Osteonecrosis of the Jaw influenced by Bisphosphonates Presented By: Manessah Cox, Student Anna Nguyen, Student

What is osteonecrosis of the jaw (ONJ)?  Described as the persistence of exposed bone in the oral cavity.  Results in loss of viability due to lack of blood supply.  Jaw bone is “starving”.

Bisphosphonates  Alendronate, Ibandronate, Risedronate, Zoledronic acid.  Can be oral or intravenously administered.  Antiresorptive Meds: they slow or stop the natural process that dissolves bone tissue.  They can prevent osteoporosis if already developed. It can slow rate of bone thinning.  USES: Prevention/treatment of osteopenia and osteoporosis.  Osteonecrosis of the Jaw (ONJ) is a condition found in patients who received IV and oral forms of bisphosphonates.

Purpose:  To become aware of the disease and correct procedures/instructions to present to the patient  Systemic antibiotic premedication should be prescribed immediately prior to debridement of the ONJ site and followed for 10 to 14 days post- debridement.  To provide correct patient education for patients with ONJ  Chlorhexidine mouth rinses should be prescribed for twice daily use.  Meticulous oral hygiene must be emphasized.  Any sharp, ill fitting prosthodontics appliances The site should be debrided and monitored every 2-3 weeks until the site is healed.

ONJ and Bisphosphonates  ONJ is uncommon but can have severe adverse effects.  It is hypothesized that the bisphosphonates lead to a possible accumulation of micro-damage which can lead to micro-fractures.  Additional trauma, infection, periodontal disease, and chemotherapy increases chances of getting ONJ.

Susceptibility to the disease  Women/men  Cancer patients receiving high doses of intravenous bisphosphonates

Clinical Signs and Prevention  Intraoral lesions with areas of exposed yellow-white hard bone.  Ulcers  Severe, abnormal Radiolucencies  Prevention: maintain optimum oral health before any bisphosphonate treatment. (Complete dental exam, completing any traumatic treatment including extractions.  Regular 6 month recall  Patients taking bisphosphonates should avoid alcohol and tobacco.

Treatment and Maintenance  The best treatment is prevention. Before a patient is placed on an IV bisphosphonate:  Once developed there is no effective therapy.  Antibiotics (Topical)  Chlorhexidine gluconate rinses.  The further use of bisphosphonates should be discussed with physician/oncologist.  A full dental clearance should be performed using appropriate diagnostic information.  Periodontal debridement (scaling/root planning/periodontal surgery) should be performed as needed  Restorative dentistry should be performed to eliminate caries.  Teeth with poor or hopeless prognoses should be extracted.  The patient needs to be on a tightly managed maintenance program that includes continued oral hygiene reinforcement and education on the oral risks of IV bisphosphonate therapy.

Should patients discontinue use of bisphosphonates if osteonecrosis is diagnosed?  Discontinuing therapy must be discussed with the patient’s oncologist or primary physician.  To date, scientific evidence does not support the discontinuation of bisphosphonate therapy to improve soft or osseous tissue healing. The half-life of IV bisphosphonates is years in duration and the medication itself deposits in the bone matrix.  Further research is needed to provide clinical guidelines.

Dental Considerations  Maintain good oral health before the start of bisphosphonate treatment so any invasive dental procedures are not needed.  If a dental procedure (teeth extraction, etc.) is needed, try to do it before start of treatment.

Suggested Staging and Management of Osteonecrosis of the Jaw Stage (Frequency)Defining FeaturesManagement by Stage Stage I (-30%)Bare bone in oral cavity; no infection; often asymptomatic Chlorhexidine mouth rinse twice daily. Stage II (-40%)Bare bone in oral cavity; soft-tissue infection present; usually symptomatic Chlorhexidine rinse twice daily; PRN; antibiotic for infection and medication for pain Stage III (-20%)Extensive bare bone in oral cavity; extensive soft- tissue infection Conservative soft-tissue debridement to clear necrotic soft tissue Chlorhexidine rinse twice daily; PRN: antibiotic for infection and medication for pain Stage IV (-10%)Extensive bare bone in oral cavity; extensive soft- tissue infection with hard- tissue involvement Conservative soft- and hard- tissue debridement to clear necrotic tissue and establish blood flow Chlorhexidine rinse twice daily; PRN: antibiotic for infection and medication for pain

Benefits vs. Risk of taking Bisphosphonates  If you’re at significant risk at breaking bones and you can reduce risk by taking bisphosphonates by half.  Bisphosphonates reduces the risk of osteoporosis by half.  That benefit overwhelmingly outweighs the very small risk of getting osteonecrosis of the jaw.  With ONJ, there are factors that will increase your chances of getting this disease while taking these drugs.

Reference  Gavrić, M., Antić, S., Jelovac, D. B., Zarev, A. I., Petrović, M. B., Golubović, M., & Antunović,  M. (2014). Osteonecrosis of the jaw as a serious adverse effect of bisphosphonate therapy and its indistinct etiopathogenesis. Vojnosanitetski Pregled: Military Medical & Pharmaceutical Journal Of Serbia & Montenegro, 71(8), doi: /VSP G  Akhtar, N. H., Afzal, M. Z., & Ahmed, A. A. (2011). Osteonecrosis of jaw with the use of  denosumab. Journal Of Cancer Research & Therapeutics, 7(4), doi: /  Miyazaki, H., Nishimatsu, H., Kume, H., Suzuki, M., Fujimura, T., Fukuhara, H., &... Homma,  Y. (2012). Leukopenia as a risk factor for osteonecrosis of the jaw in metastatic prostate cancer treated using zoledronic acid and docetaxel. BJU International, 110(11b), E520-E525. doi: /j X x  Quispe, D., Shi, R., & Burton, G. (2011). Osteonecrosis of the Jaw in Patients with Metastatic  Breast Cancer: Ethnic and Socio-Economic Aspects. Breast Journal, 17(5), doi: /j x