ONJ (Osteonecrosis of the Jaw) in Bisphosphonate-Treated Cancer Patients

Bisphosphonates effectively manage bone complications from cancer Approved for treatment of malignant bone disease from solid tumors and multiple myeloma Zoledronic acid (Zometa) is approved for the treatment of any advanced malignancy involving bone

● Common adverse events - Flu-like symptoms - Fever - Myalgias/ Arthralgias ● Uncommon adverse events: - Renal-function effects - Osteonecrosis of the jaw

ONJ Etiology and pathogenesis are not well characterized The clinical identification of ONJ is usually made on the basis of visual inspection and/or radiographic appearance

Study Study type Patients treated with BP, n Patients with suspected or proven ONJ, n Frequency % Hoff et al.MDACC ASCO 2006 Chart review 3,994 29 0.7% Durie et al Web-based survey 1,203 152 12.6% Pozzi et all italian multicenter study 888 16 1.8% Badros et al Chart review/observational 340 11 3.2% Tosi et al. Analysis of Bologna 2002 trial Retrospective review of trial data base 259 9 3.5% Dimopoulos et al 202 15 7.4% Cafro et al 118 14 11.9%

Risk Factors for ONJ •Periodontal disease •Dento-alveolar surgery •Oral trauma •Corticosteroid therapy •Immuno-compromised state

Recommendations for the Management of ONJ Prevention of ONJ • Prior to treatment with bisphosphonates: – Dental exam with appropriate preventive dentistry – Remove abscessed teeth, and teeth with poor long-term prognosis – Educate patients on oral hygiene and signs and symptoms of ONJ

• During bisphosphonate treatment – Seek dental maintenance care at least every 6 months – Avoid invasive dental procedures if possible

• In case of ONJ – Refer to dental professional as soon as possible – Reassess benefit/risk of continued bisphosphonate therapy • No prospective data exist to withhold therapy–Conservative management

ONJ Outcomes • Emerging data indicate that stability / improvement of lesions occurs in the majority of patients with conservative management – With preventive measures and conservative management, deterioration occurs only in a minority of patients

ONJ : personal clinical case V.H.52 year old man receiving IV Biphosphonate as maintenance therapy for Multiple Myeloma ONJ healing after 3 months ONL annual incidence : 1/300. it dropped to 1/7000 by practicing prevention dental care. ONJ after two years of Biphosphonate therapy

Summary - ONJ is an uncommon event - Most patients can be managed conservatively according to guidelines with minimal impact on quality of life - Ongoing studies will increase the understanding of ONJ…

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