Nd:YAG laser biostimulation of bisphosphonate-associated necrosis of the jawbone with and without surgical treatment
Introduction
Necrosis of the jaw has recently been described in association with treatment with several bisphosphonates including zoledronic acid, and pamidronate since it was first described in 2003. There have been nearly 400 cases documented of bisphosphonate-associated osteonecrosis,1, 2 and its treatment is a challenge for oral and maxillofacial surgeons, dentists, oral pathologists, and oncologists. Some studies have tried to explain the pathogenetic mechanism by which this atypical osteonecrosis develops, but the results are still controversial. The roles of factors such as trauma induced by dental extractions or operations, damage to the peripheral vascular system, metabolism of bisphosphonates within the jaws, and infections by microbial pathogens are still poorly understood.3
The effects of laser on the nutrition of skin and mucosa, both in vivo and in vitro, have been reported by several authors and these observations may support the possible use of laser biostimulation in the treatment of bisphosphonate-associated osteonecrosis of the jaws. The wavelengths used to biostimulate the bone are argon,4 carbon dioxide,5 helium/neon (He:Ne),6 diode,7, 8, 9, and Neodimium: yttrium–aluminium–garnet (Nd:YAG).10
The effect of the laser on the speed of the reparative process, on the increase in the inorganic matrix of bone, and on the mitotic osteoblastic index could be appreciable.
We describe our experience with 19 patients with bisphosphonate-associated osteonecrosis of the jaws who were treated with conventional surgical or medical treatment alone or in combination with Nd:YAG laser applications. Clinical variables such as symptoms, presence of pus, and closure of mucosal flaps before and after treatment, were evaluated to establish its usefulness.
Section snippets
Patients and methods
Between January 2004 and February 2006, 19 patients with bisphosphonate-induced osteonecrosis were treated at the Unit of Oral Medicine of the University of Parma. The follow-up ended in June 2006.
Patients were classified into four groups according to treatment: patients treated only medically (antibiotics with or without antimycotics, or antiseptic rinses, or both); patients treated medically and surgically (sequestrectomy and bone curettage); patients treated medically and with laser; and
Results
We studied 19 patients with various conditions, signs, and symptoms (Table 1). The results are summarised in Table 2.
Fig. 1, Fig. 2 show the preoperative and postoperative picture of a patient treated medically and with laser biostimulation, and Fig. 3, Fig. 4, Fig. 5, Fig. 6 show the progress of a patient treated surgically and with laser. Oral lesions healed completely in only one of three patients treated only medically, and in both patients treated with antibiotics and laser biostimulation.
Discussion
Controversies still remain about biostimulation of tissue induced by laser irradiation. A lack of uniform reporting of physical and biological variables such as type of laser, output power, frequency of light pulse, fluence, time of application, distance of source from the irradiated tissue, and histological differences between treated tissues, makes summarising the results extremely difficult. Molecular factors such as light absorption by mitochondrial enzymes, cytochromes, flavins, and
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