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Journal of Molecular and Clinical Medicine  2018, Vol. 1 Issue (2): 85-92    DOI: 10.31083/j.jmcm.2018.02.005
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Extent of surgical trauma may not be a key factor in Medication-related osteonecrosis of the jaw -- a pilot study
Lana Eskander-Hashoul1, 2, Rina Elimelech1, 2, Zvi Gutmacher1, 3, Shai Frankenthal1, Doron Rozitsky1, Tal Tamari2, Hadar Zigdon-Giladi1, 2, 3, *()
1 School of Graduate Dentistry, Rambam Health Care Campus, Haifa 31096, Israel
2 Laboratory for Bone Repair, Rambam Health Care Campus, Haifa 31096, Israel
3 The Rappaport Family Faculty of Medicine, Technion - Israel Institute of Technology, Haifa 31096, Israel
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The pathogenesis of Medication-Related Osteonecrosis of the Jaw (MRONJ) is not fully understood, however, surgical trauma is thought to play a role. Therefore, the aim of the current pilot study was to compare the incidence and characteristics of MRONJ following single or multiple molar tooth extractions in a rat model. To this aim, twenty male Lewis rats were treated with subcutaneous injection of zolendronic acid (ZA), an established bone anti-resorption agent, (7.5 $\mu $g/kg) and dexamethasone (Dex), (1 mg/kg), or saline, once a week, for 11 weeks. At three weeks, the first or both first and second maxillary molar teeth were extracted. Eight weeks following extraction, rats were sacrificed and extraction sites were evaluated. Clinical macroscopic examination showed MRONJ-like lesions in all single extraction ZA/Dex-treated rats, showing exposed bone. In the control and multiple extraction ZA/Dex-treated groups, none of the rats showed visible signs of MRONJ. Histological characteristics of MRONJ were found in all ZA/Dex-treated rats (both single and multiple extractions), whereas rats treated with saline showed almost no empty lacunae and necrotic bone. In conclusion, the extent of the surgical field may not be the key factor in MRONJ development since only rats with single tooth extraction displayed exposed bone. However, histological characteristics were identified in both models. Therefore, preclinical studies that aim to evaluate histological features of MRONJ may use both models, whereas when a clinically exposed bone is required, the single tooth extraction model appears to be preferable. Further large scale studies are warranted to corroborate the present findings.

Key words:  Osteonecrosis      Histopathology      Pathogenesis      Wound healing     
Submitted:  31 December 2017      Revised:  10 January 2018      Accepted:  11 January 2018      Published:  20 April 2018     
*Corresponding Author(s):  Hadar Zigdon-Giladi     E-mail:

Cite this article: 

Lana Eskander-Hashoul, Rina Elimelech, Zvi Gutmacher, Shai Frankenthal, Doron Rozitsky, Tal Tamari, Hadar Zigdon-Giladi. Extent of surgical trauma may not be a key factor in Medication-related osteonecrosis of the jaw -- a pilot study. Journal of Molecular and Clinical Medicine, 2018, 1(2): 85-92.

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Fig.1.  Region of interest (ROI) for histomorphometric analysis. (A) Representative histological image of single extraction ZA/Dex-treated group. Area of extraction site was identified and histomorphometric measurements were taken for determination of epithelial thickness (vertical arrows), epithelial ulceration and discontinuation (horizontal arrows), and bone necrosis (black asterisk). Blood vessel density was measured in the connective tissue (CT) and in the basal bone (bone). (B) Higher magnification of the area of bone necrosis (black asterisk), demonstrate the number of empty lacunae with extensive inflammatory infiltrate.

Fig.2.  Clinical healing of the extraction sites in ZA/Dex and saline groups. (A-B) Clinical images of the first molar extraction sites. (A) Saline (control) group demonstrating normal mucosa. (B) The ZA/Dex group revealing the exposed bone. (C-D) Clinical images of the multiple extraction group demonstrating normal healing. (C) saline (control). (D) ZA/Dex-treated group.

Fig.3.  Open contact between the 2$^{\rm nd}$ and 3$^{\rm rd}$ molars associates with food impaction, inflammation and bone loss in the single tooth extraction group. (A) Clinical macroscopic view showing open contact and food impaction. (B) A representative radiograph of single extraction ZA/Dex group demonstrating open contact point between M1 and M2 with significant bone loss. At the extraction socket area, a sequestrum was observed (arrow). (C) Histological section (H{\&}E) of open contact area with food impaction, ulcerated epithelium and bone loss. (D) Higher magnification of the rectangular region demonstrating extensive inflammation (arrows).

Fig.4.  Histological characteristics of MRONJ. (A-B) H&E staining sections of the saline (control) treated rats, and (C-D) ZA/Dex-treated rats. (A) Continuous epithelium, developed rete ridges (black arrows) with underlying wide connective tissue and bone in the tooth extraction area. (B) Higher magnification of the basal bone, demonstrates normal bone remodeling, bone formation with cellular lacunae. (C) Discontinuity of the epithelium and sequestrum formation (arrow). (D) Magnified area of the exposed necrotic bone, displaying lack of vascularity, empty lacunae and inflammatory cell infiltration (arrow). (E-F) blood vessels stained with anti-CD31 in control (E) and ZA/Dex (F).

Table1  Histomorphometric analysis of total ZA/Dex-treated rats compared to all saline treated rats.
Mean 士 SD Area of necrosis (μm2) Empty lacunae (1/mm2) BV Bone/area (1/mm2) BV CT/area (1/mm2)
Saline (n = 8) 0 3.13 士 8.84 7.23 士 1.62 6.52 士 2.26
ZA/Dex (n = 9) 154.88 士 194.06 22.44 士 9.79 2.86 士 1.43 3.44 士 1.63
P-value (Saline vs ZA/Dex) 0.04 0.0007 < 0.0001 0.0054
Fig.5.  Histomorphometric analysis of ZA/Dex and saline groups. (A-D) Comparison between ZA/Dex- and saline-treated rats, in single and multiple tooth extraction models *$p<$ 0.05. Blood vessel density in the connective tissue (BV and CT, respectively) and blood vessels density in the bone (BV bone).

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