Trattamento dell’osteonecrosi dei mascellari indotta da bifosfonat

Nei casi in cui è possibile determinare esattamente la diagnosi di osteonecrosi indotta da bifosfonati, si dovrebbe informare dell’evento insorto il medico proscrittore, addetto al monitoraggio delle condizioni di osteopenia/osteoporosi. E’ inoltre opportuno raccomandare la sospensione del farmaco per almeno un anno, e iniziare terapie farmacologiche alternative per il trattamento della condizione di osteoporosi o sospendere il trattamento farmacologico e adottare un attento monitoraggio delle condizioni del paziente.

Il chirurgo orale deve essere esortato a non procedere a interventi di rimozione dei frammenti di osso esposto in questo stadio iniziale; infatti l’intervento resettivo di aree osteonecrotiche effettuato durante la piena assunzione di bifosfonati o troppo precocemente dopo la sospensione può aumentare l’estensione di osso esposto e estendere ulteriormente l’area di necrosi.

Dal momento in cui l’assunzione viene sospesa, la popolazione di osteoclasti coinvolti nei processi di guarigione può cominciare a riassorbire il tessuto circostante il focolaio di necrosi con la finalità di separare quest’ultimo dal tessuto vitale circostante, promuovendo la formazione di un sequestro. In circa il 60% dei casi questo processo

arriva al completamento in un periodo compreso tra 6 mesi e un anno e si osservano guarigioni di esposizioni ossee senza che queste vengano sottoposte ad alcun intervento chirurgico. Nel restante 40% dei casi il processo spontaneo non si completa e il caso richiede la revisione chirurgica locale. L’atto chirurgico rimane tuttavia la procedura più indicata perché l’area di osteonecrosi risulta ben distinguibile dall’area circostante vitale e il sito chirurgico può facilmente guarire. Questa procedura è principalmente volta all’eliminazione degli elementi dentari nell’area di necrosi ossea e alla resezione di porzioni di osso alveolare, effettuando una chiusura per prima intenzione del lembo mucoperiosteo linguale e vestibolare. Una resezione completa non è opportuna (anche se risulta indicata in una piccola minoranza di casi di fenomeni osteonecrotici indotti da bifosfonati per uso endovenoso resistenti al controllo con antibiotici). In rari casi tuttavia, un evento di osteonecrosi indotto da bifosfonati per uso orale può diventare sufficientemente grave dopo assunzione a lungo termine e/o associazione di prednisone e richiedere anch’esso una resezione completa.

Dopo la risoluzione del quadro di osteonecrosi si presuppone che il tessuto circostante sia vitale. La conseguente perdita di elementi dentari può essere compensata dall’adozione di presidi protesici rimovibili e fissi senza ancoraggio implantare, se il paziente è in procinto di ripristinare l’assunzione di bifosfonati. Se invece la terapia viene sostituita da presidi farmacologici alternativi, rimangono valide le possibilità di riabilitazione con implantologia e/o con procedure di incremento osseo alveolare per il ripristino degli elementi dentari perduti. (Marx, 2009)

Conclusioni

I bisfosfonati sono una classe di farmaci ampiamente utilizzati nella pratica clinica per il trattamento di patologie caratterizzate da elevato turnover osseo, quali l’osteoporosi, la malattia ossea di Paget e le sindromi ipercalcemiche.

Grazie alla efficacia, relativa sicurezza e facilità di impiego dei più recenti aminobisfosfonati, il numero di pazienti trattati è in costante aumento. Poiché sono incorporati dal tessuto osseo con elevata affinità senza essere degradati, tali farmaci restano accumulati nello scheletro per molto tempo (più di 10 anni) anche dopo la sospensione del trattamento. Inoltre, il loro prolungato utilizzo potrebbe sopprimere eccessivamente il rimodellamento osseo ostacolando la riparazione dei microtraumi nelle sedi maggiormente sottoposte, quali la mandibola. A partire dalle prime osservazioni in letteratura, le segnalazioni di casi di osteonecrosi della mandibola in pazienti in trattamento con bisfosfonati sono emerse come una vera epidemia ed hanno probabilmente portato ad una sovrastima del problema. Vi sono infatti ancora incertezze sui criteri diagnostici ed inoltre è necessario distinguere l’osteonecrosi dalla osteomielite o dalla osteoradionecrosi legata all’effetto della terapia radiante.

Sono indispensabili nuovi studi prospettici e studi sperimentali per una migliore comprensione dell’eziopatogenesi, dei criteri diagnostici e delle reali conseguenze di questa temibile complicanza. Tali ricerche saranno importanti per valutare il concomitante effetto di altri trattamenti (glucocorticoidi, talidomide, chemioterapici), di condizioni cliniche preesistenti (diabete, patologie vascolari, patologie infettive, artrite reumatoide) o di possibili fattori di rischio (fumo di sigaretta, traumi) sull’incidenza dell’osteonecrosi della mandibola. In attesa di ulteriori conoscenze sembra prudente considerare che tutti i pazienti che assumono bifosfonati siano potenzialmente a rischio di osteonecrosi della mandibola, anche se la dimensione del rischio varia notevolmente in base al bisfosfonato assunto (molto maggiore in caso di aminobisfosfonati per via endovenosa), alla durata

del trattamento, ai fattori di rischio del paziente (impiego concomitante di farmaci, malattie neoplastiche, ecc ) ed alla storia di trattamento dentale.

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