LETTERS TO THE EDITOR
J Oral Maxillofac Surg 73:797-801, 2015
MEDICATION-RELATED OSTEONECROSIS OF
THE JAWS, STAGE 0—DOWE NEED STAGE 0
To the Editor:—As more is learned about medication-related vation, and, possibly, surgical intervention. No difference likely exists in the current management between stage 3 MRONJ with and without exposed bone. 2. Fedele S, Porter SR, D’Aiuto F, et al: Nonexposed variant of bisphosphonate-associated osteonecrosis of the jaw: A case the jaw requires computed tomography for accurate definition of the extent of bony disease. Br J Oral Maxillofac Surg 52:603, 2014 repair contains valuable information about a challenging 1 often be able to regain useful sensory function after micro2 ticle icatio ally v 0 wo photograph may accompany the letter if it is essential to understanding the subject. Letters should not duplicate similar material or material published elsewhere. There is no guarantee that any letter will be published. Prepublication proofs797issue or edition of the journal, in any form or medium. will not be provided. Submitting a Letter to the Editor constitutes the author’s permission for its publication in anyosteonecrosis of the jaws (MRONJ) and its etiopathogenesis, diagnosis, and efficacious treatment, the American Academy of Oral and Maxillofacial Surgery (AAOMS) has updated its position papers, with the current 2014 report being the third. The AAOMS staging system is the most widely used in the United States and, possibly, worldwide. A staging system that is simple and meaningful and that has clinical and management significance is essential for research, conducting clinical trials, and comparing treatment outcomes among institutions.
In 2009, we had suggested the terms ‘‘stage 0sa’’ (suspicious asymptomatic) and ‘‘stage 0ss’’ (suspicious symptomatic), recognizing that exposure of bone is a late process.1
Patientswith stage 0sawere treatedwith antimicrobial rinses and observation, similar to the treatment of the current stage 1. Similarly, patients with stage 0ss were treated with antibiotics and antimicrobial rinses, similar to the treatment of the current stage 2. Later that year, the AAOMS recognized stage 0 as a form of MRONJ, in which the bone has not become exposed, but inwhich the clinical features are highly suggestive of evolving MRONJ. Since then, many other reports have shown that the so-called nonexposed form of
MRONJ might represent 13 to 20% of all cases of MRONJ.2,3
Furthermore, Schiodt et al4 has shown that stage 0 or ‘‘nonexposed’’ MRONJ constituted 13%, 12%, and 23% of stage 1, 2, and 3 MRONJ, respectively. In the current position paper, stages 1 and 2 already include nonexposed MRONJ cases with fistulas that probe to the bone, although this finding could be equivocal in some situations. As such, it might be useful to remove Stage 0 entirely and maintain only stages 1, 2, and 3 only, similar towhat Schiodt et al4 suggested, as follows:
Stage 1 Asymptomatic, with either exposed (stage 1E) or nonexposed (stage 1NE) bone; treatment should be antimicromibial rinses and observation. No difference is present in the current management between asymptomatic MRONJ with and without exposed bone.
Stage 2 Pain and infection with either exposed (stage 2E) or nonexposed (stage 2NE) bone; treatment should be antimicrobial rinses, antibiotics, and observation. No difference is present in the current management between symptomatic MRONJ with and without exposed bone.
Stage 3 More extensive involvement, with pain and infection present, and with either exposed (stage 3E) or nonexposed (stage 3NE) bone; treatment should be antimicrobial rinses, antibiotics, obserLetters to the Editor must be in reference to a specific ar must be submitted within 6 weeks of the article’s print publ first appeared online. Letters must be submitted electronic joms. Letters are subject to editing and those exceeding 50neurosurgical repair. However, those patients whose major complaint is pain, rather than numbness, might obtain little or no relief of their pain after surgical intervention. That such treatment for NP is often unsuccessful should redirect the clinician’s efforts to ascertain which patients with NP will most likely benefit from surgical intervention and which or editorial that has been published by the Journal. Letters n or, for an online-only article, within 8 weeks of the date it ia the Elsevier Editorial System at http://ees.elsevier.com/ rds may be shortened or not accepted due to length. Oneclinical problem. Patients who develop persistent significant sensory dysfunction after a PTN injury often seek surgical treatment to improve sensation in the affected area.
Those patients who complain primarily of numbness will4. Schiodt M, Reibel J, Oturai P, et al: Comparison of nonexposed and exposed bisphosphonate-induced osteonecrosis of the jaws: A retrospective analysis from the Copenhagen cohort and a proposal for an updated classification system. Oral Surg Oral
Med Oral Pathol Oral Radiol 117:204, 2014 http://dx.doi.org/10.1016/j.joms.2014.12.028
NEUROPATHIC PAIN AFTER PERIPHERALTRIGEMINAL
NERVE MICROSURGICAL REPAIR
To the Editor:—The recent report about neuropathic pain (NP) after peripheral trigeminal nerve (PTN) injury andseries. Am J Med 123:1060, 2010 3. Bedogni A, Fedele S, Bedogni G, et al: Staging of osteonecrosis ofIncorporating stage 0 or ‘‘nonexposed’’ MRONJ into the expanded stages 1, 2, and 3 will simplify the staging system and ultimately will simplify the approach to management.
S.-B. Woo was supported by a grant from Novartis Pharmaceutical (IP50 CA10070-01) in 2006–2007.
HANI MAWARDI, BDS, DMSC
SOOK-BIN WOO, DMD, MMSC
References 1. Mawardi H, Treister N, Richardson P, et al: Sinus tracts—An early sign of bisphosphonate-associated osteonecrosis of the jaws?
J Oral Maxillofac Surg 67:593, 2009 patients will be better treated by nonoperative therapy. It should also temper the surgeon’s enthusiasm for surgery post-PTN injury NP for surgical intervention, not mentioned by Zuniga et al,1 is the patient’s response to a local anesthetic