Surgical approach with Er:YAG laser on osteonecrosis of the jaws (ONJ) in patients under bisphosphonate therapy (BPT)

Osteonecrosis of the jaw (ONJ) in patients on long-term bisphosphonate Therapy (BPT) has been reported with increasing frequency in literature over the past 4 years. Therapy for this condition is still a dilemma. Temporary suspension of BPT offers no short-term benefits; hyperbaric oxygen has no proven efficacy and therefore is not recommended. Intermittent or continuous antibiotic therapy with surgical debridement can be beneficial to palliate the symptoms. Er:YAG laser can be used to eliminate necrotic bone portions by partial or total resection as an alternative to conventional rotary devices. In our study, 91 patients affected by ONJ-BP lesion, for a total of 115 ONJ sites were observed between January 2004 and May 2008 (Department of Odontostomatology, University of Parma). Fifty-five ONJ sites were considered for this study in four different groups, retrospectively identified on the basis of treatment performed (G1–G4). G1: 13 ONJ-BP sites were treated with medical therapy (amoxicillin 1gr x 3/die per os with metronidazole 250 mg x 2/die per os) for at least 2 weeks; G2: 17 ONJ-BP sites received medical treatment in association with cycles of low-level laser therapy (LLLT) applications performed using an Nd:YAG laser (1,064 nm) once a week for 2 months; G3: 13 ONJ-BP sites were surgically treated (sequestrectomy of necrotic bone, debridement, corticotomy/surgical removal of alveolar and/or cortical bone); G4: 12 ONJ-BP sites were treated with surgical therapy performed using an Er:YAG laser (2,940 nm) in association with LLLT. Clinical success has been defined for each treatment performed as: (a) complete mucosal healing free from signs and symptoms (classified as stage “0”) or (b) transition from a higher to a lower stage (Ruggiero staging) for at least 3 months. All the ONJ-BP sites treated with Er:YAG laser (G4 group) had a clinical improvement (100%) and 87.5% of sites had a complete mucosal healing with a mean follow-up of 13 months. The result obtained in the G4 is extremely significant in comparison with those obtained by medical treatment alone or in a traditional surgical approach. Thanks to the high degree of affinity of this wavelength for water and hydroxyapatite, both soft and bone tissues can be easily treated. This technique can also be used for conservative operations whereby necrotic bone is vaporized until healthy bone is reached. In addition, an additional advantage of the Er:YAG laser is its bactericidal and possible biostimulatory action, accelerating the healing of both soft tissues and bone tissues, in comparison to conventional treatments. In conclusion, from our experience, it is possible to observe that an early conservative surgical approach with Er:YAG laser associated with LLLT, for BP-induced ONJ could be considered as more efficient in comparison with medical therapy or other conventional techniques.