Friedlander Arthur H, Chang Tina I, Hazboun Renna C, Garrett Neal R
Associate Chief of Staff and Director of Graduate Medical Education, Veterans Affairs Greater Los Angeles Healthcare System; Director of Quality Assurance, Hospital Dental Service, Ronald Reagan University of California, Los Angeles, Medical Center; and Professor-in-Residence, Department of Oral and Maxillofacial Surgery, University of California, Los Angeles, School of Dentistry, Los Angeles, CA.
Director of the Research Fellowship and Inpatient Oral and Maxillofacial Surgery, Veterans Affairs Greater Los Angeles Healthcare System; Instructor, Department of Oral and Maxillofacial Surgery, University of California, Los Angeles, School of Dentistry, Los Angeles, CA.
J Oral Maxillofac Surg. 2015 Sep;73(9):1735-40. doi: 10.1016/j.joms.2015.03.015. Epub 2015 Mar 18.
The clinical significance of bone turnover marker C-terminal cross-linking telopeptide (CTX) levels less than 150 pg/mL among recipients of oral bisphosphonate (OBP) medications who develop osteonecrosis of the jaws (MRONJ) after exodontia is unclear. We searched the published data to determine the prevalence of such levels and the association, if any, with development of MRONJ.
A systematic review of published studies in the PubMed database was undertaken to ascertain the prevalence of preoperative, fasting CTX levels less than 150 pg/mL among recipients of OBP scheduled for exodontia and to determine whether such levels are associated with the development of postoperative MRONJ. The data were aggregated and analyzed to provide the sensitivity, specificity, and positive and negative predictive values of the association between low CTX levels and the development of MRONJ.
Two studies were chosen for review. The first, with an enrollment of 21 patients, reported that 10 (48%) patients had a preoperative CTX level less than 150 pg/mL and that after exodontia, none developed MRONJ. The second study, with an enrollment of 950 patients, reported that approximately 282 (30%) had a preoperative CTX level less than 150 pg/mL. All the patients with depressed CTX levels were offered a "drug holiday"; however, only 101 accepted the offer. Of the remaining 181 patients, 4 developed MRONJ. The aggregated study data have demonstrated that 30% of patients evidence CTX levels less than 150 pg/mL and that the sensitivity and specificity of these levels in association with the development of MRONJ was 100% and 80.7%, respectively. The positive predictive value was 2.09% and the negative predictive value was 100%.
The published data suggest that approximately one third of patients exposed to OBP will evidence depressed CTX levels and that only a very small minority (∼2%) will develop postexodontia MRONJ. Prudence would suggest that patients scheduled for exodontia and receiving OBPs should be informed about the strengths and weaknesses of the CTX test and that it should be offered during the consent process.
对于接受口服双膦酸盐（OBP）治疗且拔牙后发生颌骨骨坏死（MRONJ）的患者，骨转换标志物C末端交联端肽（CTX）水平低于150 pg/mL的临床意义尚不清楚。我们检索已发表的数据，以确定此类水平的患病率以及与MRONJ发生之间的关联（若有）。
对PubMed数据库中已发表的研究进行系统评价，以确定计划拔牙的OBP接受者术前空腹CTX水平低于150 pg/mL的患病率，并确定此类水平是否与术后MRONJ的发生相关。汇总并分析数据，以提供低CTX水平与MRONJ发生之间关联的敏感性、特异性以及阳性和阴性预测值。
选择两项研究进行综述。第一项研究纳入21例患者，报告称10例（48%）患者术前CTX水平低于150 pg/mL，拔牙后无一例发生MRONJ。第二项研究纳入950例患者，报告称约282例（30%）患者术前CTX水平低于150 pg/mL。所有CTX水平降低的患者都被给予了“药物假期”；然而，只有101例接受了提议。在其余181例患者中，4例发生了MRONJ。汇总的研究数据表明，30%的患者CTX水平低于150 pg/mL，这些水平与MRONJ发生相关的敏感性和特异性分别为100%和80.7%。阳性预测值为2.09%，阴性预测值为100%。
已发表的数据表明，约三分之一接受OBP治疗的患者CTX水平会降低，且只有极少数（约2%）会在拔牙后发生MRONJ。谨慎起见，建议计划拔牙并接受OBP治疗的患者了解CTX检测的优缺点，并应在知情同意过程中提供该检测。
