https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6459452/ — Value of pre-operative CTX serum levels in the prediction of medication-related osteonecrosis of the jaw (MRONJ): a retrospective clinical study
The low incidence yet severe presentation of medication-related osteonecrosis of the jaw (MRONJ) makes it necessary to develop reliable predictive and preventive strategies. This study explored the value of pre-operative carboxy-terminal collagen crosslinks …
Conclusions
Serum levels of CTX by itself are not reliable as a predictive or preventive measure for such complications. Our data also suggested that a drug holiday of 5 months was not helpful in preventing osteonecrosis-related complications in patients on intravenous bisphosphonates. Further studies are urgently needed to develop adequate predictive and preventive strategies of MRONJ.
C-terminal telopeptide cross-link (CTX) is a product of bone remodeling that can be measured in blood. Early reports suggested that serum levels of CTX progressively decline with anti-resorptive treatment and recover after the treatment stops. Therefore, it can be used to predict the occurrence of osteonecrosis following a dental procedure in patients on anti-resorptive medications [6].
The study suggested that the risk of MRONJ following a dental procedure in patients on bisphosphonates was high if the CTX level was below 100 pg/ml, moderate at 100–150 pg/ml, and low above 150 pg/ml [6, 10, 11]. Based on these studies and others, many clinicians all over the world performed CTX routinely before any dental procedure in patients on anti-resorptive treatment. Serum levels of CTX were also used to monitor the condition of bone remodeling during drug holiday and to determine the appropriate duration of such holiday before a procedure can be safely performed. The practice continues despite multiple subsequent studies questioning the practice [12, 13].
The blood level of CTX is considered a good marker of bone remodeling. It can be used to measure the effect of different medications on the systemic rate of bone turnover under experimental conditions [22]. Indeed, the data showed that CTX levels increased steadily during the short drug holiday in this study. However, extensive research has shown that the pathogenesis of ONJ is not unifactorial. The systemic effect of anti-resorptive medications on osteoclasts could not fully explain the susceptibility of alveolar bone to osteonecrosis. Multiple other factors, such as the localized change in vascularity, local immune response, oral microbiome, gingival epithelium, and localized deposition of bisphosphonates, have been implicated in the impaired healing following dental procedures in these patients [23, 24].
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