Introduction
Osteonecrosis of the jaw (ONJ) is an adverse event reported in patients receiving BPs and RANKL inhibitors such as denosumab [1] , [2] , [3] , [4] , [5] , [6] , [7] , [8] , [9] .
ONJ is defined as the persistence of exposed bone in the oral cavity, despite an adequate treatment for six weeks, without local evidence of malignancy and no prior radiotherapy to the affected region [10] . However, ONJ may present with the non-exposed variant of ONJ.
The pooled risk estimated incidence of ONJ, in BPs users, is 2,4% [11] , [12] , [13] , [14] . In RCTs comparing zoledronic acid and denosumab in 5677 patients who underwent screening dental procedure, 89 ONJ cases were reported of which 52 in the denosumab group [8] , [11] , [12] , [13] .
Factors adversely influencing bone remodelling are considered to be pivotal in the pathophysiology of the ONJ and preclinical data shows that the bone turnover is higher in the jaws with respect to other skeletal areas [10] , [15] , [16] , [17] . The presence of chronic periodontal pathologies, the duration and type of BP therapy, tooth extractions, the use of dental appliances, denture traumatisms, invasive dental surgery during the course of BP therapy, poor oral hygiene, concurrent disease (e.g. diabetes, peripheral vasculopathy) and the concomitant use of chemotherapy, antiretroviral therapies, thalidomide, and corticosteroids or the presence of anaemia are considered putative additional risk factors [1] , [2] , [3] , [4] , [5] , [18] , [19] . In a retrospective analysis of 567 cases Vescovi et al. [20] studied the differences between the non surgery-triggered vs surgery-triggered variants bisphosphonate-related osteonecrosis of the jaws. In 205 cases (36.2%) of ONJ no surgery was performed as against 362 cases (63.8%) of post-local invasive procedure forms including tooth extraction in 361 cases and implant placement in one case only.
Bisphosphonates are a well-established, standard-of care treatment option to reduce the frequency and severity and time of onset of the skeletal related events (SREs) in patients with bone metastases due to either solid tumours or multiple myeloma [21] , [22] , [23] , [24] , [25] , [26] , [27] , [28] , [29] , [30] , [31] , [32] , [33] . From many years, BPs have been incorporated into clinical practice recommendations for these patients [33] , [34] , [35] , [36] , [37] , [38] , [39] and denosumab has been approved in many countries for the delay of onset of SREs due to bone metastasis in breast or prostatic cancer patients.
Preventive dental measures, after dental screening examination [1] , [40] , [41] , [42] , [43] , [44] , are advocated to reduce the ONJ incidence [14] , [45] , [46] due to their efficacy in patients with bone metastases but not in oncological patients with osteoporosis yet. Recent recommendations for ONJ, include a conservative approach with intermittent prophylactic antibiotic therapy, rinses with oral chlorhexidine and debridement [44] ; moreover a careful sequestrum removal is recommended [1] , [17] , [40] , [41] , [42] , [43] , [44] , [45] , [46] , [47] .
In a previous study [47] we evaluated the efficacy and tolerability of localised topical application of an oil suspension enriched with medical O 3 gas, as treatment for ONJ lesions ≤2.5 cm in another sample of patients who failed to respond to various cycles of antibiotics. Unexpectedly, total sequestration of the necrotic bone, with spontaneous expulsion in eight patients and new bone formation around the necrotic area in two patients was observed. No patient required surgical intervention. In two patients with pre- and post-treatment X-rays, no residual bone lesions were observed after treatment.
Ozone is a gas naturally produced by atmospheric air; medical ozone is produced from oxygen. Its role in treating bone lesions has been previously reported [47] . Ozone has antimicrobical and wound-healing properties. The role of O 3 produced by air to treat ONJ has been evaluated in some pre-clinical and clinical studies because it was thought that O 3 could induce the repair of tissues by cleansing the osteonecrotic lesions, which leads to mucosal healing [47] , [48] , [49] , [50] , [51] , [52] , [53] . Ozone therapy has previously shown to enhance the benefits of surgical and pharmacologic treatments of ONJ when administered before and after treatment procedures [47] , [51] , [53] .
The aim of this open-label, prospective study, was to investigate the efficacy and tolerability of medical O 3 gas (produced from pure oxygen and not from air) topical insufflations, as the treatment for ONJ lesions >2.5 cm in patients treated with BPs whose ONJ lesion did not heal with prior conservative therapy or relapsed after surgery performed before the patients arrived to our hospital for the specific consultation and cure with the Dental Team and the Supportive Care in Cancer Team.
Patients and methods
Eligibility criteria
All adult patients with solid tumours and multiple myeloma on stable disease or patients with osteoporosis due to hormonal therapy, who previously received nitrogen-containing BP treatment in the absence of preventive screening carried out by a dentist and a dental care team and who developed stage two ONJ lesions [10] , [44] , and had no benefit after the treatment with the standard therapy, were included in the study. The patients with lesions >2.5 cm were considered for O 3 gas therapy after they gave the consensus.
No patient took part in the previous published study [47] . No patient with metastatic disease of the jaw or osteoradionecrosis or treated with radiotherapy to the jaws were included.
Efficacy criteria
The level of clinical response was: (1) bone sequestrum followed by spontaneous expulsion of the necrotic bone with re-epithelization of oral mucosa and with regenerated epithelial tissue or (2) bone sequestrum followed by surgery to remove necrotic bone.
Safety criteria
The treatment area was assessed for the presence or absence of oral mucosa redness around the lesion area, pain, progressive increasing of lesion, appearance of necrotic area, pethechiae and/or bleeding. Moreover odour intolerance, burning mucosa, coughing due to local irritation of respiratory tract, dysphagia post treatment, symptoms related to skin sore or mucosal lesion was assessed.
Procedure of O 3 gas insufflation
All the procedures are performed by two experienced dentists of the Dental Care Team (MM, EC).
Although antibiotic therapy had been received frequently by the patients prior to study entry, all the patients were pre-treated with azithromicin 500 mg/day for 10 days prior to the initiation of the medical O 3 gas treatment to reduce the local essudation/infection caused by the exposition of necrotic bone, the dehiscence of the mucous membranes and the difficulty in maintaining proper oral hygiene.
The choice of azithromicin was dictated by the fact that the patients had previously been treated with various types of antibiotics other than azithromicin. Moreover, clinical experience has shown treatment with azitromicinale to be the best, fastest and most durable remissions of local suppuration. To date, after several years of treatment of patients with ONJ, we believe that the drug is more ‘in the appropriate population of patients’ which came to our attention.
Table 1 shows the procedures for O 3 insufflation after 10 days of antibiotic treatment.
Table 1
Procedures performed to administer O 3 gas.
| - The exposed bone and osteomucosal edge were cleaned with a tartar supersonic scaler in order to reduce the infections at gum level and favour the penetration of O 3 gas through the mucosa around the ONJ lesion. |
| - An impression of the affected arch was taken using a perforated impression tray and addition silicone impression material. |
| - Once the impression has been removed from the mouth, the marginal seal of the impression material on the healthy gum around the lesion was checked; if necessary a demographic pencil was used to make ONJ lesion reference points on the impression material. |
| - Having identified the area corresponding to the lesion site, the “insufflations chamber” was prepared, creating a hollow in the impression by carefully removing the impression material to obtain a space in which the gas to be insufflate onto the treatment area can circulate ( Fig. 1 ). |
| - We make calibrated holes in the perforated impression tray, at the proximal and distal margins of the lesion, for the tubes delivering the ozone gas to pass through. |
| - Once in position, we checked the fit of the “insufflations chamber”, by checking the stability and seal on the marginal mucosa. |
| - The tubes were then connected to the ozone dispensing device, along with the return pipe that, using an aspiration pump, allows a perfect fit on the mucosa at the chamber's seal margin, thus making it possible to recover any ozone present after contact that is not transformed into oxygen inside the chamber. |
| - Insufflations, were monitored constantly by the practitioner who can, when necessary, use a flow-metre to adjust the amount of ozone applied, which must be kept constant at 20 ppm +/−1. |
| - Flow control was made possible by constant monitoring of the ozone produced thanks to the presence in the device of a mass spectrophotometer that allows real-time concentration control. |
| - At the end of the treatment, the insufflations chamber was removed from the mouth, then washed and disinfected by emersion in sterilising product for subsequent use. |
Before each treatment the condition of the mucosa and the stability of the necrotic bone must be checked to evaluate whether or not it needs to be removed.
Each patient was treated for with a minimum of 10 applications of O 3 gas once every three days on each lesion area. When patients showed necrotic bone sequestrum and spontaneous expulsion with O 3 gas applications were stopped after few insufflations . In patients with plurifocal locations, with extensive injury (and for which a insufflation bell Fig. 1 was packed and used for each side application) or in the case of abundant purulent secretions, a higher number of O 3 gas applications were administered because the concentrations of O 3 initially interacted with the bacteria and purulent or essudative secretions. Each O 3 gas insufflation lasted for 10 min.
When necrotic bone was not spontaneously expelled even if the sequestrum was present, the patients were eligible for surgical resection of the necrotic bone, rotation of the mucosa lap, and surgical joining of the two edges.
Assessments
Efficacy and safety evaluations were performed after each O 3 gas application and during the follow-up period scheduled at one, two, three, and four months after the completion of the treatment and then every six months. In particular at the end of all O 3 gas insufflation the damage of mucous tissues has been evaluated.
Moreover, pain intensity was assessed at each visit by means of a self-reported numerical rating scale (NRS). The treatment was stopped when patients showed clinical response (spontaneous expulsion of necrotic bone or surgery to remove the sequestrum) or undesirable adverse effects or when Performance Status worsened due to disease progression.
Study design and statistical considerations
This was a single-centre, open-label, Simon two-stage optimal design study [54] . The primary efficacy end point of the study was the clinical response, as previously defined. During stage one, an enrolment of nine patients was required. If no response was observed, then the study had to be terminated. If at least one response was observed, the trial could continue to stage two and an additional 15 patients enroled. After completion of the second stage of the study, the treatment would be considered worthy of further investigation if at least three responses were observed. The study design yielded a >90% probability of a positive result if the true response rate was >25%, and >90% probability of a negative result if the true response rate was <5%. The study design incorporated monitoring of treatment associated toxicity, with a Bayesian stopping rule in case of a 90% posterior probability of a toxicity rate greater than 10%. The response rate was computed as the percentage of responding patients over the total number of patients accrued. Calculation of the corresponding 95% confidence interval (95% CI) was based on the binomial distribution.
Results
The patients' demographics, baseline disease characteristics and outcomes with medical O 3 gas therapy are shown in Table 2 . The patients received a number of zoledronic acid infusions ranging from 10 to 18. At the time of ONJ diagnosis no patient presented risk factors such as diabetes or the use of corticosteroids.
Table 2
Patients' demographics, baseline disease characteristics and outcomes with medical O 3 gas therapy.
NB=Necrotic bone. a Classification according to Weitzman et al. Ref. [43] :lesion size measured as the largest diameter 4A=single lesion>2 cm; 4B multiple lesions, largest>2 cm. b The patients who received more than 10 insufflations of O 3 medical gas had multiple lesions or single lesion but copious purulent discarge even if treated with antibiotic prophylaxis. c ODP oncological disease progression. d The patient received two more insufflations of O 3 medical gas while he was waiting for the surgery.
| Patient | Age | Gender | Primary cancer or osteoporosis | ONJ lesion size grading a | Time (days) from diagnosis of ONJ to first O 3 gas insufflations | Number of O 3 gas insufflations b | Clinical outcomes |
| 1 | 73 | M | Prostate | 4A | 1080 | Three applications than interruption | Dropped-outstop of O 3 therapy due to ODP c . |
| 2 | 53 | M | Lung | 4A | 240 | 10 | Surgery to remove NB after sequestrum. No ONJ relapse. |
| 3 | 70 | F | Breast | 4A | 540 | 7 | NB sequestrum+spontaneous expulsion+ re-epithelisation. No ONJ relapse. |
| 4 | 74 | F | Breast | 4A | 30 | 4 | NB sequestrum+spontaneous expulsion+ re-epithelisation. No ONJ relapse. |
| 5 | 41 | M | Osteoporosis | 4A | 840 ONJ relapse in area 44–48 after surgery | 38 on single lesion | Surgery to remove NB after sequestrum. No ONJ relapse. |
| 6 | 64 | M | Prostate | 4B | 510 | 17 applications than interruption | Dropped-out, stop of O 3 therapy due to ODP. |
| 7 | 65 | M | Myeloma | 4A | 30 | 9 | NB sequestrum+spontaneous expulsion+ re-epithelisation. No ONJ relapse. |
| 8 d | 60 | M | Prostate | 4A | 90 | 12 bone sequestrum ready to be removed surgically | No surgical removal of NB because of ODP. |
| 9 | 64 | M | Myeloma | 4B | 570 | 17 | Surgery to remove NB after sequestrum. No ONJ relapse. |
| 10 | 49 | F | Breast | 4A | 390 ONJ relapse after partial resection of the left maxillary not responsive to antibiotics | 16 | Surgery to remove NB after sequestrum. No ONJ relapse after O 3 gas applications. |
| 11 | 79 | M | Lung | 4B | 270 | 15+12 multiple lesions on sx and dx sites | NB sequestrum and spontaneous expulsion+mucosal re-epithelisation at all sites. No ONJ relapse nor decubitus after denture placement in the inferior arch. |
| 12 | 80 | F | Breast | 4B | 720 | Two applications than interruption | Dropped-out stop of O 3 therapy due to ODP. |
| 13 | 67 | F | Breast | 4B | 420 | 10+9 multiple lesions on sx and dx sites. | Surgery to remove NB after sequestrum. No ONJ relapse. |
| 14 | 66 | F | Osteoporosis | 4A | 120 | One application than interruption. | Dropped-out. Stop of therapy for fear of adverse effects. |
| 15 | 79 | M | Breast | 4A | 420 | 9 | NB sequestrum and spontaneous partial expulsion+re-epithelisation. Stop of therapy for ODP. |
| 16 | 51 | F | Breast | 4B | 300 | 15 applications than interruption. | dropped-out stop of therapy for ODP. |
| 17 | 47 | F | Breast | 4A | 90 | Six applications than interruption. | Dropped-out stop of O 3 therapy due to ODP. |
| 18 | 63 | M | Lung | 4A | 44 | 6 | NB sequestrum+spontaneous expulsion+re-epithelisation. No ONJ relapse. |
| 19 | 77 | M | Prostate | 4A | 82 | 10 | Surgery to remove NB after sequestrum. No ONJ relapse. |
| 20 | 60 | F | Osteoporosis | 4B | 476 | 16 | Surgery to remove NB after sequestrum. No ONJ relapse. |
| 21 | 58 | F | Breast | 4B | 360 | 15 | Surgery to remove NB after sequestrum No ONJ relapse. |
| 22 | 43 | M | Lung | 4A | 286 | 8 | Surgery to remove NB after sequestrum. No ONJ relapse. |
| 23 | 62 | F | Breast | 4B | 375 | 9 | Surgery to remove NB after sequestrum. No ONJ relapse. |
| 24 | 55 | F | Breast | 4A | 266 | 10 | Surgery to remove NB after sequestrum. No ONJ relapse. |
Twenty-four patients (mean age 62.5, range 41–80, 12 female) with bone metastases due to breast (11), prostate (4)and lung (4)cancers, myeloma (2), or osteoporosis (3), and with ONJ lesions >2.5 cm previously treated with zoledronic acid, were enroled in the study.
No patient underwent to preventive dental screening before starting BPs infusions. All patients received various cycles of antibiotic therapies after diagnosis of ONJ until the initiation of O 3 treatment without any clinical or radiological evidence of ONJ healing. Two patients underwent hyperbaric oxygen therapy without ONJ healing.
At the time of this investigation, no patient reported spontaneous ONJ healing. Three patients (number 5, 10 and 14) presented with relapsing ONJ after surgical therapy performed to cure ONJ in other hospitals ( Table 2 ).
ONJ was diagnosed by an experienced maxillofacial dentist on the basis of the following criteria: presence of exposed bone in the maxillofacial region with no evidence of healing after six weeks of appropriate dental care [10] and in some cases of CT evaluation.
According to Weitzman classification [43] 15 patients had a single ONJ lesion (4A) and 9 patients had multiple lesions (4B) or a “multifocal” lesion ( Table 2 ).
Six patients interrupted the treatment with O 3 gas application for disease progression (five patients) and for fear of an experimental therapy (one patient). The drop-outs were considered as failure in the Intention to treat (ITT) analysis, and excluded, in the per-protocol (PP) analysis.
No patients reported adverse events during O 3 insufflations and the days after; moreover no objective or subjective symptoms of intolerance to the O 3 gas applications were observed.
In 10 patients with the largest and deeper ONJ lesions, O 3 gas therapy produced the sequestrum of the necrotic bone. Nine patients required more than ten O 3 gas applications due to multiple lesions and/or abundant purulent secretion notwithstanding the concomitant antibiotic therapy. In all these patients surgery was necessary to remove the necrotic bone after sequestrum. Of interest, surgical removal was possible without the resection of healthy mandible edge because of the presence of bone sequestrum. One patient (number 8) received two further insufflations while waiting for the surgery because he had bone sequestrum ready to be removed surgically; however because of sudden disease progression and Performance Status worsening, he was not operated on.
Fig. 2 shows the ONJ lesion before starting O 3 gas insufflations (picture A), the X-ray before the first therapy with O 3 (it is possible to see the extent of necrotic lesion and the involvement of the loop of the mandibular nerve) (B), and the necrotic area post 10 gas insufflations, with the perfect soft tissue tropism, cannot be evaluated in the picture and the mobility of the necrotic area, easily detectable clinically (C).
The perfect condition of the soft tissues allows an extremely conservative treatment, with a perfect mucoperiosteal seal, once the necrotic bone has been removed. This is possible due to the paradoxical effect of ozone, which, being an oxidant, in the cell membranes of complex organisms, triggers a reparatory phase that leads to the healing of mucous tissues that had been overturned by the damage caused by the presence of necrotic tissue and the consequent bacterial and fungal superinfections produced in the lesion site.
Fig. 2 also shows the post-insufflation X-ray (D), where the complete demarcation of the area of necrotic bone and its particular nearness to the emergence of the mandibular nerve can be observed. In this case, the nerve is not at all involved in removal and the patient will not suffer any loss of sensitivity or paraesthesia. The photograph of removal of the necrotic fragment (E) in the operating theatre can also be seen. After the elevation of the mucoperiosteal, vestibular and lingual flaps, the necrotic fragment can be more easily removed using a periosteal elevator, without having to use tools for cutting bone walls. This allows special softness during the procedure, without causing any surgical traumas to the bone treated with bisphosphonates.
During the surgical phase, it is easy to lift the mucoperiosteal tissue, which is completely healthy and free of fibrosis and with excellent cleavage planes, contrary to what one would expect of an area that for months has harboured infections associated with purulent serous secretion (the paradoxical repair effect generated by ozone).
Six patients had complete sequestrum or partial (one patient) spontaneous expulsion of the necrotic bone with oral mucosa re-epithelisation, after 4 to 27 insufflations of O 3 gas.
Fig. 3 shows the patient number 3 before starting O 3 gas insufflations, the necrotic bone removed by a pinch and re-epithelizated area after the O 3 gas therapy. In the area 47 (A), it is possible to observe the infectious inflammatory damage to the soft tissues, despite the fact that the necrotic lesion is slightly infiltrating just below the mucosal margin. Picture (C) shows the mobile necrotic bone removed without anaesthesia during the seventh application, simply using an anatomical forceps in an outpatient setting. Insufflation treatment was performed as usual after removal. Picture (D) shows area 34 immediately after the removal of the necrotic bone in an outpatient setting. It is worth noting that the mucosal surface is completely different from the condition in regard with both colour and continuity. The area does not present any signs of bleeding as experienced in other cases, the mucous membrane has formed again between the healthy bone and the necrotic area, leading to the expulsion of the sequestrum.
No ONJ relapse was observed in any of the 18 patients treated with O 3 gas ± surgery, during a mean of follow-up of 18 months (range 1–3 years). After completion of the treatment, all patients were able to eat normally and prothesic dentures were adapted and re-positioned for those patients who had dentures. The patients restarted the therapy only if their Performance Karnosfsky Status was >70; the dental team visited them every 6 months.
All together, the response rate was 75% (95% CI, 53.3–90.2%) in the ITT analysis, and 100% (95% CI, 81.5–100%) in the per-protocol (PP) analysis.
Discussion
Unfortunately it was not possible to perfom a RCT comparing medical ozone gas therapy in respect to standard therapy because all our 24 patients had been previously treated with various cycles of antibiotic therapies before we could start the therapy with O 3 gas. Moreover the patients needed to wait for a long time ( Table 2 ) the approval of Ministry of Health in using medical O 3 gas with the new indication for the treatment of patients with ONJ related to bisphosphonate treatments.
With the data on the role of preventive measure in reducing the risk of ONJ in patients treated with BPs [1] , [2] , [3] , [4] , [5] , [6] , [7] , [14] , [44] , [45] , [46] and the efficacy and tolerability of ozone gas [51] , [52] , [53] and medical O 3 oil in treating small ONJ lesions [47] , we have another therapeutical option for treating ONJ lesions when they are >2.5 cm.
Our study shows that the topical insufflation of ozone medical gas on ONJ lesion >2.5 cm is able to produce a sequestrum of the necrotic bone with 1. its spontaneous or not traumatic explusion and the healing of the gum mucosa followed by re-epithelization 2. or surgical removal of the necrotic bone and healing of the gum mucosa. This is an effective and original method, in the absence of observable toxicity. Thus medical O 3 gas insufflations appears to be an effective and safe treatment for patients treated with BPs who developed ONJ lesions >2.5 cm.
Three are the most important results of our study and the result produced:
Six patients reached the sequestrum and had a spontaneous expulsion of the necrotic bone in respect to the 10/10 patients with ONJ≤2.5 cm and treated with topical application of an oil suspension enriched with medical O 3 gas [47] ,
when surgical removal of the necrotic bone after sequestrum was necessary, the surgical resection of healthy mandible edge was not necessary because of the presence of the sequestrum,
no ONJ relapse appeared in our patients visited every six months and after a mean follow -up of 18 months (range 1–3 years).
Curiously, two patients with osteoporosis who completed the trial, requested the highest number of O 3 gas insufflations and this fact needs further investigation.
In conclusion, the preliminary results of this study demonstrate that medical O 3 delivered as topical gas insufflation can be considered a promising, effective, safe and simple therapeutic option for the treatment of ONJ lesions>2.5 cm.
Emerging promising therapeutic options such as O 3 gas investigated in this study indicate that ONJ can be treated, allowing patients to recover and heal from this debilitating condition.
These results add to the evidence that cancer patients and clinicians should weigh considerable benefits of BPs toward management of skeletal health as opposed to the possible risks posed by ONJ, an uncommon condition that may be prevented and managed.
These results should be considered as preliminary and further investigations in a larger sample trial are required to validate findings.
Acknowledgements
The authors thank Dr. Roberto Ghiringhelli and Sanipan S.p.A. and also thank Dr. Claudia Bareggi, Dr. Elena Fagnoni, and Dr. Tiziana Campa for their practical and helpful discussion.
Footnotes
The procedures followed in this study were reviewed and approved by the Ethics Committee of National Cancer Institute of Milan and are in accordance with the ethical standards of the Helsinki Declaration (1964, amended in 1975, 1983, 1989, 1996 and 2000) of the World Medical Association.
References
1. Migliorati C.A., Schubert M.M., Peterson D.E., Seneda L.M. Bisphosphonate-associated osteonecrosis of mandibular and maxillary bone: an emerging oral complication of supportive cancer therapy. Cancer. 2005;104(1):83–93. doi: 10.1002/cncr.21130.
2. Badros A., Weikel D., Salama A., Goloubeva O., Schneider A., Rapoport A. Osteonecrosis of the jaw in multiple myeloma patients: clinical features and risk factors. Journal of Clinical Oncology. 2006;24(6):945–952. doi: 10.1200/JCO.2005.04.2465.
3. Bamias A., Kastritis E., Bamia C., Moulopoulos L.A., Melakopoulos I., Bozas G. Osteonecrosis of the jaw in cancer after treatment with bisphosphonates: incidence and risk factors. Journal of Clinical Oncology. 2005;23(34):8580–8587. doi: 10.1200/JCO.2005.02.8670.
4. Wang E.P., Kaban L.B., Strewler G.J., Raje N., Troulis M.J. Incidence of osteonecrosis of the jaw in patients with multiple myeloma and breast or prostate cancer on intravenous bisphosphonate therapy. Journal of Oral and Maxillofacial Surgery. 2007;65(7):1328–1331. doi: 10.1016/j.joms.2007.03.006.
5. Van den Wyngaert T. Osteonecrosis of the jaw (ONJ) might explain the increased oral surgery risk in cancer patients treated with bisphosphonates. Journal of Evidence Based Dental Practice. 2007;7(3):132–135. doi: 10.1016/j.jebdp.2007.05.013.
6. Henry D., von Moos R., Vadhan-Raj S., Hungria V., Spencer A., Hirsh V. A double-blind, randomized study of denosumab versus zoledronic acid for the treatment of bone metastases in patients with advanced cancer (excluding breast and prostate cancer) or multiple myeloma. European Journal of Cancer Supplements. 2009;7(3):12. doi: 10.1200/JCO.2010.31.3304.
7. Stopeck A., Body J.J., Fujiwara Y., Lipton A., Steger G.G., Viniegra M. Denosumab versus zoledronic acid for the treatment of breast cancer patients with bone metastases: results of a randomized phase 3 study. European Journal of Cancer Supplements. 2009;7(3):2–3.
8. Saad F., Brown J.E., Van Poznak C., Ibrahim T., Stemmer S.M., Stopeck A.T. Incidence, risk factors, and outcomes of osteonecrosis of the jaw: integrated analysis from three blinded active-controlled phase III trials in cancer patients with bone metastases. Annals of Oncology. 2012;23:1341–1347. doi: 10.1093/annonc/mdr435.
9. Food and Drug Administration, Risk evaluation and mitigation strategies (REMS) BL 125320 Prolia (denosumab). available at: 〈http://www.fda.gov/downloads/Drugs/DrugSafety/PostmarketDrugSafetyInformationforPatientsandProviders/UCM214883.pdf〉 ; [accesssed 23.09.10].
10. Ruggiero S.L., Dodson T.B., Assael L.A., Landesberg R., Marx R.E., Mehrotra B. American association of oral and maxillofacial surgeons position paper on bisphosphonate-related osteonecrosis of the jaws–2009 update. Journal of Oral and Maxillofacial Surgery. 2009;67(Suppl. 5):2–12. doi: 10.1016/j.joms.2009.01.009.
11. Van den Wyngaert T., Huizing M.T., Fossion E., Vermorken J.B. Bisphosphonates in oncology: rising stars or fallen heroes. Oncologist. 2009;14:181–191. doi: 10.1634/theoncologist.2008-0209.
12. Stopeck A., Body J., Fujiwara Y., Lipton A., Steger G., Viniegra M. Denosumab versus zoledronic acid for the treatment of breast cancer patients with bone metastases: results of a randomized phase 3 study. European Journal of Cancer Supplements. 2009;7:2–3.
13. Fizazi K., Carducci M., Smith M., Damiao R., Brown J., Karsh L. randomized phase III trial of denosumab versus zoledronic acid in patients with bone metastases from castration-resistant prostate cancer. Journal of Clinical Oncology. 2010;28:LCB4507.
14. Ripamonti C.I., Maniezzo M., Campa T., Fagnoni E., Brunelli C., Saibene G. Decreased occurrence of osteonecrosis of the jaw after implementation of dental preventive measures in solid tumour patients with bone metastases treated with bisphosphonates. The experience of the National Cancer Institute of Milan. Annals of Oncology. 2009;20(1):137–145. doi: 10.1093/annonc/mdn526.
15. Tricker N., Dixon R., Garetto L. Cortical Bone Turnover and Mineral Apposition in Dental Bone Mandible. In: Garetto L., Turner C., Duncan R., Burr D., editors. Bridging the Gap Between Dental and Orthopaedic Implants. Indiana University School of Dentistry; Indianapolis: 2002. pp. 226–227.
16. Hoefert S., Schmitz I., Tannapfel A., Eufinger H. Importance of microcracks in etiology of bisphosphonate-related osteonecrosis of the jaw: a possible pathogenetic model of symptomatic and non-symptomatic osteonecrosis of the jaw based on scanning electron microscopy findings. Clinical Oral Investigations. 2010;14:271–284. doi: 10.1007/s00784-009-0300-6.
17. Huja S.S., Fernandez S.A., Hill K.J., Li Y. Remodeling dynamics in the alveolar process in skeletally mature dogs. Anatomical Record A Discoveries in Molecular, Cellular, and Evolutionary Biology. 2006;288:1243–1249. doi: 10.1002/ar.a.20396.
18. Woo S.B., Hellstein J.W., Kalmar J.R. Narrative [corrected]review: bisphosphonates and osteonecrosis of the jaws. Annals of Internal Medicine. 2006;144(10):753–761. doi: 10.7326/0003-4819-144-10-200605160-00009.
19. Barasch A., Cunha-Cruz J., Curro F.A., Hujoel P., Sung A.H., Vena D. Journal of Dental Research. 2011;90(4):439–444. doi: 10.1177/0022034510397196.
20. Vescovi P., Campisi G., Fusco V., Mergoni G., Manfredi M., Merigo E. Surgery-triggered and non surgery-triggered Bisphosphonate-related Osteonecrosis of the Jaws (BRONJ): a retrospective analysis of 567 cases in an Italian multicenter study. Oral Oncology. 2011;47(3):191–194. doi: 10.1016/j.oraloncology.2010.11.007.
21. Coleman R.E. Skeletal complications of malignancy. Cancer. 1997;80(Suppl. 8):1588–1594. doi: 10.1002/(sici)1097-0142(19971015)80:8+<1588::aid-cncr9>3.3.co;2-z.
22. Fulfaro F., Casuccio A., Ticozzi C., Ripamonti C. The role of bisphosphonates in the treatment of painful metastatic bone disease: a review of phase III trials. Pain. 1998;78(3):157–169. doi: 10.1016/S0304-3959(98)00135-3.
23. Body J.J., Diel I.J., Lichinitser M.R., Kreuser E.D., Dornoff W., Gorbunova V.A. Intravenous ibandronate reduces the incidence of skeletal complications in patients with breast cancer and bone metastases. Annals of Oncology. 2003;14(9):1399–1405. doi: 10.1093/annonc/mdg367.
24. Kohno N., Aogi K., Minami H., Nakamura S., Asaga T., Iino Y. Zoledronic acid significantly reduces skeletal complications compared with placebo in Japanese women with bone metastases from breast cancer: a randomized, placebo-controlled trial. Journal of Clinical Oncology. 2005;23(15):3314–3321. doi: 10.1200/JCO.2005.05.116.
25. Lipton A., Theriault R.L., Hortobagyi G.N., Simeone J., Knight R.D., Mellars K. Pamidronate prevents skeletal complications and is effective palliative treatment in women with breast carcinoma and osteolytic bone metastases: long term follow-up of two randomized, placebo-controlled trials. Cancer. 2000;88(5):1082–1090. doi: 10.1002/(sici)1097-0142(20000301)88:5<1082::aid-cncr20>3.0.co;2-z.
26. Lipton A., Zheng M., Seaman J. Zoledronic acid delays the onset of skeletal-related events and progression of skeletal disease in patients with advanced renal cell carcinoma. Cancer. 2003;98(5):962–969. doi: 10.1002/cncr.11571.
27. McCloskey E.V., MacLennan I.C., Drayson M.T., Chapman C., Dunn J., Kanis J.A. A randomized trial of the effect of clodronate on skeletal morbidity in multiple myeloma. MRC working party on Leukaemia in Adults. British Journal of Haematology. 1998;100(2):317–325. doi: 10.1046/j.1365-2141.1998.00567.x.
28. Paterson A.H., Powles T.J., Kanis J.A., McCloskey E., Hanson J., Ashley S. Double-blind controlled trial of oral clodronate in patients with bone metastases from breast cancer. Journal of Clinical Oncology. 1993;11(1):59–65. doi: 10.1200/JCO.1993.11.1.59.
29. Rosen L.S., Gordon D., Tchekmedyian S., Yanagihara R., Hirsh V., Krzakowski M. Zoledronic acid versus placebo in the treatment of skeletal metastases in patients with lung cancer and other solid tumors: a phase III, double-blind, randomized trial—the zoledronic acid lung cancer and other solid tumors study group. Journal of Clinical Oncology. 2003;21(16):3150–3157. doi: 10.1200/JCO.2003.04.105.
30. Saad F., Gleason D.M., Murray R., Tchekmedyian S., Venner P., Lacombe L. Long-term efficacy of zoledronic acid for the prevention of skeletal complications in patients with metastatic hormone-refractory prostate cancer. Journal of National Cancer Institute. 2004;96(11):879–882. doi: 10.1093/jnci/djh141.
31. Rosen L.S., Gordon D., Kaminski M., Howell A., Belch A., Mackey J. Long-term efficacy and safety of zoledronic acid compared with pamidronate disodium in the treatment of skeletal complications in patients with advanced multiple myeloma or breast carcinoma: a randomized, double-blind, multicenter, comparative trial. Cancer. 2003;98(8):1735–1744. doi: 10.1002/cncr.11701.
32. Saarto T., Blomqvist C., Valimaki M., Makela P., Sarna S., Elomaa I. Clodronate improves bone mineral density in post-menopausal breast cancer patients treated with adjuvant antioestrogens. British Journal of Cancer. 1997;75(4):602–605. doi: 10.1038/bjc.1997.105.
33. Berenson J.R., Hillner B.E., Kyle R.A., Anderson K., Lipton A., Yee G.C. American Society of Clinical Oncology clinical practice guidelines: the role of bisphosphonates in multiple myeloma. Journal of Clinical Oncology. 2002;20(17):3719–3736. doi: 10.1200/JCO.2002.06.037.
34. Van Poznak C.H. American society of clinical oncology executive summary of the clinical practice guideline update on the role of bone-modifying agents in metastatic breast cancer. Journal of Clinical Oncology. 2011;29(9):1221–1227. doi: 10.1200/JCO.2010.32.5209.
35. Kyle R.A., Yee G.C., Somerfield M.R., Flynn P.J., Halabi S., Jagannath S. American society of clinical oncology 2007 clinical practice guideline update on the role of bisphosphonates in multiple myeloma. Journal of Clinical Oncology. 2007;25(17):2464–2472. doi: 10.1200/JCO.2007.12.1269.
36. Terpos E., Sezer O., Croucher P.I., Garcia-Sanz R., Boccadoro M., San Miguel J. The use of bisphosphonates in multiple myeloma: recommendations of an expert panel on behalf of the European myeloma network. Annals of Oncology. 2009;20(8):1303–1317. doi: 10.1093/annonc/mdn796.
37. De Marinis F., Eberhardt W., Harper P.G., Sureda B.M., Nackaerts K., Soerensen J.B. Bisphosphonate use in patients with lung cancer and bone metastases: recommendations of a European expert panel. Journal of Thoracic Oncology. 2009;4(10):1280–1288. doi: 10.1097/JTO.0b013e3181b68e5a.
38. Aapro M., Abrahamsson P.A., Body J.J., Coleman R.E., Colomer R., Costa L. Guidance on the use of bisphosphonates in solid tumours: recommendations of an international expert panel. Annals of Oncology. 2008;19(3):420–432. doi: 10.1093/annonc/mdm442.
39. Body J.J., Coleman R., Clezardin P., Ripamonti C., Rizzoli R., Aapro M. International society of geriatric oncology (SIOG) clinical practice recommendations for the use of bisphosphonates in elderly patients. European Journal of Cancer. 2007;43(5):852–858. doi: 10.1016/j.ejca.2006.12.006.
40. Damato K, Gralow J, Hoff A, Huryn J, Ruggiero S, Schubert M, Toth B, Valero V. Expert panel recommendations for the prevention, diagnosis, and treatment of osteonecrosis of the jaws. LDA Journal. 2005;64(3):21–4.
41. American Association of Oral and Maxillofacial Surgeons Position paper on bisphosphonate-related osteonecrosis of the jaws. Journal of Oral and Maxillofacial Surgery. 2007;65(3):369–376. doi: 10.1016/j.joms.2006.11.003.
42. Ruggiero S., Gralow J., Marx R.E., Hoff A.O., Schubert M.M., Huryn J.M. Practical guidelines for the prevention, diagnosis, and treatment of osteonecrosis of the jaw in patients with cancer. Journal of Oncology Practice. 2006;2(1):7–14. doi: 10.1200/jop.2006.2.1.7.
43. Weitzman R., Sauter N., Eriksen E.F., Tarassoff P.G., Lacerna L.V., Dias R. Critical review: updated recommendations for the prevention, diagnosis, and treatment of osteonecrosis of the jaw in cancer patients–May 2006. Critical Reviews in Oncology Hematology. 2007;62(2):148–152. doi: 10.1016/j.critrevonc.2006.12.005.
44. American Association of Oral and Maxillofacial Surgeons. Position paper on bisphosphonate-related osteonecrosis of the jaw–2009 update. 〈http://www.aaoms.org/docs/position_papers/bronj_update.pdf〉 . [accessed 14.06.10].
45. Montefusco V., Gay F., Spina F., Ambrosini M.T., Maniezzo M., Farina L. Antibiotic prophylaxis before dental procedures can reduce onj incidence. Blood (ASH Annual Meeting Abstracts) 2007;110(11):3613.
46. Dimopoulos M.A., Kastritis E., Bamia C., Melakopoulos I., Gika D., Roussou M. Reduction of osteonecrosis of the jaw (ONJ) after implementation of preventive measures in patients with multiple myeloma treated with zoledronic acid. Annals of Oncology. 2009;20(1):117–120. doi: 10.1093/annonc/mdn554.
47. Ripamonti C.I., Cislaghi E., Mariani L., Maniezzo M. Efficay and safety of medical ozone (O3) delivered in oil suspension applications for the treatment of osteonecrosis of the jaw in patients with bone metastases treated with bisphosphonates. Preliminary results of a phase I–II study. Oral Oncology. 2011;47:185–190. doi: 10.1016/j.oraloncology.2011.01.002.
48. Bocci V. Ozone as Janus: this controversial gas can be either toxic or medically useful. Mediators of Inflammation. 2004;13(1):3–11. doi: 10.1080/0962935062000197083.
49. Grigor'ian A.S., Grigor'iants L.A., Guchetl M.N. [Experimental–morphological study of the anti-inflammatory action of ozone-perfluorane complex application] Stomatologiia (Mosk) 2008;87(2):4–9.
50. Agrillo A., Petrucci M.T., Tedaldi M., Mustazza M.C., Marino S.M., Gallucci C. New therapeutic protocol in the treatment of avascular necrosis of the jaws. Journal of Craniofacial Surgery. 2006;17(6):1080–1083. doi: 10.1097/01.scs.0000249350.59096.d0.
51. Agrillo A., Sassano P., Rinna C., Priore P., Iannetti G. Ozone therapy in extractive surgery on patients treated with bisphosphonates. Journal of Craniofacial Surgery. 2007;18(5):1068–1070. doi: 10.1097/SCS.0b013e3181572609.
52. Agrillo A., Ungari C., Filiaci F., Priore P., Iannetti G. Ozone therapy in the treatment of avascular bisphosphonate-related jaw osteonecrosis. Journal of Craniofacial Surgery. 2007;18(5):1071–1075. doi: 10.1097/scs.0b013e31857261f.
53. Petrucci M.T., Gallucci C., Agrillo A., Mustazza M.C., Foa R. Role of ozone therapy in the treatment of osteonecrosis of the jaws in multiple myeloma patients. Haematologica. 2007;92(9):1289–1290. doi: 10.3324/haematol.11096.
54. Simon R. Optimal two-stage designs for phase II clinical trials. Controlled Clinical Trials. 1989;10(1):1–10. doi: 10.1016/0197-2456(89)90015-9.