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Incidence of Osteonecrosis of the Jaw in Japanese Osteoporosis Patients Taking Minodronic Acid

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Incidence of Osteonecrosis of the Jaw in Japanese Osteoporosis Patients Taking Minodronic Acid Journal of Bone and Mineral Metabolism (2019) 37:886–892 https://doi.org/10.1007/s00774-019-00990-5 ORIGINAL ARTICLE Incidence of osteonecrosis of the jaw in Japanese osteoporosis patients taking minodronic acid Akira Taguchi1,10 · Yukari Uemura2 · Takumi Imai3 · Shiro Tanaka3 · Hiroaki Ohta4 · Toshitaka Nakamura5 · Hajime Orimo6 · Toshitsugu Sugimoto7 · Satoshi Soen8 · Masataka Shiraki9 · Adequate Treatment of Osteoporosis (A-TOP) research group Received: 8 December 2018 / Accepted: 21 January 2019 / Published online: 4 February 2019 © Springer Japan KK, part of Springer Nature 2019 Abstract Osteonecrosis of the jaw (ONJ) associated with bisphosphonate therapy is a rare but severe side efect in osteoporosis patients. Recently, the number of osteoporosis patients with ONJ has dramatically increased in Japan. This has contributed to an increase in the number of patients avoiding extractions. However, there has been no prospective study providing defni- tive incidence data for ONJ in Japanese patients. The purpose of this study was to elucidate the true as well as suspected incidence of ONJ. A total of 3229 subjects (1612 subjects in the minodronic acid group and 1617 subjects in the raloxifene group) in the Japanese Osteoporosis Intervention Trial protocol number 4 participated in this study. ONJ was diagnosed by experienced dentists. Suspected Stage 0 and 1 (bone exposure of the jaw) ONJ was assessed by a structured questionnaire at baseline and at 6, 12, 18, and 24 months. No established ONJ cases were diagnosed during the study. The incidence of suspected Stage 0 and/or Stage 1 ONJ was 6.14 per 1000 patient-years in the minodronic acid group and 3.38 per 1000 patient-years in the raloxifene group [hazard ratio (95% confdence interval) = 1.82 (0.84–3.93), P = 0.13]. Approximately 50–60% of bone exposures that appeared during the study had disappeared at the next observation. Although the subjects in this study may have developed a greater interest in the health of the oral cavity, the incidence of ONJ after minodronic acid treatment would be lower than the expected incident rate. Keywords Osteonecrosis · Jaw · Osteoporosis · Antiresorptives · Bone exposure * Akira Taguchi 6 Japan Osteoporosis Foundation, 2-14 Odenma-cho, [email protected] Nihonbashi, Kobune-cho, Chuo-ku, Tokyo 103-0011, Japan 7 Internal Medicine 1, Shimane University Faculty 1 Department of Oral and Maxillofacial Radiology, School of Medicine, 89-1 Enya-cho, Izumo, Shimane 693-8501, of Dentistry, Matsumoto Dental University, 1780 Hirooka Japan Gobara, Shiojiri, Nagano 399-0781, Japan 8 Department of Orthopaedic Surgery and Rheumatology, 2 Biostatistics Division, Central Coordinating Unit, Clinical Kindai University Nara Hospital, 1248-1 Otoda-cho, Ikoma, Research Support Center, The University of Tokyo Hospital, Nara 630-0293, Japan 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-0033, Japan 9 Department of Internal Medicine, Research Institute 3 Department of Clinical Biostatistics/Clinical Biostatistics and Practice for Involutional Diseases, 1610-1 Meisei, Course, Graduate School of Medicine, Kyoto University, Misato, Azumino, Nagano 399-8101, Japan Yoshida Konoe-cho, Sakyo-ku, Kyoto 606-8501, Japan 10 Department of Hard Tissue Research, Graduate School 4 Clinical Medical Research Center, International University of Oral Medicine, Matsumoto Dental University, 1780 of Health and Welfare, Women’s Medical Center, Gobara, Hirooka, Shiojiri, Nagano 399-0781, Japan Sanno Medical Center, 8-5-35 Akasaka, Minato-ku, Tokyo 107-0052, Japan 5 Touto Sangenjaya Rehabilitation Hospital, 1-24-3 Sangenjaya, Setagaya-ku, Tokyo 154-0024, Japan Vol:.(1234567890)1 3 Journal of Bone and Mineral Metabolism (2019) 37:886–892 887 Introduction position paper [11]; however, the international ONJ task- force has expressed concern that the Stage 0 classifcation In 2003, Marx frst presented a new adverse event, avas- may lead to over-diagnosis of ONJ [3]. Over-diagnosis of cular necrosis of the jaws, in oncology patients who had ONJ could lead to detrimental efects in patients’ skel- taken high-dose intravenous bisphosphonates (BPs) [1]. etal health, especially if it results in discontinuation of BP The following year, Ruggiero et al. found this adverse medication. To date, the incidence of suspected Stage 0 event in osteoporosis patients who had a history of chronic ONJ remains unknown in patients on BP therapy. A lack of low-dose BP therapy, and named this condition osteone- precise information regarding the incidence of true as well crosis of the jaw (ONJ) associated with the use of BP [2]. as suspected ONJ may contribute to increased controversy Subsequently, many studies about bisphosphonate-related and reduced cooperation between physicians and dentists, ONJ (BRONJ) have been published in both basic and clini- as well as an increased number of patients refusing to cal felds to elucidate the pathogenesis of BRONJ. How- undergo tooth extractions and to continue BP therapy [10]. ever, the defnitive pathogenesis of BRONJ is still debated Minodronic acid, a Japanese-made bisphosphonate, and [3]. This has been a serious limitation in the treatment raloxifene, a member of the class of selective estrogen recep- of osteoporosis. Because it has been reported that osteo- tor modulators (SERMs), have demonstrated their efcacy porosis patients who take BPs and who undergo surgical in fracture prevention [12, 13]. With regard to inhibition dental procedures such as tooth extraction are at high risk of bone resorption, minodronic acid is 10–100 times more of developing BRONJ [4], there is widespread confusion efective than alendronic acid. A recent review revealed that regarding BRONJ among physicians, dentists, and osteo- the proportion of minodronic acid users was similar to that porosis patients throughout Japan. Dentists in Japan have of alendronate in Japan [14]. Both medications are classifed become reluctant to provide dental treatment for osteo- as anti-bone-resorbing agents, although ONJ was observed porosis patients under BP treatment. In addition to these in osteoporosis patients on BP therapy, but not those on concerns about BPs, recent reports have proposed that a SERM therapy in Japan. The purpose of this study was to RANKL inhibitor, denosumab (Dmab), may also be asso- elucidate the incidence of true as well as suspected ONJ in ciated with an increased incidence of ONJ [5]. osteoporosis patients on BP therapy in a Japanese multi- A Japanese position paper regarding BRONJ was frst center, open-label, randomized controlled, head-to-head trial released by the Japanese Society for Bone and Mineral comparing minodronic acid and raloxifene in osteoporosis Research (JSBMR) in 2010 [6]. A minor revised version patients. in 2012 added a fow diagram for the discontinuation of BP at the time of minor oral surgery such as extrac- tions. These position papers were developed according to Materials and methods those released by the American Association of Oral and Maxillofacial Surgeons (AAOMS) in 2009 [7]. However, Study protocol and participants despite a reduction in the use of BPs in Japan, the number of patients with BRONJ increased markedly after 2009 [8, The Japanese Osteoporosis Intervention Trial protocol 9]. This caused concern for dentists and for osteoporosis number 4 (JOINT-04 trial) is a multi-center, open-label, patients who had been prescribed BPs and contributed to randomized controlled trial in Japan; it is registered at the a reluctance to extract teeth without drug discontinuation University Hospital Medical Information Network—Clini- in osteoporosis patients [10]. The practice of discontinu- cal Trials Registry (UMIN-CTR) under trial identifcation ation of BP before tooth extraction has produced discord number UMIN000005433. The protocol was approved by between physicians and dentists in Japan [10]. the Central Ethical Committee for the Adequate Treatment The incidence of BRONJ in patients undergoing treat- of Osteoporosis (A-TOP) group (Dr. Rikushi Morita, Chair- ment for osteoporosis ranges from 0 to 90 per 100,000 man) and was reviewed by the institutional review board patient-years worldwide [3]. However, because there has of each participating institution. The trial was conducted been no prospective study regarding the incidence of in accordance with the Declaration of Helsinki. Written BRONJ in Japan, the true incidence of BRONJ in Japan informed consent was obtained prior to patient enrollment remains unknown. Bone exposure/necrosis is not always after a thorough explanation of the trial objectives, duration induced by BPs. Bone exposure may occur in the absence (2 years), and procedures. Study design, eligibility criteria, of BP therapy, with attendant oral ulceration and bone assessment of clinical data, and sample size calculations sequestration (OUBS) [3]. Furthermore, Stage 0 ONJ, in were described in our recent report [15]. The primary end- which there is no bone exposure, was added in a Japanese points of JOINT-04 are osteoporotic (vertebral, humeral, position paper revised in 2016 according to the AAOMS femoral, and radial), vertebral, and major osteoporotic (clinical vertebral, humeral, femoral, and radial) fractures. 1 3 888 Journal of Bone and Mineral Metabolism (2019) 37:886–892 In addition to the primary endpoint, dental health was fol- survey was 70.3%, the estimated incidence of BRONJ would lowed as one of the secondary endpoints [15]. A total of be as high as 57–71 per 100,000 patient-years if the response 3229 subjects (1612 subjects in the minodronic
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