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Short Communication Volume 8 Issue 3
Risks of medication-related osteonecrosis of the jaw in older patients with COVID-19
Gabriel Mulinari Santos,1 
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Amanda Paino Sant’ Ana,2 Valdir Gouveia Garciar,3 Letícia Helena Theodoro1
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1Department of Diagnostic and Surgery, Aracatuba School of Dentistry, São Paulo State University (UNESP), Brazil
2Department of Dental Materials and Prosthodontics, Aracatuba School of Dentistry, São Paulo State University (UNESP), Brazil
3Department of Implantology, Latin American Dental Research and Teaching Institute, Brazil
Correspondence: Gabriel Mulinari-Santos, Department of Diagnostic and Surgery, São Paulo State University (UNESP), Aracatuba School of Dentistry, José Bonifácio Street 1193, Araçatuba, São Paulo State, Brazil
Received: July 18, 2023 | Published: July 21, 2023
Citation: Mulinari-Santos G, Paino-Sant’Ana A, Garciar VG, et al. Risks of medication-related osteonecrosis of the jaw in older patients with COVID-19. MOJ Gerontol Ger. 2023;8(3):59-60. DOI: 10.15406/mojgg.2023.08.00311
Abstract
Coronavirus disease can cause respiratory complications and a systemic hyper inflammation. One of the most proposed treatments for COVID-19 still is the use of corticosteroids or antiresorptive drugs. Despite these drugs have positive effects to COVID-19 patients, they also are associated with medication-related osteonecrosis of the jaw. Therefore, older adults requiring procedures involving bone need detailed anamnesis to avoid osteonecrosis of the jaw after infection with COVID-19.
Keywords: covid-19, bone, osteonecrosis, inflammation, SARS-Cov-2
Abbreviations
COVID-19, coronavirus disease 2019; MRONJ, medication-related osteonecrosis of the jaw
Introduction
The lungs are the structures most affected by coronavirus disease 2019 (COVID-19). Though COVID-19 affect respiratory tissue, patients with severe COVID-19 have symptoms of an extensive inflammation.1 The use of corticosteroid is positively recommended to reduce the inflammation and consequent risk of death in severe cases.2 With the spread use of corticoid and another drugs, it is critical to comprehend their consequences on alveolar bone. The possibility of osteonecrosis of the jaw after COVID-19 treatment with high doses of corticoids or antiresorptive drugs in older adults needs to be clearly evaluated.
Medication-Related Osteonecrosis of the Jaw (MRONJ) is an infectious complication of antiresorptive and antiangiogenic drugs.3 Besides bisphosphonates, corticosteroids also increase the risk of MRONJ.3 Despite the use of corticoids has favorable effect on COVID-19 treatment, their use can cause bone abnormalities4 as well as MRONJ.5 A recent study supported decreased bone mineral density caused by steroids after coronavirus infection.5 Reports already advised osteonecrosis of hip, femur, knee5 and tibia6 or jaws7 in patients with severe acute respiratory syndrome. The authors linked bone complications with high-dose of steroid treatment.4–7
Monoclonal antibodies including tocilizumab is also suggested for treatment of COVID-19.8 Tocilizumab stimulate interleukin-6 receptor blockade and it can reduce the risk of mortality.8 Even though the positive therapeutic for COVID-19, tocilizumab was associated with MRONJ.8 Another monoclonal antibody Denosumab is very correlated with MRONJ9. Curiously, denosumab have been recommended for treat consequent of osteoporosis after COVID-19.4–10.
Previous studies have described COVID-19 patients with MRONJ after usage of high doses of oral or intravenous corticosteroids.7,11 A case series mentioned four patients with MRONJ caused by use of dexamethasone or prednisolone during 2 weeks.11 All patients presented pain, facial swelling, and tooth mobility within 2 weeks after COVID-19 treatment.11 The other series report also included twelve cases of MRONJ after dexamethasone for ten days, in addition the symptoms started spontaneous at three and twelve weeks.7 Both case series signaled radiography features with osteolytic areas mainly using computed tomography.7,11
Therefore, older patients requiring dentoalveolar procedures such as tooth extraction, periodontal treatment, bone grafts or dental implants can have an increased risk of MRONJ after coronavirus disease following the use of drugs associated with MRONJ. Moreover, a cautiously clinical exam and medical history investigation is required in patients who claim of tooth mobility, pain, facial swelling and present osteolytic radiograph areas after COVID-19 treatment. Further studies are required to elucidate the medication-related osteonecrosis of the jaw in patients with COVID-19.
Conclusion
In conclusion, a detailed anamnesis about the drugs used for coronavirus treatment is crucial to avoid osteonecrosis of the jaw in older patients with recent COVID-19. Therefore, this short communication highlighted the risk of high doses of corticosteroids or monoclonal antibodies to causes MRONJ in COVID-19 patients.
Acknowledgments
The authors would like to thank the São Paulo State University.
Conflicts of interest
The authors declare any conflict of interest.
Funding
The authors received the funding from the Sao Paulo State University (UNESP)- Pro Rectory for Research(PROPE 13/2022).
References
- Brosnahan SB, Jonkman AH, Kugler MC, et al. COVID-19 and Respiratory System Disorders: Current Knowledge, Future Clinical and Translational Research Questions. Arterioscler Thromb Vasc Biol. 2020;40(11):2586–2597.
- Manjili RH, Zarei M, Habibi M, et al. COVID-19 as an acute inflammatory disease. J Immunol. 2020;205(1):12–19.
- Saad F, Brown JE, Van Poznak C, et al. Incidence, risk factors, and outcomes of osteonecrosis of the jaw: integrated analysis from three blinded active-controlled phase III trials in cancer patients with bone metastases. Ann Oncol. 2012;23(5):1341–1347.
- Salvio G, Gianfelice C, Firmani F, et al. Bone Metabolism in SARS-cov-2 Disease: Possible Osteoimmunology and Gender Implications. Clin Rev Bone Miner Metab. 2020;18(4):51–57.
- Veizi E, Erdoğan Y, Sezgin BS, et al. The painful joint after COVID-19 treatment: A study on joint osteonecrosis following COVID-19-related corticosteroid use. Jt Dis Relat Surg. 2023;34(1):75–83.
- Griffith JF, Antonio GE, Kumta SM, et al. Osteonecrosis of hip and knee in patients with severe acute respiratory syndrome treated with steroids. Radiology. 2005;235(1):168–175.
- Al-Mahalawy H, El-Mahallawy Y, Dessoky NY, et al. Post-COVID-19 related osteonecrosis of the jaw (PC-RONJ): an alarming morbidity in COVID-19 surviving patients. BMC Infect Dis. 2022;22(1):544.
- Bennardo F, Buffone C, Giudice A. New therapeutic opportunities for COVID-19 patients with Tocilizumab: Possible correlation of interleukin-6 receptor inhibitors with osteonecrosis of the jaws. Oral Oncol. 2020;106:104659.
- Limones A, Sáez-Alcaide LM, Díaz-Parreño SA, et al. Medication-related osteonecrosis of the jaws (MRONJ) in cancer patients treated with denosumab VS. Zoledronic acid: A systematic review and meta-analysis. Med Oral Patol Oral Cir Bucal. 2020;25(3):e326–e336.
- Chotiyarnwong P, mccloskey EV. Pathogenesis of glucocorticoid-induced osteoporosis and options for treatment. Nat Rev Endocrinol. 2020;16(8):437–447.
- Sood A, Nayyar V, Roychoudhury A, et al. Post-COVID steroid induced avascular necrosis of the jaw: Emerging challenge in India. Oral Surg Oral Med Oral Pathol Oral Radiol. 2023;135(4):e89–e93.
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