Pentoxifylline, tocopherol, and sequestrectomy are effective for the management of advanced osteoradionecrosis of the jaws-a case series

Raíssa Soares Dos Anjos, Giovana Nóbrega de Pádua Walfrido, Rômulo Oliveira de Hollanda Valente, Luiz Alcino Gueiros, Alessandra Albuquerque Tavares Carvalho, Preeyan Patel, Stephen Porter, Jair Carneiro Leão, Igor Henrique Morais Silva

Support Care Cancer . 2020 Oct 27. doi: 10.1007/s00520-020-05847-6. Online ahead of print.


Background: The aim of the present study was to evaluate the efficacy of pentoxifylline and tocopherol for the management of osteoradionecrosis of the jaws.

Methods: Twenty-five patients diagnosed with osteoradionecrosis of the jaws treated with pentoxifylline 400 mg + tocopherol 400 mg three times daily (tid) were evaluated. Clinical records and image tests were reviewed. All patients were previously submitted to head and neck radiation therapy and presented with a clinical and radiographic diagnosis of osteoradionecrosis of the jaws.

Results: Following therapy with pentoxifylline and tocopherol, 76% (19/25) of the patients showed complete mucosal healing, in which 47.3% (9/19) did not undergo sequestrectomy. From this particular group, 77.7% (7/9) were in stage I and 33.3% (3/9) used the protocol for up to 3 months. Among those who underwent to sequestrectomy, complete mucosal healing was observed in 52.7% (10/19). Among these, 60% (6/10) were in stage I and 100% of the patients were using the protocol for more than 3 months. In all other patients, partial healing of the mucosa was observed since they presented advanced disease. These represented 24% of the sample (6/25), 66.6% (4/6) were in stage III, and 60% (4/6) used the protocol for over 6 months.

Conclusion: Pentoxifylline and tocopherol may provide effective management of osteoradionecrosis of the jaws, and the association with sequestrectomy may avoid major surgical procedures.

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Quercetin and vitamin E alleviate ovariectomy-induced osteoporosis by modulating autophagy and apoptosis in rat bone cells

Sina Vakili, Fatemeh Zal, Zohreh Mostafavi-Pour, Amir Savardashtaki, Farhad Koohpeyma

J Cell Physiol . 2020 Oct 8. doi: 10.1002/jcp.30087. Online ahead of print.


Osteoporosis is the most prevalent metabolic bone disease and one of the most important postmenopausal consequences. The aim of this study was to investigate the effects of quercetin (Q) and vitamin E (vitE) on ovariectomy-induced osteoporosis. Animals were ovariectomized and treated with Q (15 mg/kg/day), vitE (60 mg/kg/day), estradiol (10 µg/kg/day), and Q (7.5 mg/kg/day) + vitE (30 mg/kg/day) for 10 weeks by gavage, and osteoporosis markers and messenger RNA (mRNA) expression of autophagy and apoptosis-related genes were analyzed in serum and tibia of rats. Data indicated that ovariectomy resulted in development of osteoporosis as demonstrated by reduction in serum calcium, bone weight, bone volume, trabeculae volume, and the total number of osteocytes and osteoblasts, and increase in the total number of osteoclasts and serum osteocalcin. Total mRNA expressions of LC3, beclin1, and caspase 3 were also increased and bcl2 expression was decreased in the tibia. By reversing these changes, treatment with Q and vitE markedly improved osteoporosis. In conclusion, Q, and to a lesser extent, vitE, prevented osteoporosis by regulating the total number of bone cells, maybe through regulating autophagy and apoptosis.

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Pentoxifylline and tocopherol protocol to treat medication-related osteonecrosis of the jaw: A systematic literature review

Rafael Correia Cavalcante, Guilherme Tomasetti

J Craniomaxillofac Surg . 2020 Sep 18;S1010-5182(20)30206-7. doi: 10.1016/j.jcms.2020.09.008. Online ahead of print.


Purpose: Medication-related osteonecrosis of the jaw (MRONJ) is a previously described debilitating condition in which patients experience progressive bone destruction in the maxilla and/or mandible after exposure to certain drugs. Clinical management of MRONJ remains controversial, with no established guidelines. The aim of our study was to conduct a literature review on the effectiveness of pentoxifylline (PTX) and tocopherol (PENTO protocol) on MRONJ.

Study design: A literature review was conducted, using two different scientific databases, to evaluate the effects of PTX and tocopherol on MRONJ.

Discussion: PENTO protocol prescription to treat MRONJ was reported to be well tolerated, with minimal side-effects, and non-expensive when compared with other non-surgical treatment modalities. It was shown to relieve painful symptoms in all patients, and significant new bone formation was observed at final follow-up.

Conclusion: Observational and case-series studies have demonstrated that pentoxifylline and tocopherol are potentially useful in the non-surgical management of MRONJ.

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Vitamin C and E Treatment Blunts Sprint Interval Training-Induced Changes in Inflammatory Mediator-, Calcium-, and Mitochondria-Related Signaling in Recreationally Active Elderly Humans

Victoria L Wyckelsma, Tomas Venckunas, Marius Brazaitis, Stefano Gastaldello, Audrius Snieckus, Nerijus Eimantas, Neringa Baranauskiene, Andrejus Subocius, Albertas Skurvydas, Mati Pääsuke, Helena Gapeyeva, Priit Kaasik, Reedik Pääsuke, Jaak Jürimäe, Brigitte A Graf, Bengt Kayser, Nicolas Place, Daniel C Andersson, Sigitas Kamandulis, Håkan Westerblad

Antioxidants (Basel) . 2020 Sep 17;9(9):E879. doi: 10.3390/antiox9090879.


Sprint interval training (SIT) has emerged as a time-efficient training regimen for young individuals. Here, we studied whether SIT is effective also in elderly individuals and whether the training response was affected by treatment with the antioxidants vitamin C and E. Recreationally active elderly (mean age 65) men received either vitamin C (1 g/day) and vitamin E (235 mg/day) or placebo. Training consisted of nine SIT sessions (three sessions/week for three weeks of 4-6 repetitions of 30-s all-out cycling sprints) interposed by 4 min rest. Vastus lateralis muscle biopsies were taken before, 1 h after, and 24 h after the first and last SIT sessions. At the end of the three weeks of training, SIT-induced changes in relative mRNA expression of reactive oxygen/nitrogen species (ROS)- and mitochondria-related proteins, inflammatory mediators, and the sarcoplasmic reticulum Ca2+ channel, the ryanodine receptor 1 (RyR1), were blunted in the vitamin treated group. Western blots frequently showed a major (>50%) decrease in the full-length expression of RyR1 24 h after SIT sessions; in the trained state, vitamin treatment seemed to provide protection against this severe RyR1 modification. Power at exhaustion during an incremental cycling test was increased by ~5% at the end of the training period, whereas maximal oxygen uptake remained unchanged; vitamin treatment did not affect these measures. In conclusion, treatment with the antioxidants vitamin C and E blunts SIT-induced cellular signaling in skeletal muscle of elderly individuals, while the present training regimen was too short or too intense for the changes in signaling to be translated into a clear-cut change in physical performance.

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Reply “Comment on: Food for Bone: Evidence for a Role for Delta-Tocotrienol in the Physiological Control of Osteoblast Migration. Int. J. Mol. Sci. 2020, 21, 4661”

Lavinia Casati, Francesca Pagani, Roberto Maggi, Francesco Ferrucci, Valeria Sibilia

Int J Mol Sci . 2020 Sep 12;21(18):E6675. doi: 10.3390/ijms21186675.

Dear Editor,
We have carefully read the Letter to the Editor by Pang and Chin related to our paper entitled “Food for bone: evidence for a role for delta-tocotrienol in the physiological control of osteoblast migration” [1] published in the International Journal of Molecular Science.
We have some issues regarding the points raised by the authors.
  • The paper from Shen and colleagues 2018 [2] clearly shows the effect of dietary supplementation of tocotrienol in the suppression of bone resorption, probably mediated by the reduction of oxidative stress. Our statement “osteoporosis has been correlated with low intake, and serum levels of TTs” refers to this paper. We disagree with the authors that “dietary tocotrienol level has not been shown to correlate with bone health, probably due to the absence of a reliable dietary questionnaire that could assess the tocotrienol intake”, since Shen and colleagues (2018) have reported that a 12 week annatto-derived tocotrienol supplementation, previously used to examine the effects of tocotrienol on bone turnover, resulted in a significant increase in serum delta-tocotrienol levels in postmenopausal osteoporotic women [2].

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Comment on: Food for Bone: Evidence for a Role for Delta-Tocotrienol in the Physiological Control of Osteoblast Migration. Int. J. Mol. Sci. 2020, 21, 4661

Kok-Lun Pang, Kok-Yong Chin

Int J Mol Sci . 2020 Sep 12;21(18):E6674. doi: 10.3390/ijms21186674.

Dear Editor,
We applaud the innovative work by Casati et al., which explored the effects of delta-tocotrienol (δ-TT) in promoting osteoblast migration [1]. Vitamin E is reported as a nutrient important for maintaining bone health in epidemiological studies [2]. However, the statement “osteoporosis has been correlated with low intake, and serum levels of TTs” is inaccurate because dietary tocotrienol level has not been shown to correlate with bone health, probably due to the absence of a reliable dietary questionnaire that could assess the tocotrienol intake. Nevertheless, there is an abundance of preclinical evidence on the beneficial skeletal effects of tocotrienol. Most in vitro studies focus on the differentiation of osteoblasts, while the animal studies used bone cellular histomorphometry to quantify the bone cells in osteopenic rats treated with tocotrienol [3,4]. The work by Casati et al. is the first that focuses on the influence of tocotrienol on osteoblast migration, which plays an essential role in fracture healing. More accurately, mesenchymal stem cells migrated to the fracture site during fibrovascular phase and callus formation will differentiate into osteoblasts and perform bone formation [5]. A previous study also showed that particles incorporated with annatto tocotrienol rich in δ-TT could enhance callus strength of male rats with long bone fracture fixed with plate and screws [6]. The finding of δ-TT enhances the transcriptional activities of β-catenin also echoes our previous study, which demonstrated that annatto tocotrienol supplementation (60 mg/kg/day for 2 months) increased beta-catenin gene expression in the bone of orchidectomized rats [7].

Osteoprotective effect of green tea polyphenols and annatto-extracted tocotrienol in obese mice is associated with enhanced microbiome vitamin K 2 biosynthetic pathways

Moamen M Elmassry, Eunhee Chung, Jay J Cao, Abdul N Hamood, Chwan-Li Shen

J Nutr Biochem . 2020 Sep 10;108492. doi: 10.1016/j.jnutbio.2020.108492. Online ahead of print.


The role of the gut microbiome in bone health has received significant attention in the past decade. We investigated the effects of green tea polyphenols (GTP) and annatto-extracted tocotrienols (AT) on bone properties and gut microbiome in obese mice. Male mice were assigned to a two (no AT vs. 400 mg/kg diet AT)×two (no GTP vs. 0.5% w/v GTP) factorial design, namely control, G, T, and G+T group respectively, for 14 weeks. The 4th lumbar vertebra (LV-4) and femur were harvested for bone microstructural analysis using μ-CT. Microbiome analysis using 16S rRNA gene sequencing of cecal feces was performed. AT increased bone volume at distal femur. GTP increased serum procollagen type 1 N-terminal propeptide concentration, bone volume at the distal femur and the LV-4, and trabecular number at distal femur; whereas GTP decreased trabecular separation at distal femur. Interactions between GTP and AT were observed in serum C-terminal telopeptide of type I collagen level (control>G=T=G+T) as well as the cortical bone area (control<G=T=G+T) and thickness (T≥G+T≥G≥control) at femur mid-diaphysis. Redundancy analysis showed a significant difference in the gut microbiome profile among different groups and the relative abundance of Akkermansia muciniphila, Clostridum saccharogumia, and Subdoligranulum variabile was increased in the GTP- and AT-supplemented groups. Functional profiling of the gut microbiome showed the combination of GTP and AT induced biosynthetic pathways for vitamin K2. Our results suggest that GTP and AT supplementation benefits bone properties in obese mice through modifying gut microbiome composition and function.

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A vitamin E blended highly cross-linked polyethylene acetabular cup results in less wear: 6-year results of a randomized controlled trial in 199 patients

Julie R A Massier, Joost H J Van Erp, Thom E Snijders, Arthur DE Gast

Acta Orthop . 2020 Aug 24;1-6. doi: 10.1080/17453674.2020.1807220. Online ahead of print.


Background and purpose – Survivorship of total hip arthroplasty (THA) with the ultra-high molecular weight polyethylene (UHMWPE) monoblock cup has been limited due to periprosthetic osteolysis and aseptic loosening, secondary to wear of the UHMWPE. In response, a vitamin E blended highly cross-linked polyethylene (HXLPE) cup was developed. This study set out to compare the wear and clinical 6-year outcomes of vitamin E blended HXLPE with UHMWPE in an isoelastic monoblock cup in patients with hip osteoarthritis who underwent uncemented THA. The 2-year results have been reported previously.Patients and methods – For this randomized controlled trial 199 patients were included. 102 patients received the vitamin E blended HXLPE uncemented acetabular cup and 97 patients the uncemented UHMWPE monoblock cup. Clinical and radiographic parameters were obtained preoperatively, directly postoperatively, and at 3, 12, 24, and 72 months. Wear rates were compared using the femoral head penetration (FHP) rate.Results – 173 patients (87%) completed the 6-year follow-up. The mean NRS scores for rest pain, load pain, and patient satisfaction were 0.3 (SD 1), 0.6 (SD 1), and 8.6 (SD 1) respectively. The mean Harris Hip Score was 93 (SD 12). The FHP rate was lower in the vitamin E blended HXLPE cup (0.028 mm/year) compared with the UHMWPE cup (0.035 mm/year) (p = 0.002). No adverse reactions associated with the clinical application of vitamin E blended HXLPE were observed. 15 complications occurred, equally distributed between the two cups. The 6-year survival to revision rate was 98% for both cups. There was no aseptic loosening.Interpretation – This study shows the superior performance of the HXLPE blended with vitamin E acetabular cup with clinical and radiographic results similar to the UHMWPE acetabular cup.

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Does the addition of vitamin E to conventional UHMWPE improve the wear performance of hip acetabular cups? Micro-Raman characterization of differently processed polyethylene acetabular cups worn on a hip joint simulator

M Di Foggia, S Affatato, P Taddei

Braz J Med Biol Res . 2020;53(10):e9930. doi: 10.1590/1414-431x20209930. Epub 2020 Aug 17.


In knee replacements, vitamin E-doped ultra-high molecular weight polyethylene (UHMWPE) shows a better wear behavior than standard UHMWPE. Therefore, different sets of polyethylene (PE) acetabular cups, i.e. standard UHMWPE and cross-linked polyethylene irradiated with 50 kGy and 75 kGy, were compared, at a molecular level, with vitamin E-doped UHMWPE to evaluate their wear performance after being tested on a hip joint simulator for five million cycles. Unworn control and worn acetabular cups were analyzed by micro-Raman spectroscopy to gain insight into the effects of wear on the microstructure and phase composition of PE. Macroscopic wear was evaluated through mass loss measurements. The data showed that the samples could be divided into two groups: 1) standard and vitamin E-doped cups (mass loss of about 100 mg) and 2) the cross-linked cups (mass loss of about 30-40 mg). Micro-Raman spectroscopy disclosed different wear mechanisms in the four sets of acetabular cups, which were related to surface topography data. The vitamin E-doped samples did not show a better wear behavior than the cross-linked ones in terms of either mass loss or morphology changes. However, they showed lower variation at the morphological level (lower changes in phase composition) than the UHMWPE cups, thus confirming a certain protecting role of vitamin E against microstructural changes induced by wear testing.

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Pentoxifylline and Tocopherol in the Management of Temporal Bone Osteoradionecrosis: A Case Series

Benjamin D Lovin, Jonathan S Choi, Nathan R Lindquist, Jack Phan, Paul W Gidley, Marc-Elie Nader

Otol Neurotol . 2020 Jul 27. doi: 10.1097/MAO.0000000000002781. Online ahead of print.


Objective: Temporal bone osteoradionecrosis (TBORN) is a rare, chronic complication of head and neck radiation. Initial treatment consists of conservative management, with surgical resection of necrotic bone indicated for cases of severe, symptomatic, or progressive disease. Pentoxifylline-tocopherol (PENTO) has demonstrated usefulness for osteoradionecrosis of other head and neck subsites. Herein, we report five TBORN cases utilizing this protocol.

Study design: Retrospective case series.

Setting: Tertiary referral center.

Patients: This case series describes five TBORN cases in which the PENTO protocol was used in conjunction with conservative management. All patients were women and average age was 61 ± 8 years.

Intervention: All patients received a daily dose of 800 mg of pentoxifylline and 1 g of tocopherol. Four of the five patients received systemic and/or ototopical antibiotics as an antimicrobial regimen before and/or during the PENTO protocol.

Main outcome measures: Details regarding the total duration of protocol, improvement in symptoms, exposed bone and radiographic changes, and duration until first improvement of exposed bone were collected retrospectively.

Results: The average duration of PENTO protocol was 302 ± 166 days. Four of the five (80%) patients demonstrated a decrease in exposed ear canal bone. Three of the five (60%) patients had stable or improvement in otologic symptoms of TBORN. One patient progressed to diffuse TBORN. The average duration until first improvement in exposed bone was 193 ± 137 days.

Conclusions: The PENTO protocol may be a useful adjunct to conservative measures in the management of localized TBORN. We recommend trialing the protocol for at least 12 months.

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