Comparative Analysis of Different Protocols for Dental Exactions in Patients at Risk of MRONJ: Case-control Study
Phase: PHASE1
Conditions: MEDICATION RELATED OSTEONECROSIS OF THE JAW
Sponsor: University of Palermo

01/09/2023
[NCT ID not yet assigned] Unique Protocol ID: OZONE_EXO
OZONE_EXO: Comparative Analysis of Protocols for Dental Exactions in Patients at Risk of MRONJ:
Case-control Study
Study Protocol
This study, entitled the OZOPROMAF protocol, was reviewed and approved by the Ethics Committee of
University Hospital of Palermo, Policlinico P. Giaccone (approval number 01/2018).
Patients were consecutively enrolled from February 2018 to March 2020.
The study protocol conformed with the ethical guidelines of the 1964 Declaration of Helsinki and its later
amendments or comparable ethical standards. All participants gave their written informed consent.
The aim of this study was to carry out a case-control study in order to compare two different protocols of
dental extractions in patients at risk of MRONJ, with and without infiltration of a mixture of oxygen-ozone.
According to the considered criteria of inclusion and exclusion (Table 1), this study recruited 117 patients, 27
male and 90 female. Out of these patients, 54 had osteometabolic conditions, 57 were cancer patients, and 6
had both osteometabolic disease and cancer.
Table 1. Inclusion and exclusion criteria.
·
age ≥ 18 yrs
Inclusion criteria
·
patients at risk of developing MRONJ for previous or current administration of drugs
related
·
poor prognosis (for caries and/or periodontitis) of one or more teeth suitable for
dental extraction
·
previous radiation in the head and neck area
Exclusion criteria
·
neoplastic involvement of the jaw
·
previous MRONJ diagnosis
The patients were randomly assigned to two groups using a simple randomization method. Specifically, a
software program was used to arbitrarily select 38 patients (group Test) to receive ozone therapy by insufflation
to the post-extraction site. The remaining 79 patients (group Control) did not receive this treatment.
During first consultation, medical, pharmacological, and dental history of patients were recorded, including
age, sex, indications for use of MRONJ-related drugs, type and duration of MRONJ-related medication use,
medical history of chemotherapy, concurrent use of other medications, other concomitant diseases, and
smoking habits.
The patients recruited for the study (Table 2) were: “onc1” (cancer patients undergoing antiresorptive and/or
anti-angiogenic therapies for medical indications), “onc2” (cancer patients taking antiresorptive treatments to
manage osteometabolic disorders), and “ost” (non-oncologic patients taking antiresorptives for the treatment
of osteometabolic conditions). So, based on type of drugs, route of administration and cumulative dose two
risk categories were identified, namely low and high risk: onc1 patients were generally considered to be at
high risk; onc 2 and ost patients belonged to low-risk category.

Table 2. Descriptive data of enrolled patients.
Test
(N=38)
Age
Controls
(N=79)
Mean (SD)
Median [Q1, Q3]
Sex
F
M
Patient risk category
high
low
Patient type
onc1
onc2
ost
Type of therapy
antiresorptive medications
anti-angiogenetic medications
both
66.7 (12.1)
71.00 [56.00,
74.75]
27 (71.1%)
11 (28.9%)
22 (57.9%)
16 (42.1%)
22 (57.9%)
4 (10.5%)
12 (31.6%)
31 (81.6%)
2 (5.3%)
5 (13.2%)
69.6 (9.82)
70.00 [63.00, 77.00]
63 (79.7%)
16 (20.3%)
35 (44.3%)
44 (55.7%)
35 (44.3%)
2 (2.5%)
42 (53.2%)
74 (93.7%)
1 (1.3%)
4 (5.1%)
2.3 Protocol of intervention
To assess status of oral health, inspection and orthopantomography have carried out; if decay or periodontitis
were suspected, an endoral radiograph was performed in order to confirm poor prognosis before extraction.
Only when indicated (i.e., teeth near to inferior alveolar nerve and paranasal sinuses), a cone beam computed
tomography (CBCT) of the maxillofacial region was performed. Extractions were performed by a resident in
oral surgery.
Starting from the day before extraction, oral antibiotics (amoxicillin-clavulanate 1g and metronidazole 500mg,
three times daily; in case of penicillin allergy, erythromycin 600mg, three times daily), and local antiseptics
(0.2% chlorhexidine mouthwash) for a period of 7 days were prescribed (Table 3).
Written informed consents about off-label use of metronidazole (needed in Italy), oral surgery protocol and
MRONJ risk were obtained from patients.

Table 3. Descriptive of profilaxis protocols to prevent MRONJ
Group T
Group C
Prophylaxis
Adjuvant Therapy
Amoxicillin-clavulanate
1g
+
Metronidazole 500 mg three times daily
(in
case
of
penicillin      allergy:
Erythromycin 600mg + Metronidazole
500 mg three times daily)
Injections of a 15 mL mixture of
Oxygen-Ozone (O2O3) with a 26Gx 1⁄2
- 0.45x13 mm needle
Amoxicillin-clavulanate
1g
+
Metronidazole 500 mg three times daily
(in
case
of
penicillin      allergy:
Erythromycin 600mg + Metronidazole
500 mg three times daily)
NA
GROUP T
On the day of the surgery (T0), the surgical protocol involved superficial local anesthesia by EMLA® cream,
loco-regional anesthesia, incision and flap debridement, extraction of the tooth with poor prognosis,
osteoplasty, intra-tissutal perialveolar injections of a 15-mL mixture of OxigenOzone (O2O3) with a 26Gx 1⁄2
- 0.45x13 mm needle and insufflation of the same mixture in the post-extraction site for at least 1 minute,
hemostasis, and suture.
Additionally, each patient was scheduled for supplementary visits during which the OxigenOzone mixture was
applied at T1 (3-5 days), T2 (14 days) and T3 (6 weeks) after the extraction.
When possible, depending on the patient's compliance and willingness, in 9 patients the mixture was applied
twice a week within T2, until complete clinical healing or in case of ONJ sequestration formation.
GROUP C
On the day of the surgery (T0), the surgical protocol for Group B included the following steps: superficial local
anesthesia using EMLA® cream, loco-regional anesthesia, incision and flap debridement, extraction of teeth
with a poor prognosis, osteoplasty, achieving hemostasis, and suture.
Healing Evaluation and follow-up
In both groups, patients underwent additional follow-up visits at T1 (3-5 days), T2 (14 days), and T3 (6 weeks)
post-extraction to meticulously monitor surgical wound healing by Inflammatory Proliferative Remodeling
(IPR) Wound Healing Scale (Table 4) [20], and to record pain intensity by the NRS scale for enhanced ease of
use, rather than the originally planned VAS scale [22].
The IPR scale provided a comprehensive assessment of wound healing through distinct subscales, each ranging
from 0 to 1, resulting in a total score ranging from 0 to 16. These subscales evaluated the inflammatory
response, proliferative response, and remodeling process. At the end of the follow-up period, the total IPR
score was computed, with scores spanning from 0 to 16. Scores of 0-4 denoted poor healings, scores of 5-10
indicated acceptable healing, while scores of 11-16 suggested excellent healing.
Table 4. IPR (Inflammatory Proliferative Remodeling) Scale [21]
T/PHASE
INFLAMMATORY
T: 3−5 DAYS
Parameter
Bleeding,
spontaneously
or
on palpation
Granulation tissue
Haematoma
Tissue colour
Incision margins
Score 0
Yes
Yes
Yes
Redder or whiter than
opposite side tissue
Incomplete
flap
closure/fibrin
clot/partial
necrosis/complete
necrosis
Score 1                               Total
score
No
/8
No
No
Like the opposite side
tissue
Complete
flap
closure/fine fibrin line

PROLIFERATIVE
T: 14 DAYS
REMODELING
T: 6 WEEKS
TOTAL PROCESS
Suppuration
Edema NRS (1−10)
Pain NRS (1−10)
Re-epithelialisation
Tissue colour
Scar
Suppuration
Pain NRS (1−10)
Scar
Tissue colour
Pain NRS (1−10)
Yes
NRS 6−10
NRS 6−10
Partial
Redder or whiter than
opposite side tissue
Scar
wider
than
2
mm/contour irregularity
Yes
NRS 6−10
Scar
wider
than
2
mm/contour irregularity
Redder or whiter than
opposite side tissue
NRS 6−10
No
NRS 1−5
NRS 1−5
Complete
/5
Like the opposite side
tissue
No scar/scar less wide
than
2
mm/contour
regularity
No
NRS 1−5
No scar/scar less wide /3
than
2
mm/contour
regularity
Like the opposite side
tissue
NRS 1−5
/16
2.4 Statistical methods
The statistical analysis was performed using the R Statistical Software (v4.1.2; R Core Team 2021). Categorical
variables were expressed as counts and percentages, quantitative variables as mean (standard deviation) or as
median and interquartile range (the 25th and 75th percentiles), in case of skewed distributions. The Chi-square
or the Fisher’s exact test was used to compare groups A and B for categorical variables. Student’s t test or the
Wilcoxon-Mann-Whitney test was calculated to compare groups Aand B for continuous variables. Statistically
significant differences were assessed using two-sided P-values below 0.05.
At multivariable analysis, logistic regression was used to model binary responses (IPR>Median vs
IPR≤Median) as related to demographic, pharmacological, systemic, and clinical covariates that have resulted
significant at univariable analysis.
Table 4. IPR comparative statistical analysis
Inflammatory T1
(3-5 Days) §
Mean (SD)
Median [Q1, Q3]
Proliferative T2
(14 Days) §
Mean (SD)
Median [Q1, Q3]
Remodelling T3
(6 Weeks) §
Mean (SD)
Median [Q1, Q3]
IPR_Total Process§
Mean (SD)
Median [Q1, Q3]
Group T (ozone therapy)
(N=38)
2.00 (0.870)
2.00 [1.00, 2.75]
4.24 (1.51)
5.00 [4.00, 5.00]
3.00 (0)
3.00 [3.00, 3.00]
9.37 (1.79)
9.50 [9.00, 10.00]
Group C (controls)
(N=79)
2.49 (0.875)
2.00 [2.00, 3.00]
3.70 (1.02)
4.00 [3.00, 4.00]
2.96 (0.192)
3.00 [3.00, 3.00]
9.15 (1.38)
9.00 [8.00, 10.00]
P-value
0,006
<0.001
0,230
0,275
§Wilcoxon signed-rang test