# Management of Patients under Treatment with Monoclonal Antibodies and New Biological Therapies
## 1 Introduction  
Biological therapies are a new method of treating some autoimmune diseases and cancer. They were defined by the FDA (Food and Drugs Administration) as any virus, therapeutic serum, toxin, antitoxin, or similar product applicable to the prevention and treatment of human diseases. These biologics include vaccines, blood and blood-derived preparations, antitoxins, growth hormones, human insulin, gene therapies, recombinant therapies, proteins, and allergens, along with the newer biologics: cytokines, monoclonal antibodies, and fusion proteins [1, 2].  
Cytokines are immunomodulators that regulate the host's response to inflammation and infections. In this way they work by signaling molecules that will bind to protein receptors on cells, generating a physiological change in them.  
Monoclonal antibodies are synthetic molecules that activate against certain antigens to improve immune recognition. They are divided into four subgroups: murine, chimeric, humanized, and human.  
Fusion proteins are composed of transmembrane proteins connected to another molecule through the Fc portion of human immunoglobulin.  
The mechanisms of action of biological therapies involve a series of physiological changes that can trigger side effects in the patient. One of these mechanisms is the inhibition of molecules such as TNF\(\alpha\), which are essential in the inflammatory response. This produces a change in the immune system that can lead to these patients having a greater predisposition to infections [1].  
Other mechanisms of action to take into account, due to their physiological repercussions, are antiresorptive and antiangiogenic, influencing osteoclasts and vascular endothelial growth factor (VEGF), respectively [2, 3].  
Despite the efficacy and safety of these drugs in the vast majority of patients, there is a significant risk of producing adverse effects such as mucositis, hyperkeratotic lesions,mucosal dyschromia, geographic tongue, dysgeusia, lichenoid lesions, telangiectasias, xerostomia, dysesthesia, and, the most prominent, osteonecrosis of the jaw, due to its antiangiogenic and/or antiresorptive power [4]. This osteonecrosis will be considered related to these medications when the following characteristics described by the AAOMS (American Association of Oral and Maxillofacial Surgeons) are present in a patient:  
Previous or current treatment with antiresorptive or antiangiogenic agents.  
Exposed bone or bone that can be probed through an intra- or extra-oral fistula in the maxillofacial region, which has persisted for more than 8 weeks.  
Absence of radiotherapy or previous metastasis in the jaw [2].  
In 2014, the AAOMS changed the term \"Bisphosphonate-Related Osteonecrosis of the Jaws\" (BRONJ) to \"Medication-related Osteonecrosis of the Jaws\" (MRONJ) to include all other drugs related to osteogenesis. However, since 2017 there are only three monoclonal antibodies officially recognized by the FDA as causing MRONJ: denosumab, bevacizumab, and sunitinib. The rest of the reported drugs have not yet been recognized as such due to the lack of scientific evidence [5].  
The objective of this study is to know the drugs related to adverse events in oral surgery, what effects they produce, and to record how they have been resolved according to the available literature.