Dr. Redfern's Research Presentations on Polycystic Ovary Syndrome Induced Headaches, Osteonecrosis of the Jaw and Other Research

Dr. Redfern has been at the forefront in the recognition and treatment of Stage "0" Bisphosphonate Related OsteoNecrosis of the Jaw (BRONJ) also called Medication or Drug Related OsteoNecrosis of the mandible, to include the TMJ. He is also researching the effects of Polycystic Ovary Syndrome causing headaches. Also head, jaw and facial pain, sleep disorders, including sleep apnea involved with overuse and or injury to the Masticatory system. Dr. Redfern, DDS  of Colorado Springs, Colorado coordinates with T. J. Hanson, MD, of the Mayo Clinic of Rochester, MN, to present the results of their research at numerous national and international medical and dental conferences over the past several years. The following is a partial summary of those presentations:

Presently a research project is being organized to be done in the Mayo Clinic Rochester's Women's Clinic regarding Poly Cystic Ovary Syndrome and effect on the TMJs and other bones as well as headache, sleep disorders etc.

Stage "0" (zero) Bisphosphonate Related Osteonecrosis of the Jaw Involving the Temporomandibular Joint.

See Research Project 121.pdf (6.3 MB).  Presentation of 4 case studies.

Presented at the International Academy of Gnathology, San Antonio, Texas, Sept. 28 - Oct. 1 2011.

Introduction: The effects of bisphosphonates (BPH) on the maxilla and mandible are well documented, however the effect on the temporomandibular joint (TMJ) is not well defined. Stage "0" bisphosphonate related osteonecrosis of the jaw, (BRONJ) has been described. Dr. Redfern has presented several cases that indicate Stage "0" effects the TMJ, causing destruction/collapse of the condyle of the mandible.  Joint loading of the TMJ increases bone reactivity resulting in increased stresses and remodeling. BPH is attracted to areas of bone reactivity and osteonecrotic changes  occur early as Stage "0" BRONJ.  Osteonecrosis undermines the cortical layer of the mandibular condyles leading to collapse of the condylar cortex. Alteration in condylar dimensions result in changes in the dental occlusion and masticatory bio-mechanics. The fossae are also effected.

Objective: 

•  To increase awareness of BRONJ to include the TMJ.

•  To emphasize implementation of measures including splints to decrease bone reactivity in the TM.

• To demonstrate the role of advanced imaging for early diagnosis and treatment of BRONJ.

Methods:  A case study format is used. Four case studies are presented using ADVANCED IMAGINGfor possible diagnosis of BRONJ Stage “0”.

Case 1:  57 Year old female. History of clenching, dislocation with reduction, nighttime splint wear. Mild hypothyroidism (.75 Synthyroid daily). Oral BPH circa 18 months. Hyperparathyroidism. Hormone replacement therapy.

Mild pain one year after beginning BPH. Severe pain and then sudden collapse of left condyle. Ceased medication, began occlusal treatment. 24/7 MPO splint wear. Relieved resultant symptoms and stabilized |aw.

Severe erosive changes seen in condyle and fossa. Spires of cancerous bone appear to “key” into fossa.

Case 2:  62 year old Caucasian female. Referred by her rheumatologist for evaluation of joint crepitus, moderate to severe pain, decreased mandibular range of motion and change of occlusion, history of jaw problems, on oral BPH x 4 years.

BPH, discontinued; maintained on MPO splint 24/7 with reduction of pain.

Case 3:  55 year old female with osteopenia (On BPH x 3 years). Presented with mild to moderate '‘TMJ" symptoms with joint popping.

MRI resembles MRI of osteonecrosis (OSN) of the head of the femur, CBCT sclerosis, bone cysts, ? Crescent sign.

BPH discontinued, TMD home care and MPO splint 24/7 relieved symptoms. Needs occlusal treatment.

Case 4:  Radiographs show no signs but MRI shows osteonecrosis.

62 year old female on oral BPH greater than one year for osteopenia. Minor symptoms "TMJ” symptoms, referred by ENT.

MPO splint worn 24/7 relieved symptoms but condyle was undermined and collapsed.

Discussion:  BRONJ Stage "0" occurs in the entire mandible. The TMJs are loaded and if compromised there is increased bone reactivity which attracts BPH. Areas of bone that flex are more reactive, receiving additional loads, and are more susceptible to BRONJ. Collapse of the condyle will cause occlusal changes increasing loads on the dentition, maxilla and mandible. Efforts to prevent and treat BRONJ should include MPO splints and occlusal treatments. Pharmacologic and medical management of the underlying conditions for which the BPH is prescribed are coordinated with the patient's physician.

Conclusions:  

•  Dentists must be aware of the potential effect of BPH.

•  Osteonecrosis can affect the entire mandible (including the TMJ).

•  Splints reduce bone load and reactivity.

•  Advanced imaging is necessary for differential diagnosis

•   More research is required to understand BPH-related osteonecrosis of the jaw.

Bisphosphononate Related Osteonecrosis of the TMJ: A Case Study.

See Research Project 068.pdf (7.9 MB).  A 6 year study of a 60 year old patient

Presented at American Academy of Physical Medicine and Rehabilitation, Las Vegas March 2012.

Bisphosphonate Related Stage "0" (zero) Osteonecrosis Involving the Temporomandibular Joint: A Case Study.

See Research Project 406.pdf (2.7 MB).  A case study of a 62 year old vocal music teacher with a history of progressively increasing pain.

Presented at an International Conference, Spain, Feb. 9-45, 2012.

Stage "0" Osteonecrosis of the TMJ in a musician after a short course of an Oral Bisphosphonate. Before collapse shown using computer tomography and MRI and after collapse using computed tomography and MRI.

She presented with non specific ear pain and some pain she thought was in the TMJ. CT was not diagnostic so a MRI of the TMJ was ordered. The MRI showed necrosis in the mandibular condyle. Treatment included and intra oral appliance to protect the tmj and allow the muscles to rest more. The pain symptoms were mostly alleviated but the necrosis of the medullary bone was too advanced and the cortical layer collapsed. Continued use of the appliance helped promote recortication and function. However the occlusion was altered by the joint collapse.

Masseter Muscle Trigger Point Injections for Differential Diagnosis of Head Pain.

See Research Project 849.pdf (7.7 MB).  4 case studies presented.

Presented at American Academy of PMR Conference, West Palm Beach, Fl, March 11-17, 2013.

Abstract 204: Bisphosphonate-Related Osteonecrosis of the Jaw/TMJ Presenting as Facial, Head, and Neck Pain: Case Study with 7-year Follow-Up.

See Research Project 204.pdf (3.1 MB).

Presented at the 30th Annual 2014 American Academy of Pain (AAAPM) Annual Meeting - Phoenix, AZ March 6-9, 2014.

 Toni Jo Hanson, MD1, Rand L Redfern, DDS2, (1) Mayo Clinic, Rochester, MN, (2) Colorado Springs, CO.

Objective: Diagnosis and management of patients with head, facial, and neck pain is frequently a multidisciplinary collaboration. A case study to increase awareness of bisphosphonate related osteonecrosis of the jaw (BRONJ) as a potential pain generator and to demonstrate the role of advanced imaging and management to improve outcomes is employed.

Design and Setting: Case study in a clinical setting. Intervention: 58-year-old woman with a 2-year history of oral bisphosphonate (osteopenia) presented with head, neck, and facial pain. Pain with jaw movement and palpation of the masseter temporalis, TMJ, and nuchal musculature was noted. Cone Beam CT, MRI, and dental x-rays confirmed diagnosis of stage 0 BRONJ. Treatment included discontinuing the bisphosphonates, dental referral for splint (to reduce TMJ loading, muscular activity), and physical therapy. TMJ was debrided. Bone quality was suboptimal for joint replacement. Main Outcome Measures: Clinical outcome was excellent. Pain decreased 90% (8-10/10 to 0-1/10). Serial CT revealed recortification of the TMJ condyle and fossa. Cancellous bone signal on MRI normalized.

Results: A patient with head, jaw, and neck pain diagnosed with BRONJ markedly improved with diagnosis and intervention. Pain level decreased, functional outcome improved, and radiologic imaging normalized. She reported excellent outcome.

Conclusions: Diagnosis and management of patients with head, jaw, and neck pain treated with multidisciplinary collaboration optimizes patient outcome in BRONJ. Splint use, physiotherapy, and discontinuation of bisphosphonates resulted in excellent patient outcome.

References: 1) Drake, M.T.; Clark, B. L.; et al. (2008). "œBisphosphonates: mechanism of action and role in clinical practice." Mayo Clin Proc 83(9):1032-1045. 2) Goncalves, D.A.; Camparis, C.M.; et al. (2011). "Temporomandibular disorders are differentially associated with headache diagnoses: a controlled study." Clin J Pain 27(7):611-615. 3) Hatcher, D.C.; Faulkner, M.G. (1986). "Development of mechanical and mathematical models to study temporomandibular joint loading." J Prosthet Dent 55(3):377-384. 4) Isberg, Annika, ed.Temporomandibular Joint Dysfunction: A Practitioner's Guide. Quintessence Publishing. Hanover Park, IL. 5) Jonasson, G.; Sundh V.; et al. (2011). "A prospective study of mandibular trabecular bone to predict fracture incidence in women: A low-cost screening tool in the dental clinic." Bone 49(4):873-879. 6) Laskin, DM; Greene, CS; Hylander, W.L., eds. (2006). Temporomandibular Disorders: An evidenced based approach to diagnosis and treatment. Quintessence Publishing; Hanover Park, IL. 7) Marx, RE, Sawatari, Y. (2005). BPH-induced bone of the jaws: risk factors, recognition, prevention, and treatment. J Oral Maxillofac Surg 63:1567-1575. 8) McNeil, C, eds.Engineering Principles and Modeling Strategies/Raymond T. Mah, Steven P. McEvoy, David C. Hatcher, M. Gary Faulkner. Quintessence Publishing, Hanover Park, IL. 9) Ott, S.M. "What is the optimal duration of bisphosphonate therapy?", from www.ccjm.org/content/78/9/619. 10) Piper, M.A.; Chuong, R. (1991). Avascular necrosis of the mandibular condyle: histologic correlation with MRI. American Society of Temporomandibular Joint Surgeons Annual Meeting. Palm Springs, CA.

Stage 0 Bisphosphonate Related Osteonecrosis of the Jaw in a Female Vocalist.

See Research Project 3349940.pdf (3.3 MB).

Presented at the Performing Arts Medicine Association PAMA Symposium, Aspen/Snowmass, June 26-30, 2014.

Drug-Related Osteonecrosis of the Jaw Presenting as Orofacial, Head and Neck Pain.

Stage "0" Bisphosphonate Related Osteonecrosis of the jaw or Drug Induced Osteonecrosis of the Jaw causing severe orofacial pain and trigeminal neuralgia symptoms. Lesions seen in the body of the mandible and seen in the condyles of the mandible. The patient made suicidal comments. Diagnostic treatment coordinated with her MDs included cessation of the oral medication, education and use of an intra-oral appliance designed to protect the joints and allow for the masticatory musculature and masticatory system to rest. Mutually Protective Appliance designed to unload the joints and allow the musculature to seek/return to a more pysiologic position.

See Research Project 3378535.pdf (2.9 MB).

International Academy of Pain, October 2014, Buenos Aires, Argentina. 

Polycystic Ovary Syndrome and Osteonecrosis of the
TMJ, Headache and Sleep Apnea

See RT Poster Color 8-2.pdf (15.7 MB).

Presented at International Academy of Dental Research meeting held in Florida, March 21-24, 2018.