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Antimicrobian Photodynamic Therapy in Medication-Related Osteonecrosis

of the Jaws

Article in The Journal of craniofacial surgery · August 2022

DOI: 10.1097/SCS.0000000000008887

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Mirela Caroline Silva Stéfany Barbosa

São Paulo State University São Paulo State University
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Anderson Maikon de Souza Santos Daniela Atili Brandini

São Paulo State University São Paulo State University
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 LETTER TO THE EDITOR

no history of head and neck radiotherapy.1–4 These drugs act by

Antimicrobian Photodynamic
Therapy in Medication-Related
Osteonecrosis of the Jaws
To the Editor:
Medication-induced osteonecrosis of the jaw (MRONJ) is a
bone disorder defined by the American Association of Oral and
Maxillofacial Surgeons (AAOMS) as the presence of exposed
bone tissue in the maxillofacial region for a period of more than 8
weeks in patients undergoing therapies using antiresorptives and
decreasing the activity of osteoclasts, preventing bone remodel-
ing, in addition to interfering with the blood supply, which leads
to avascular necrosis of bone tissue.2,5,6 The mucosal tissue also
has difficult healing in the presence of these drugs, due to their
intervention in the migration of fibroblasts, and bone coverage is
not always successful, generating exposures and facilitating sec-
ondary infections. Due to this, and because it does not present a
fully clarified pathogenesis, there is a difficulty in the treatment of
MRONJ and even in the association of therapies.7 A 62-year-old
female patient presented bone exposure in a small area of the
anterior maxilla and 3 larger exposures in the mandible with a
small amount of purulent drainage (stage II of Osteonecrosis)

FIGURE 1. A, Initial clinical appearance in the mandible, showing exposed necrotic bone tissue covering the anterior and posterior regions. B, Initial clinical
appearance of a small area of necrotic bone tissue exposed in the maxilla, located more to the right side. C, Preoperative computed tomography of the mandible
showing the position of the mandibular canal and the inferior alveolar nerve in relation to the region of the alveolar process and bone sequestration detached from
the basal bone.

The authors report no conflicts of interest.

Address correspondence and reprint requests to Mirela C. Silva, MSc, Avenida Joaquim Pompeu de Toledo, Araçatuba (SP) 1777, Brasil;
E-mail: mirela_carol12@hotmail.com

The Journal of Craniofacial Surgery  Volume 00, Number 00, ’’ 2022 1

Copyright © 2022 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
Correspondence The Journal of Craniofacial Surgery  Volume 00, Number 00, ’’ 2022

FIGURE 2. A, Removal of bone sequestration from the mandible. B, Application of blue light with a wavelength between 400 and 460 nm to differentiate necrotic bone
tissue and vital bone, it is noted that the region of necrotic bone tissue is darker. C, Removal of necrotic bone tissue using piezosurgical. D, Application of methylene blue as
a photosensitizing substance in the surgical area. E, Application of low-power laser using red light. F, Application of low-power laser using infrared light.

(Fig. 1). The patient reported having osteoporosis and using Nicotine causes a condition of hypoxia in tissues in the healing
alendronate sodium for 3 years denied other systemic changes but process, which further aggravates the healing process when
reported being a smoker with more than 20 cigarettes per day. associated with bisphosphonates. Preoperative tomography

FIGURE 3. A and B, Clinical appearance at 3 weeks postoperatively showing bone tissue covered by soft tissue, with no signs of infection and dehiscence. C and D,
Clinical aspect of 1-year postoperatively showing intact, normocolored mucous membranes, with absence of bone tissue exposure and symptoms.

2 Copyright © 2022 by Mutaz B. Habal, MD

Copyright © 2022 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
The Journal of Craniofacial Surgery  Volume 00, Number 00, ’’ 2022
showed areas of bone tissue with basal cortical detachment
bilaterally in the mandible. Also preoperatively, Doxycycline
(100 mg, 1× a day) was administered for 10 days, with the aim of
stimulating bone fluorescence and improving the visualization of
areas of vital bone and thus identifying the remaining areas of
bone necrosis, to remove them precisely. The bone sequestration
was removed and, with the aid of an ultraviolet light with a
wavelength between 400 and 460 nm to check the fluorescently
marked areas (vital bone), the removal of necrotic bone,
osteotomy with piezosurgery device and then antimicrobial
photodynamic therapy (aPDT) therapy. The photosensitizing
agent was 1 ml of methylene blue, 1 minute preirradiation
(100 µg/mL) and red light (660 nm; 35 mW; 180 s; 6 J/points).
Soon after, infrared light was applied for photobiomodulation
(880 nm; 35 Mw; 60 s; 2.1 J/point) (Fig. 2). The both protocols
without the photosensitizer was applied once a week. Auxiliary
therapies such as aPDT stimulate and accelerate healing
processes, favoring the repair of periodontal tissues even in
cases of nicotine use and/or menopause with or without hormone
replacement. In addition, it assists in bacterial reduction, through
the photosensitizing agent that specifically binds to
microorganisms and, after being stimulated by the correct wave
of light, leads to cytotoxic effects by releasing reactive oxygen
species, helping to combat secondary infection in the necrotic
site. Another important factor to be remembered in this case was
piezosurgery since the bone area is already damaged and necrotic
and still needs a new trauma in the form of an osteotomy for
complete removal of the entire necrotic area and exposure of vital
tissue.8,9 Piezosurgery traumatizes less bone tissue and induces
the remodeling process more quickly than with conventional
rotary drills, allowing for faster tissue repair. It acts on ultrasonic
waves at a wavelength in the order of 25 kHz, while to injure soft
tissues, waves above 50 kHz are required, thus being very safe for
the protection of covering tissue.10 The patient was followed up
periodically and in the third postoperative week, she showed
good tissue repair, with the entire wound covered with reddish
tissue, demonstrating vitality of the entire tissue. After 3 months,
the patient presented complete epithelial repair, with full
coverage of the exposed areas and with significant resolution of
the pain. Also, in the 1-year follow-up, a normal mucosal aspect
was observed, without bone exposure and absence of painful
symptoms (Fig. 3). Despite the limitations related to the
treatment of MRONJ, the choice of appropriate adjunctive
therapies, such as aPDT and auxiliary mechanisms during
sequestrectomy, such as fluorescence and piezosurgery, are
fundamental for success long-term therapy in patients with this
condition.
Copyright © 2022 by Mutaz B. Habal, MD
Copyright © 2022 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
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Correspondence
Mirela C. Silva, MSc Tiburtino J.d.L. Neto, MSc, PhD
Mateus D. Pavelski, MSc, PhD Stefany Barbosa, MSc
Anderson M.S. Santos, MSc, PhD
Daniela A. Brandini, MSc, PhD
Valdir G. Garcia, MSc, PhD
Leticia H. Theodoro, MSc, PhD
and Leonardo P. Faverani, MSc, PhD
Department of Diagnosis and Surgery, School of Dentistry, São
Paulo State University (UNESP), Aracatuba, Sao Paulo, Brazil
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