Response to the letter to the editor: Osteonecrosis of the jaws in patients under osteoporosis treatment: nine-year experience report

DEAR EDITORS AND COLLEAGUES,

We would like to thank Dr. Efsun Somay for the comments concerning our study (¹), which will permit us to clarify some critical points.

Regarding the first comment, "Penoni and cols. did not provide the window period between implant placement and prosthetic loading", we agree that prosthetic loading constitutes an integral aspect of implant therapy. The time required to start the prosthetic loading depends on the surgical technique chosen, which can be immediate implantation, early implantation, or late implantation. This decision is related to the type of implant used, factors inherent to the patient, and the work philosophy of each implant dentistry service, among others (²). Although a good prognosis can be obtained following immediate/early functional or non-functional loading of immediately placed implants, a higher risk of failures seems to exist compared with a delayed, conventional approach (³). In order to provide an estimated window period between implant placement and prosthetic loading in our dental center, we obtained a random sample of 99 placed implants over the 9-year study period using a computer random number generator. A random number table was created using alpha-numeric codes to select 11 patients per year. Of these sample, 75 (75.8%) received late loading (after a complete socket healing); 14 (14.1%) received early loading (after soft tissue healing), and only 10 (10.1%) immediate loading. The late loading is the approach adopted for the majority of our patients. Concerning MRONJ, as properly mentioned in the letter, Escobedo and cols. have stated that using antiresorptive drugs may cause osteonecrosis with implants subjected to functional loading at a higher frequency than after implant placement surgery. After the surgical procedure, peri-implant health over time is essential to prevent MRONJ since the presence and persistence of peri-implant inflammation could trigger it. Based on this knowledge, prostheses and peri-implant health control and maintenance are scheduled regularly in our dental center. This approach, plus the late loading in the great majority of the placed implants, may have contributed to preventing MRONJ over these years.

Regarding the second comment, "the absence of information regarding the duration of antiresorptive drug usage among patients, despite being acknowledged as a limitation of the study, may compromise the accuracy of assessing the impact of antiresorptive use on the incidence of MRONJ." We have already recognized this as a limitation of the study, but some efforts were made to add more information on the duration of antiresorptive drug usage, at least to bring an estimated period. We report data from two studies performed in our dental center during the 9-year period of the present one. These studies involved women with osteoporosis. One revealed a mean period under antiresorptive medication of 4.43 ± 2.72 years in the sample involved (⁴). The other, a prospective 5-year study recently published, has shown that, among 48 women with osteoporosis, 64.6% were using antiresorptive drugs for more than three years (⁵). We consider it adequate assuming that a greater part of the procedures performed in the dental center over this 9-year study was in patients who used bone medication for more than four years. So, the higher risk of developing MRONJ for patients who have used bisphosphonates for more than four years has not been absent from the present study.

• Funding: none.

REFERENCES

• ¹
  Penoni DC, Canellas JVS, Silami MANC, Sader F, Pimentel GS Neto, Leão ATT. Osteonecrosis of the jaws in patients under osteoporosis treatment: a nine-year experience report. Arch Endocrinol Metab. 2023 May 12;67(4):e000612. doi: 10.20945/2359-3997000000612.
  » https://doi.org/10.20945/2359-3997000000612
• ²
  Gallucci GO, Hamilton A, Zhou W, Buser D, Chen S. Implant placement and loading protocols in partially edentulous patients: A systematic review. Clin Oral Implants Res. 2018 Oct;29 Suppl 16:106-34. doi: 10.1111/clr.13276.
  » https://doi.org/10.1111/clr.13276
• ³
  Schropp L, Isidor F. Timing of implant placement relative to tooth extraction. J Oral Rehabil. 2008 Jan;35 Suppl 1:33-43. doi: 10.1111/j.1365-2842.2007.01827.x.
  » https://doi.org/10.1111/j.1365-2842.2007.01827.x
• ⁴
  Penoni DC, Vettore MV, Torres SR, Farias MLF, Leão ATT. An investigation of the bidirectional link between osteoporosis and periodontitis. Arch Osteoporos. 2019 Aug 23;14(1):94. doi: 10.1007/s11657-019-0643-9.
  » https://doi.org/10.1007/s11657-019-0643-9
• ⁵
  Penoni DC, Torres SR, Oliveira ML, Farias MLF, Vettore MV, Leão ATT. Untreated osteoporosis and higher FRAX as risk factors for tooth loss: a 5-year prospective study. J Bone Miner Metab. 2023 Sep;41(5):727-37. doi: 10.1007/s00774-023-01451-w.
  » https://doi.org/10.1007/s00774-023-01451-w

Publication Dates

• Publication in this collection
  07 June 2024
• Date of issue
  2024

History

• Received
  01 July 2023
• Accepted
  01 Aug 2023