LETTER TO THE EDITOR

1 J Oral Maxillofac Surg 58

2 -:1, 2017 59
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THE MRONJ LESION—DEAD OR DYNAMIC? MRONJ lesion, potentially enabling delineation of the true
5 extent of the MRONJ lesion. 62
6 To the Editor:—We read the article titled ‘‘Clinical 63
Although the use of intraoperative AF could still facilitate
Differences in Autofluorescence Between Viable and Nonvi-
7 removal of MRONJ-involved bone, the basis of this technique 64
tal Bone: A Case Report With Histopathologic Evaluation Per-
8 needs to be investigated, because it demarcates not just 65
formed on Medication-Related Osteonecrosis of the Jaws’’ by
necrotic bone but appears to collectively exclude necrotic
9 Giovannacci et al1 with interest. The article centers on histo- 66
and diseased bone, necessitating the removal of ‘‘dark’’ and
10 pathologic correlates for clinical specimens obtained from 67
hypofluorescent bone to eliminate the MRONJ lesion. How-
11 ‘‘dark’’ (loss of autofluorescence [AF]) and hyperfluorescent 68
ever promising, these 2 techniques need to be validated.
regions during surgical debridement of lesions caused by
12 medication-related osteonecrosis of the jaws (MRONJ). The
Nevertheless, these 2 modalities for MRONJ assessment 69
13 might be complementary: 1) a noninvasive assay that could 70
authors attribute loss of AF to necrotic bone tissue and
serve as a longitudinal marker to follow the response to med-
14 conclude that the ‘‘histopathologic view confirmed presence 71
ical management of MRONJ in the future, apart from a pre-
15 of necrotic tissue’’ (Fig 6) and state that the ‘‘Fibroinflamma- 72
surgical MRONJ lesion assessment tool, and 2) an
16 tory area was surrounded by necrotic osteomyelitic bone,’’ 73
intraoperative surrogate marker of the MRONJ lesion.
failing to reconcile the consistent presence of osteocytes in
17 the lacunar spaces in the specimen, a hallmark for bone
74
18 viability.2 Further, deeming all MRONJ-affected bone as 75
GAYATHRI SUBRAMANIAN, PHD, DMD Q1
19 nonvital can be flawed, given the authors’ own histopatho- JOSEPH RINAGGIO, DDS 76
20 logic data contradicting this premise. LAWRENCE SCHNEIDER, BDS, PHD 77
21 Alternatively, we regard the MRONJ lesion as a composite SAMUEL Y.P. QUEK, DMD, MPH 78
of necrotic and compromised (viable-but-affected) bone, a Newark, NJ
22 lesion in a dynamic continuum owing to dysregulated bone
79
23 remodeling and repair.3,4 Hence, the histopathologic 80
24 finding of viable bone within the clinical MRONJ lesion is 81
25 consistent with our model for MRONJ pathogenesis. References 82
26 Although seemingly semantic, this shift in viewpoint 83
supports the possibility of stimulating bone remodeling as 1. Giovannacci I, Meleti M, Corradi D, et al: Clinical differences in
27 a means to ‘‘cure’’ or resolve an MRONJ lesion, in contrast autofluorescence between viable and nonvital bone: A case 84
28 report with histopathologic evaluation performed on 85
to the need for surgical elimination of an MRONJ lesion as medication-related osteonecrosis of the jaws [published online
29 ‘‘mandated by its irreversible necrotic state.’’ However, ahead of print December 15, 2016]. J Oral Maxillofac Surg 86
30 surgical elimination of the lesion is the only ‘‘curative’’ http://dx.doi.org/10.1016/j.joms.2016.12.011 87
31 option currently available unless such a therapeutic agent 2. McCarthy EF, Frassica FJ: Pathology of Bone and Joint Disorders: 88
is indeed identified and validated. With Clinical and Radiographic Correlation. Cambridge, UK,
32 We recently reported on the potential of functional imag- Cambridge University Press, 2015 89
33 ing (FI) in preoperative assessment and surgical planning for 3. Subramanian G, Kalyoussef E, Blitz-Goldstein M, et al: Identifying 90
34 MRONJ, which is feasible at least in patients with existing FI, MRONJ-affected bone with digital fusion of functional imaging 91
(FI) and cone-beam computed tomography (CBCT): Case reports
35 such as those with cancer metastatic to bone. The use of FI 92
and hypothesis. Oral Surg Oral Med Oral Pathol Oral Radiol 123:
36 and cone-beam computed tomography (CBCT) collectively e106, 2017 93
could allow the discernment of the extent of necrotic and 4. Subramanian G, Cohen HV, Quek SY: A model for the pathogen-
37 affected parts of the MRONJ lesion from surrounding
94
esis of bisphosphonate-associated osteonecrosis of the jaw and
38 healthy bone exhibiting reactive remodeling. The 3 compo- teriparatide’s potential role in its resolution. Oral Surg Oral Med 95
39 nents of FI plus CBCT provide information on anatomic Oral Pathol Oral Radiol Endod 112:744, 2011 96
40 changes (CBCT), remodeling activity (single-photon 97
41 emission CT), and inflammatory activity (fluorodeoxyglu- 98
cose positron-emission tomography) in the region of the http://dx.doi.org/10.1016/j.joms.2017.02.031
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