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Panorama atual da abordagem à osteonecrose do maxilar induzida por fármacos (MRONJ) : uma revisão da literatura
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Orientador(es)
Resumo(s)
A Osteonecrose Mandibular Induzida por Fármacos (internacionalmente designada MRONJ) é um efeito adverso raro, contudo grave, atualmente associado a vários fármacos, sendo os bifosfonatos e o denosumab os mais estudados. Até hoje, existem algumas teorias que tentam explicar a sua fisiopatologia, nenhuma delas comprovada.
Apresenta-se, frequentemente, com parestesias da mandíbula e região labial, ou halitose, podendo progredir silenciosamente e manifestar apenas as complicações da necrose óssea, como a infeção. Faz diagnóstico diferencial com várias entidades, desde sinusite, até distúrbios da ATM, sendo fundamental a colheita de uma história clínica completa, incluindo os fatores de risco do doente.
A literatura descreve dois tipos de abordagem, um conservador, que passa pelas lavagens orais com antissépticos, e, verificando-se infeção concomitante, antibioticoterapia; e um invasivo, que defende a remoção cirúrgica do tecido necrosado e reconstrução mucosa, para promover a correta cicatrização. Contudo, a falta de consenso na literatura traduz-se na falta de um algoritmo universalmente aceite de gestão desta patologia. A AAOMS, no seu mais recente consenso, de 2014, propõe um sistema de classificação da MRONJ em quatro estádios e um algoritmo de abordagem baseado nos mesmos.
Neste trabalho, faz-se uma revisão da literatura, partindo de artigos redigidos sobre o tema, entre 2011 e 2019, no sentido de esclarecer as principais discórdias entre autores, bem como as várias abordagens estudadas até à data.
Conclui-se que esta discórdia é principalmente devida à falta de definição dos conceitos base nesta área, pelo que, para que se consiga estabelecer um algoritmo de abordagem universalmente aceite, é necessário esclarecer os critérios de diagnóstico da patologia, bem como rever a sua classificação, possivelmente com recurso a técnicas de imagem, assim como clarificar os resultados pretendidos – controlo sintomático, não recorrência de lesões ou remoção do tecido necrótico com estabilização mucosa a longo prazo.
Medication Related Osteonecrosis of the Jaw (known as MRONJ) is a rare but severe adverse effect, currently associated with several drugs, the bisphosphonates and denosumab being the most largely studied. Until now, there are only theories that try to explain its pathophysiology, but no one has been proven yet. It presents frequently with paraesthesia of the mandible and labial region, or halitosis, but it may progress silently and only manifest the complications of osteonecrosis, like its infection. Its differential diagnosis goes from sinusitis to temporomandibular joint disorders, which demands a complete clinical history, including oral clinical history. Literature describes two types of approach: a conservative one, with oral rinses with antiseptic agents and, in case of concomitant infection, antibiotic therapy; and an invasive one, which defends the surgical removal of the necrotic bone and mucosal reconstruction, in order to promote a correct healing. However, the lack of consensus in the literature translates into a lack of a universally accepted algorithm of management. AAOMS, in its latter consensus, dating 2014, proposes a system of classification of MRONJ into four stages and an algorithm to approach it, based on each stage. In this paper, we revise the literature, published between 2011 and 2019, in order to clarify the major disagreements between authors, as well as the several types of approaches studied throughout this period. This leads to the conclusion that this disagreement is mainly due to the lack of explicit basic concepts. In order to establish a universally accepted algorithm of approach, it is necessary to clarify diagnostic criteria and to revise its classification, possibly using imaging techniques. Furthermore, it is also imperative that the expected outcomes are clarified – symptom control, non-recurrence of the MRONJ lesions or necrotic tissue removal, with mucosal stabilization in the long term.
Medication Related Osteonecrosis of the Jaw (known as MRONJ) is a rare but severe adverse effect, currently associated with several drugs, the bisphosphonates and denosumab being the most largely studied. Until now, there are only theories that try to explain its pathophysiology, but no one has been proven yet. It presents frequently with paraesthesia of the mandible and labial region, or halitosis, but it may progress silently and only manifest the complications of osteonecrosis, like its infection. Its differential diagnosis goes from sinusitis to temporomandibular joint disorders, which demands a complete clinical history, including oral clinical history. Literature describes two types of approach: a conservative one, with oral rinses with antiseptic agents and, in case of concomitant infection, antibiotic therapy; and an invasive one, which defends the surgical removal of the necrotic bone and mucosal reconstruction, in order to promote a correct healing. However, the lack of consensus in the literature translates into a lack of a universally accepted algorithm of management. AAOMS, in its latter consensus, dating 2014, proposes a system of classification of MRONJ into four stages and an algorithm to approach it, based on each stage. In this paper, we revise the literature, published between 2011 and 2019, in order to clarify the major disagreements between authors, as well as the several types of approaches studied throughout this period. This leads to the conclusion that this disagreement is mainly due to the lack of explicit basic concepts. In order to establish a universally accepted algorithm of approach, it is necessary to clarify diagnostic criteria and to revise its classification, possibly using imaging techniques. Furthermore, it is also imperative that the expected outcomes are clarified – symptom control, non-recurrence of the MRONJ lesions or necrotic tissue removal, with mucosal stabilization in the long term.
Descrição
Trabalho Final do Curso de Mestrado Integrado em Medicina, Faculdade de Medicina, Universidade de Lisboa, 2020
Palavras-chave
Osteonecrose mandibular induzida por fármacos Osteonecrose Bifosfonatos Denosumab Estomatologia