FROM THE DESK OF ALAN M MELTZER DMD MScD
UPDATE #1 ON BISPHOSPHONATE-ASSOCIATED
OSTEONECROSIS OF THE JAW
In 2007, a multidisciplinary task force was formed by the American Society for Bone and Mineral Research on bisphosphonate-associated osteonecrosis of the jaw (ONJ). The full reference may be found at J. Bone Miner Res 2007; 22:1479-1491. This paper, I feel, provides some of the best information available on the subject. I will review the content of the paper here, but suggest everyone read the entire paper.
What is ONJ? ONJ is the presence of exposed bone in the maxillofacial region that does not heal within eight weeks after identification by a healthcare provider.
What is the risk of ONJ associated with oral bisphosphonates taken for osteoporosis? The risk is extremely low and is ranked as between 1 in 10,000 and 1 in 100,000 patient-treatment years. The condition is more common in the mandible than the maxilla.
What is the risk of ONJ in patients with cancer being treated with high doses of IV bisphosphonates? The risk is much higher and is in the range of 10% or less, depending on the duration of treatment.
What is the risk of ONJ in patients being treated with once-a-year IV Reclast for osteoporosis? Unknown.
What are the risk factors for ONJ? The risk factors are: IV bisphosphonates, cancer and associated anti-cancer therapy, dental extractions, oral surgery with bone manipulation, poor fitting dental appliances, intraoral trauma, duration of bisphosphonate treatment, glucocorticoids, alcohol and tobacco abuse, and pre-existing dental disease.
How should a dentist manage a patient already receiving (oral) bisphosphonate therapy?
- Informed consent regarding risks as outlined above and providing copies of articles, such as the one outlined above.
- Stress good oral hygiene with regular dental care.
For patients on long-term bisphosphonate therapy (currently defined as more than three years), the following precautions are advised:
- Patients with periodontal disease should be treated with non-surgical treatment. If surgery is required, then minimal bone exposure and re-contouring can be considered.
- Taking oral bisphosphonates is not a contraindication for dental implant placement. Informed consent should be provided and documented.
- Endodontic (root canal) treatment is preferable to endodontic surgery or extraction.
- While somewhat controversial, there is a suggestion to stop oral bisphosphonates for a period before and after invasive dental treatment
A further discussion of patients receiving IV bisphosphonates will be continued in my next newsletter.