title: Staging of osteonecrosis of the jaw requires computed tomography for accurate definition of the extent of bony disease.
abstract: Management of osteonecrosis of the jaw associated with antiresorptive agents is challenging, and outcomes are unpredictable. The severity of disease is the main guide to management, and can help to predict prognosis. Most available staging systems for osteonecrosis, including the widely-used American Association of Oral and Maxillofacial Surgeons (AAOMS) system, classify severity on the basis of clinical and radiographic findings. However, clinical inspection and radiography are limited in their ability to identify the extent of necrotic bone disease compared with computed tomography (CT). We have organised a large multicentre retrospective study (known as MISSION) to investigate the agreement between the AAOMS staging system and the extent of osteonecrosis of the jaw (focal compared with diffuse involvement of bone) as detected on CT. We studied 799 patients with detailed clinical phenotyping who had CT images taken. Features of diffuse bone disease were identified on CT within all AAOMS stages (20%, 8%, 48%, and 24% of patients in stages 0, 1, 2, and 3, respectively). Of the patients classified as stage 0, 110/192 (57%) had diffuse disease on CT, and about 1 in 3 with CT evidence of diffuse bone disease was misclassified by the AAOMS system as having stages 0 and 1 osteonecrosis. In addition, more than a third of patients with AAOMS stage 2 (142/405, 35%) had focal bone disease on CT. We conclude that the AAOMS staging system does not correctly identify the extent of bony disease in patients with osteonecrosis of the jaw.
authors.affiliation: University and Hospital Trust of Verona, Department of Surgery, Section of Oral and Maxillofacial Surgery, Verona, Italy. Electronic address: alberto.bedogni@univr.it.
authors.forename: Alberto
authors.initials: A
authors.lastname: Bedogni
authors.affiliation: University College London, UCL Eastman Dental Institute, and NIHR University College London Hospitals Biomedical Research Centre, London, UK. Electronic address: s.fedele@ucl.ac.uk.
authors.forename: Stefano
authors.initials: S
authors.lastname: Fedele
authors.affiliation: Liver Research Centre, Clinical Epidemiology Unit, Basovizza, Trieste, Italy. Electronic address: giorgiobedogni@gmail.com.
authors.forename: Giorgio
authors.initials: G
authors.lastname: Bedogni
authors.affiliation: University of Turin, Department of Biomedical Science and Human Oncology, Section of Oral Medicine, UNITO Lingotto Dental Institute, Turin, Italy. Electronic address: matteo.scoletta@libero.it.
authors.forename: Matteo
authors.initials: M
authors.lastname: Scoletta
authors.affiliation: University of Bari, Department of Odontostomatology and Surgery, Bari, Italy. Electronic address: g.favia@doc.uniba.it.
authors.forename: Gianfranco
authors.initials: G
authors.lastname: Favia
authors.affiliation: Second University of Naples, Dept. of Medical, Surgical and Dental Specialties, Naples, Italy. Electronic address: giuseppe.colella@unina2.it.
authors.forename: Giuseppe
authors.initials: G
authors.lastname: Colella
authors.affiliation: University "La Sapienza", Department of Oral and Maxillofacial Sciences, Section of Maxillofacial Surgery, Rome, Italy. Electronic address: alessandro.agrillo@tiscali.it.
authors.forename: Alessandro
authors.initials: A
authors.lastname: Agrillo
authors.affiliation: University Hospital of Padova, Department of Neurosciences, Unit of Oral and Maxillofacial Surgery, Padova, Italy. Electronic address: giordanabettini@libero.it.
authors.forename: Giordana
authors.initials: G
authors.lastname: Bettini
authors.affiliation: University of Palermo, Department of Surgical, Oncological and Oral Sciences, Sector of Oral Medicine, Palermo, Italy. Electronic address: odifede@odonto.unipa.it.
authors.forename: Olga
authors.initials: O
authors.lastname: Di Fede
authors.affiliation: University of Messina, Department of Odontostomatology, Messina, Italy. Electronic address: oterig@unime.it.
authors.forename: Giacomo
authors.initials: G
authors.lastname: Oteri
authors.affiliation: Hospital "SS. Antonio, Biagio and C. Arrigo", Department of Oncology and Haematology, Unit of Medical Oncology, Alessandria, Italy. Electronic address: vfusco@ospedale.al.it.
authors.forename: Vittorio
authors.initials: V
authors.lastname: Fusco
authors.affiliation: University of Pisa, Department of Surgery, Section of Dentistry and Oral Surgery, Pisa, Italy. Electronic address: mario.gabriele@odont.med.unipi.it.
authors.forename: Mario
authors.initials: M
authors.lastname: Gabriele
authors.affiliation: University "La Sapienza", Department of Oral and Maxillofacial Sciences, Rome, Italy. Electronic address: livia.ottolenghi@uniroma1.it.
authors.forename: Livia
authors.initials: L
authors.lastname: Ottolenghi
authors.affiliation: Hospital S. Anna, Unit of Maxillofacial Surgery, Como, Italy. Electronic address: stefano.valsecchi@hsacomo.org.
authors.forename: Stefano
authors.initials: S
authors.lastname: Valsecchi
authors.affiliation: University College London, UCL Eastman Dental Institute, London, UK. Electronic address: s.porter@ucl.ac.uk.
authors.forename: Stephen
authors.initials: S
authors.lastname: Porter
authors.affiliation: University of Bari, Department of Odontostomatology and Surgery, Bari, Italy. Electronic address: m.petruzzi@doc.uniba.it.
authors.forename: Massimo
authors.initials: M
authors.lastname: Petruzzi
authors.affiliation: University of Turin, Department of Biomedical Science and Human Oncology, Section of Oral Medicine, UNITO Lingotto Dental Institute, Turin, Italy. Electronic address: paolo.arduino@gmail.com.
authors.forename: Paolo
authors.initials: P
authors.lastname: Arduino
authors.affiliation: Second University of Naples, Dept. of Medical, Surgical and Dental Specialties, Naples, Italy. Electronic address: salvatore.damato@unina2.it.
authors.forename: Salvatore
authors.initials: S
authors.lastname: D'Amato
authors.affiliation: University "La Sapienza", Department of Oral and Maxillofacial Sciences, Section of Maxillofacial Surgery, Rome, Italy. Electronic address: claudio.ungari@uniroma1.it.
authors.forename: Claudio
authors.initials: C
authors.lastname: Ungari
authors.affiliation: University College London, UCL Eastman Dental Institute, London, UK. Electronic address: pok.fung.10@ucl.ac.uk.
authors.forename: Pok-Lam
authors.initials: PL
authors.lastname: Fung Polly
authors.affiliation: University Hospital of Padova, Department of Neurosciences, Unit of Oral and Maxillofacial Surgery, Padova, Italy. Electronic address: giorgia.saia@unipd.it.
authors.forename: Giorgia
authors.initials: G
authors.lastname: Saia
authors.affiliation: University of Palermo, Department of Surgical, Oncological and Oral Sciences, Sector of Oral Medicine, Palermo, Italy. Electronic address: campisi@odonto.unipa.it.
authors.forename: Giuseppina
authors.initials: G
authors.lastname: Campisi
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000539:Alveolar Process / Q000000981:diagnostic imaging; D059266:Bisphosphonate-Associated Osteonecrosis of the Jaw / Q000145:classification* / Q000000981:diagnostic imaging; D050071:Bone Density Conservation Agents / Q000009:adverse effects; D054893:Cone-Beam Computed Tomography / Q000379:methods; D017577:Cutaneous Fistula / Q000145:classification / Q000000981:diagnostic imaging; D003751:Dental Fistula / Q000145:classification / Q000000981:diagnostic imaging; D004359:Drug Therapy, Combination; D005260:Female; D006801:Humans; D008297:Male; D008336:Mandibular Diseases / Q000145:classification / Q000000981:diagnostic imaging; D008337:Mandibular Fractures / Q000145:classification / Q000000981:diagnostic imaging; D008439:Maxillary Diseases / Q000145:classification / Q000000981:diagnostic imaging; D008875:Middle Aged; D010026:Osteosclerosis / Q000145:classification / Q000000981:diagnostic imaging; D062072:Patient Acuity; D010641:Phenotype; D012189:Retrospective Studies; D013492:Suppuration; D036542:Tomography, Spiral Computed / Q000379:methods; D014057:Tomography, X-Ray Computed / Q000379:methods*; D014081:Tooth Extraction
chemical_list: D050071:Bone Density Conservation Agents
keywords: AAOMS; Antiresorptive agents; Bisphosphonate; Computed tomography; Osteonecrosis of the jaw; Staging system