoalveolar surgery
Hafner, S., Schiel, S., Breitfeld, M, Otto, S., Mast, G. Ehrenfeld, M.

Objectives: Osteonecrosis of the jaws is a well known issue adverse side effect of bisphosphonate therapy. Bisphosphonates are used to treat osteoporosis, Paget´s disease of bone, hypercalcemia syndrom, multiple myeloma and other patients with osteolytic bone metastasis. Their primary mechanism of action is inhibition of osteoclastic resorption of bone. Within the past 4 years many papers reported that bisphosphonate use, especially intravenous nitrogen-containing preparations, may be associated with osteonecrosis of the jaws. Oversuppression of bone turnover is probably the primary mechanism for the development of this condition, although there may be contributing comorbid factors. There are no sufficient current treatment strategies to manage these osteonecrosis. Extensive resection has not consistently resulted in wound closure and may lead to worsening or progression of disease.

Methods: In our study we performed a treatment protocol by preferring a conservative débridement of necrotic bone combined with Low-level laser therapy (diodesoftlaser/ 200mW/685nm, Physiolaser Olympic) including n=42 patients (49-83a, 32 female, 10 male) with bisphosphonate associated osteonecrosis of the jaws. We used softlaser application before and after surgery at the locations of osteonecrosis directly on the bone and the environing tissue. Bisphosphonate-treatment was discontinued if it was medically sustainable and supported our therapy by prescripting antibiotics (amoxicillin/clavulanic acid or clindamycin). Low-level laser therapy was started in short intervals (2-3 a week, 4-6 Joule/cm2). If we saw a good progress in healing we reduced the treatment to once a week until healing was completed.

Results: This new regenerative therapy concept – used in 42 cases with one or more sites of osteonecrosis - showed good clinical results with an effective infection management (no major complications such as mandibulectomy, abscess or systemic inflammation although some of the patients were in chemotherapeutical treatment during the LLLT, occurred). In addition an effective pain control was reported by the patients. Healing or significant improve of the local condition could be seen in 20 patients within the first weeks after starting the treatment. The other n=22 patients are still in therapy while a major part of these patients shows continuing progress in wound healing. Low-level laser therapy seemed to be most effective if the treatment is carried out immediately after surgery.

Conclusions: In our study we determined a effective treatment protocol for bisphosphonate associated steonecrosis of the jaws by using softlaser combined with dentoalveolar surgery. The key of therapy could be the local reduction of oversuppression of bone turnover by stimulating

osteoclasts using Low-level laser therapy (LLLT). The removal of the antiangiogenic effects of the drug on the soft tissues and periosteum combined with the angiogenetic and osteogenetic effect of the softlaser therapy may play a role in healing (3, 4, 6). Some studies indicate that bone irradiated with softlaser shows increased osteoclastic and osteoblastic proliferation, collagen deposition, and bone neoformation (3, 6). Vascular responses to softlaser phototherapy were also suggested as one of the possible mechanisms responsible for the positive clinical results observed following LLLT (6). More clinical studies are needed to evaluate and optimize the mode of softlaser application and to improve the success of this regenerative therapy concept.

Abstract Osteology Monaco Poster Session 05/2007
		Patient (66a, D: prostatic carcinoma) with osteonecrosis in the upper jaw (17-18) after bisphosphonate therapy (Zometa).

Sequestrotomy after one week of Low-level laser therapy.		Softlaser application after surgery (4-6 J/cm2) on the environing tissue.

Wound dehiscence 6 days after surgery, healing by granulation.		Wound healing is completed 4 weeks after surgery and in a stable condition 10 weeks after surgery.

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