A retrospective study assessing the incidence, risk factors and comorbidities of pamidronate-related necrosis of the jaws in multiple myeloma patients

Pathophysiology of Osteonecrosis of the Jaws

Osteonecrosis of the jaw (ONJ) is a multifactorial disease in patients with primary or metastatic bone malignancy or osteoporosis undergoing systemic antiresorptive therapy, where pathophysiology has not yet been fully determined. The staging of ONJ is based on severity of symptoms and extent of clinical and radiographic findings. Treatment strategies range from conservative local wound care to aggressive resective surgery of all necrotic bone. The first ONJ cases were reported in 2003 and 2004, and although significant progress has been made in our understanding of the disease, much more work needs to be done to completely explain its pathophysiology.

Preventive Strategies for Patients at Risk of Medication-related Osteonecrosis of the Jaw

For patients at risk of osteonecrosis of the jaw (ONJ), information can be provided by the pharmaceutical manufacturer, pharmacist, prescribing physician, dentist, and oral and maxillofacial surgeon. Prevention strategies to reduce the incidence of osteonecrosis should be applied as soon as it is determined that a patient will be placed on antiresorptive medication. Proper screening involves a comprehensive oral examination with radiographs followed by oral hygiene instruction and necessary dental treatment; surgical techniques and adjunctive therapies that favor optimum healing of bone and soft tissue decrease the risk of ONJ. No dental procedures are absolutely contraindicated.

Bisphosphonate and Implant Dentistry - Is it Safe?

Bisphosphonates are a group of drugs that are commonly used to alter bone metabolism in order to prevent bone loss in diseases such as osteoporosis and bone cancers. Unfortunately, the use of bisphosphonates has been associated with bisphosphonate-related osteonecrosis of the jaws. The debate as to whether it is wise to consider implant therapy in patients being treated with bisphosphonate therapy remains a grey area. This review will present the latest evidence and guidelines available on bisphosphonates and their possible effects on implant dentistry. The risk factors, co-morbidities, clinical presentation and findings from various imaging modalities for bisphosphonate-related osteonecrosis of the jaws are highlighted. The management of patients being treated with bisphosphonates, in whom dental implants might be considered or have already been placed, will also be discussed. Finally, the areas requiring future research are considered.

Diagnosis and management of osteonecrosis of the jaw: a systematic review and international consensus

This work provides a systematic review of the literature from January 2003 to April 2014 pertaining to the incidence, pathophysiology, diagnosis, and treatment of osteonecrosis of the jaw (ONJ), and offers recommendations for its management based on multidisciplinary international consensus. ONJ is associated with oncology-dose parenteral antiresorptive therapy of bisphosphonates (BP) and denosumab (Dmab). The incidence of ONJ is greatest in the oncology patient population (1% to 15%), where high doses of these medications are used at frequent intervals. In the osteoporosis patient population, the incidence of ONJ is estimated at 0.001% to 0.01%, marginally higher than the incidence in the general population (<0.001%). New insights into the pathophysiology of ONJ include antiresorptive effects of BPs and Dmab, effects of BPs on gamma delta T-cells and on monocyte and macrophage function, as well as the role of local bacterial infection, inflammation, and necrosis. Advances in imaging include the use of cone beam computerized tomography assessing cortical and cancellous architecture with lower radiation exposure, magnetic resonance imaging, bone scanning, and positron emission tomography, although plain films often suffice. Other risk factors for ONJ include glucocorticoid use, maxillary or mandibular bone surgery, poor oral hygiene, chronic inflammation, diabetes mellitus, ill-fitting dentures, as well as other drugs, including antiangiogenic agents. Prevention strategies for ONJ include elimination or stabilization of oral disease prior to initiation of antiresorptive agents, as well as maintenance of good oral hygiene. In those patients at high risk for the development of ONJ, including cancer patients receiving high-dose BP or Dmab therapy, consideration should be given to withholding antiresorptive therapy following extensive oral surgery until the surgical site heals with mature mucosal coverage. Management of ONJ is based on the stage of the disease, size of the lesions, and the presence of contributing drug therapy and comorbidity. Conservative therapy includes topical antibiotic oral rinses and systemic antibiotic therapy. Localized surgical debridement is indicated in advanced nonresponsive disease and has been successful. Early data have suggested enhanced osseous wound healing with teriparatide in those without contraindications for its use. Experimental therapy includes bone marrow stem cell intralesional transplantation, low-level laser therapy, local platelet-derived growth factor application, hyperbaric oxygen, and tissue grafting.

Risk factors influencing the duration of treatment with bisphosphonates until occurrence of an osteonecrosis of the jaw in 963 cancer patients

OBJECTIVE

Osteonecrosis of the jaw (ONJ) is an adverse effect that is associated with bisphosphonate (BP) use. Little data are available on risk factors influencing the time of treatment until an osteonecrosis occurs.

METHODS

From 1 Dec 2004 until 21 Sep 2012, the German Register collected all patients with validated diagnoses of ONJ (N = 1,229) that were reported to the national pharmaco-vigilance system or to the Register directly. We analysed 963 patients with cancerous disease and an ONJ during i.v. BP treatment. Duration of BP treatment until first diagnosis of ONJ and Kaplan-Meier curves of ONJ-free survival were analysed stratified by gender, type of BP and type of cancer.

RESULTS

Main indications for BP treatment were breast cancer (36%), multiple myeloma (24%), prostate cancer (16%) and kidney cancer (4%). Men suffered from their ONJ earlier than women. A total of 780 patients (81%) had their ONJ during zoledronate treatment, 93 (10%) under pamidronate and 90 (9%) under ibandronate treatment. ONJ-free survival in single BP users was significantly longer in pamidronate-treated patients than in zoledronate or ibandronate users. Ibandronate users had the shortest median duration of treatment (17 months), similar to that of zoledronate users (21.5 months). Sequential prescription of two different BPs prolonged the period of overall BP treatment until an ONJ occurred. Time of BP treatment was shortest in patients with kidney cancer. Age or a concomitant osteoporosis did not influence the time to event of an ONJ.

CONCLUSION

Systemic risk factors such as gender play a significant role in certain subgroups only. Comparative analysis of different cancer patients helps the treating oncologist/dentist to identify patients with a more imminent risk to develop an ONJ (i.e. kidney cancer, ibandronate/zoledronate use).

Concomitant factors leading to an atypical osteonecrosis of the jaw in a patient with multiple myeloma

Osteonecrosis of the jaw (ONJ) is a site specific osseous pathology, characterized by chronic exposed bone in the mouth, which needs to be reinforced periodically within the medical literature. ONJ is a clinical entity with many possible aetiologies and its pathogenesis is not well understood. The risk factors for ONJ include bisphosphonates treatments, head and neck radiotherapy, dental procedures involving bone surgery, and trauma. Management of ONJ has centred on efforts to eliminate or reduce severity of symptoms, to slow or prevent the progression of disease, and to eradicate diseased bone. This case describes a rare case of ONJ in a 64-year-old Caucasian male diagnosed with multiple myeloma stage III. The lesion was related to a traumatic injury during mastication. Eighteen months ago in the same area the molar 37 was extracted, achieving a complete satisfactory healing, when only 2 doses of zoledronic acid had been administered. Actinomyces bacterial aggregates were also identified in the microscopic analysis. The management of this osteonecrotic lesion included antibiotic treatment and chlorhexidine topical gel administration. The evolution was monitored every two weeks until patient's death. The authors provide a discussion of the etiology, pathogenesis, diagnosis, and management. This case report may shed light on the controversies about concomitant factors and mechanisms inducing ONJ.

New dimensional staging of bisphosphonate-related osteonecrosis of the jaw allowing a guided surgical treatment protocol: long-term follow-up of 266 lesions in neoplastic and osteoporotic patients from the university of bari

Bisphosphonate-related osteonecrosis of the jaw (BRONJ) is the most serious side effect in patients receiving bisphosphonates (BPs) for neoplastic disease and osteoporosis. The aim of this study is to propose a new dimensional stage classification, guiding the surgical treatment of BRONJ patients, and to evaluate the success rate of this new management. From 2004 to 2013, 203 neoplastic and osteoporotic patients with 266 BRONJ lesions were referred to the Odontostomatology Unit of the University of Bari. All patients underwent surgery after suspension of BPs therapy and antibiotic treatment. The surgical procedure was complemented by piezosurgery and followed by the application of hyaluronate and amino acids. The new dimensional staging suggests the choice of the surgical approach, and allows the prediction of postoperative complications and soft and hard tissues healing time, guiding the surgical treatment protocol. This protocol could be a successful management strategy for BRONJ, considering the low recurrences rate and the good stabilisation of the surgical sites observed after a long-term follow-up.

Treatment of bisphosphonate related osteonecrosis following root canal therapy at the 1-year follow-up: report of two cases

The objective of this report was to use topical gaseous ozone as an adjunct to conventional treatment methods and to describe the multidisciplinary management of bisphosphonate associated bone necrosis, which developed following endodontic treatment. No complaints were noted by the patients at their 1-year follow-up and the treatment showed favorable prognosis.

Review of new guidelines for the management of glucocorticoid induced osteoporosis

The chronic use of glucocorticoids results in osteoporosis. Several sets of guidelines have been published on the management of glucocorticoid induced osteoporosis (GIO). These guidelines vary on their focus and highlight different aspects of the current concepts in the management of GIO. In this current article, we summarize recent guidelines for management of GIO and highlight similarities and differences as well as address some of the controversies generated by these guidelines.

Proceedings from the 2013 American Association of Oral and Maxillofacial Surgeons Research Summit

The American Association of Oral and Maxillofacial Surgeons, the Oral and Maxillofacial Surgery Foundation, and the International Association of Oral and Maxillofacial Surgeons sponsored the fifth research summit, which convened on May 2 and 3 in Rosemont, Illinois. The Research Summits are convened biennially to facilitate the discussion and collaboration of oral and maxillofacial surgeons with clinical and basic science researchers in fields affecting the specialty. The goal is to advance the field of oral and maxillofacial surgery through exposure and education in topics that ultimately benefit the oral and maxillofacial surgical patient. This edition of the research summit included the topics of robotic surgery and antiresorptive-related osteonecrosis of the jaws (ARONJ). Most importantly, this research summit saw the development of research interest groups (RIGs) in the fields of anesthesia, maxillofacial oncology and reconstructive surgery, obstructive sleep apnea and orthognathic surgery, temporomandibular joint surgery, and trauma. These RIGs developed specific research goals with a plan to continue working on potential projects at the AAOMS Clinical Trials Course on May 7 to 9, 2013 at the University of Michigan in Ann Arbor. The summit program was developed by the AAOMS Committee on Research Planning and Technology Assessment. The charge of the committee is to encourage and promote research within the specialty and to encourage interdisciplinary collaboration. The research summit serves as a platform for oral and maxillofacial surgeons to lead the goal of advancement of research relevant to the specialty. This article provides an overview of the presentations that were made in the sessions on robotic surgery and ARONJ. The research summit keynote address and two additional presentations on patient registries are summarized and updates from the RIGs that were formed at the 2013 research summit are highlighted.

Ninety-one osteoporosis patients affected with bisphosphonate-related osteonecrosis of the jaw: a case series

Bisphosphonate (BP)-related osteonecrosis of the jaw (BRONJ) presents with necrotic bone in the mouth in the setting of BP exposure. It has been studied in cancer patients taking high-dose BP, but BRONJ has also been noted in patients taking lower-dose BP for osteoporosis. The purpose of this study was to characterize the phenotypes and outcomes in a large series of patients with osteoporosis and BRONJ in the setting of BP exposure. We conducted a retrospective case series. The sample was composed of subjects with BRONJ and osteoporosis. Subjects with a history of BP treatment for myeloma or metastatic cancer to the bones were excluded. Descriptive statistics were computed for the study variables. Ninety-one cases of BRONJ met the inclusion criteria. Subjects had a median age of 71 years and were predominantly female (94.5 %). The median time of BP exposure was 60 months (range 2-120). Most subjects were treated with alendronate (82.4 %). The mandible was involved more frequently (58.2 %) than the maxilla (37.3 %). Subjects commonly (65.9 %), but not universally, reported pain. For subjects with treatment outcome data (n = 0), most reported improvement (80.0 %). Although BRONJ is an uncommon condition, the absolute number of cases is fairly large due to the very large number of patients taking BPs for osteoporosis. The findings of this study confirm that BRONJ primarily affects the mandible, a substantial minority present without pain, and patients typically improve with treatment.

Conservative management of bisphosphonate-related osteonecrosis of the jaws: staging and treatment outcomes

OBJECTIVE

Bisphosphonate-related osteonecrosis of the jaws is a well-established disorder in which patients treated with bisphosphonates develop exposed necrotic bone in the oral cavity. The objective of this study was to report staging and treatment outcomes in a large cohort of patients with bisphosphonate-related osteonecrosis of the jaws managed primarily with non-surgical measures.

PATIENTS AND METHODS

A retrospective medical record review was conducted from 1998 to 2010 of all patients referred for the management of bisphosphonate-related osteonecrosis of the jaws. Clinical findings and staging were assessed at initial consultation and each follow-up visit. Management was provided to minimize symptoms and/or achieve resolution of lesions. Treatment responses were defined based on symptoms and/or change in staging.

RESULTS

There were 120 records reviewed and 97 patients seen for follow-up (median 12months); 90% were cancer patients. Bisphosphonate-related osteonecrosis of the jaws was managed with observation (16%), antibiotics (55%), non-surgical sequestrectomy±antibiotics (14%), or surgery±antibiotics (14%). There were 14 patients (12%) who presented with stage 0 disease; 41%, 43%, and 5% of patients presented at stages 1, 2, and 3, respectively. Greater than 70% of patients improved, remained asymptomatic, and/or showed complete re-epithelialization when evaluated at 0-3, 3-6, 6-9, 9-12, and/or >12months. Seventeen patients developed non-infectious complications of BONJ including neuropathy (N=9), painful tongue ulcers (N=7), or pathologic fracture (N=1). Twelve patients with multiple myeloma underwent hematopoietic cell transplantation without infectious complications.

CONCLUSIONS

A primarily non-surgical approach appears to be a successful management strategy for bisphosphonate-related osteonecrosis of the jaws. Overall, 71-80% of patients improved or remained asymptomatic with a median follow-up of 12months.

Bisphophonates related osteonecrosis of the jaw

OBJECTIVE

With sporadic reporting of BPs related osteonecrosis of jaw and in absence of definitive guidelines regarding the management of such patients, the dentists and the oral and maxillofacial surgeons need to be updated about this issue. The objective of this article was to produce an updated bibliographic review of BPs related ONJ. This paper reviews the literature regarding the same for better understanding of the problem and its management.

BACKGROUND

Bisphosphonates (BPs) are potent inhibitors of bone resorption and are widely used in the treatment of osteoporosis and other diseases that cause bone mass loss, such as Paget's disease, bone metastases, and multiple myeloma, to prevent pathological fractures. With increasing use, evidence is emerging that patients taking BP drugs are at risk of developing osteonecrosis of the jaws (ONJs), sometimes occurring spontaneously, but more commonly following dental extractions or oral bone surgery.

MATERIALS AND METHODS

A bibliographic search was carried out using PubMed, Medline, and search engines ending in April, 2013. The search terms used were: Oral BPs, dental implants, and osteonecrosis.

CONCLUSION

On the basis of available literature, the management of patients on bisphosphonates requiring dental treatment is classified according to the duration of BPs treatment, method of administration of BPs etc. Dental treatments when planned carefully in such patients have a fair to good prognosis.

Toxicities following treatment with bisphosphonates and receptor activator of nuclear factor-κB ligand inhibitors in patients with advanced prostate cancer

CONTEXT

Advanced prostate cancer (PCa) is associated with skeletal complications, both as a result of bone metastases and because of fractures associated with fragility due to androgen-deprivation therapy (ADT). Osteoclast inhibitors are commonly used to reduce skeletal complications but are associated with a number of potential adverse events.

OBJECTIVE

To review clinical trials of osteoclast inhibitors in advanced PCa, to discuss the adverse event profile of these agents, and to discuss strategies to address specific adverse events.

EVIDENCE ACQUISITION

PubMed was searched for reports of clinical trials of osteoclast inhibitors in advanced PCa. As zoledronic acid and denosumab are used most commonly in this disease, these trials were the focus. The literature was reviewed to identify key publications addressing the prevention and management of adverse events associated with these drugs.

EVIDENCE SYNTHESIS

The major findings of the trials and the adverse events are discussed. Prevention and management of common adverse events are addressed.

CONCLUSIONS

Zoledronic acid prevents loss of bone mineral density associated with ADT and delays skeletal-related events in metastatic castration-resistant PCa (mCRPC). Denosumab reduces the incidence of fragility fractures associated with ADT, delays the onset of bone metastases in nonmetastatic castration-resistant disease, and is superior to zoledronic acid in the prevention of skeletal complications in mCRPC. Adverse events associated with both agents include osteonecrosis of the jaw and hypocalcemia. Hypocalcemia is more common with denosumab. Zoledronic acid requires dose modifications for renal insufficiency, is contraindicated in severe renal insufficiency, and has been associated with deterioration of renal function. Appropriate patient selection with close attention to dental health, supplementation with calcium and vitamin D, and monitoring of laboratory values are effective strategies to minimize the impact of adverse events associated with osteoclast inhibitors in advanced PCa.

Does dental and oral health influence the development and course of bisphosphonate-related osteonecrosis of the jaws (BRONJ)?

PURPOSE

The main causes for the occurrence of bisphosphonate-related osteonecrosis of the jaws (BRONJ) are the application of aminobisphosphonates and the extraction of teeth. However, the question which factors in dental and oral health are relevant has not been answered completely.

MATERIALS AND METHODS

In a retrospective study, 50 patients who were treated with BRONJ between 2000 and 2009 were analyzed. As underlying diseases, they suffered from breast cancer (n = 24), multiple myeloma (n = 16), prostate cancer (n = 5), osteoporosis (n = 4), and kidney cancer (n = 1). The data were collected from the patient charts of the treating dentists, oral and maxillofacial surgeons, general practitioners, and oncologists. The time of occurrence of BRONJ after treatment onset with bisphosphonates (BP) was examined with Kaplan-Meier estimator and logrank test (level of significance 0.05).

RESULTS

At the time of BP treatment, onset the decayed, missing, and filled teeth (DMFT) index was 20.5 ± 4.2. Patients with a DMFT value less than 20 showed a significantly longer BRONJ-free time interval after BP treatment onset with 39.7 ± 1.1 months compared to patients with a DMFT value higher than 20, in whom BRONJ appeared after 14.4 ± 2.8 months (p < 0.001). However, the DMFT value had no influence on the success rate of BRONJ treatment. As a pre-existing oral disease, 60 % of the patients (n = 30) had marginal periodontitis; 38 % (n = 19), apical periodontitis; and 22 % (n = 11), a pressure lesion from their dentures. In patients with marginal periodontitis, BRONJ occurred after 26.3 months (range 20.9-31.3) and in patients without marginal periodontitis, after 27.4 months (range 14.6-40.1) (p = 0.58). Only 20 % of the patients with marginal periodontitis received adequate treatment. Without parodontal treatment, BRONJ occurred 15 months earlier compared to patients with parodontal treatment (p = 0.12). The state of the periodontium did not influence the healing rate of BRONJ (p > 0.999).

CONCLUSION

The present study highlights the great benefit of good dental and oral health in the prevention of BRONJ; but it also shows that after the appearance of BRONJ, these factors do no longer seem to play a relevant role in the disease course.

Dental complications and management of patients on bisphosphonate therapy: A review article

Bisphosphonates are group of drugs that inhibit bone resorption and are used to treat a range of pathologies including Paget's disease, osteoporosis, multiple myeloma and metastasis associated with breast or prostate cancer. The most common complication in patients on bisphosphonate therapy is osteonecrosis of jaw (ONJ) which can occur after any surgical dental procedure and the risk for the development of osteonecrosis of jaw is higher in patients receiving intravenous bisphosphonate therapy than in patients receiving oral bisphosphonate therapy. Typical presentation is in the form of non-extraction socket, presence of exposed bone, gingival swelling or purulent discharge, when local debridement and antibiotics are ineffective. At present, there is no effective treatment for bisphosphonate induced osteonecrosis, so prevention is extremely important. Maximum precautions should be taken in patients who are at the risk of development of ONJ especially when any dental surgical procedure like extractions, retrograde apicoectomies, periodontal surgery and implant placement is contemplated. Dentists and oral or maxillofacial surgeon must keep up to date with the latest approaches or guidelines to prevention and the risk factors, particularly when treating patients who are on bisphosphonates, or who will be taking bisphosphonates.

Incidence and risk factors of bisphosphonate-related osteonecrosis of the jaw in multiple myeloma patients having undergone autologous stem cell transplantation

BACKGROUND

Bisphosphonate-related osteonecrosis of the jaw (BRONJ) is a severe complication of bisphosphonate therapy. Due to their long survival and subsequently high cumulative doses of bisphosphonates, multiple myeloma patients have the highest risk of developing BRONJ of all patients treated with bisphosphonates. The purpose of the present study was to evaluate the incidence and risk factors for BRONJ in multiple myeloma patients after high-dose chemotherapy and autologous stem cell transplantation (ASCT).

PATIENTS AND METHODS

We retrospectively analyzed the data of 120 multiple myeloma patients after high-dose chemotherapy and ASCT treated with bisphosphonates and assessed the incidence and risk factors of BRONJ.

RESULTS

Of the 120 patients, 23 (19%) developed BRONJ. 6 patients suffered several BRONJ events, resulting in a total incidence of 23%. The risk for BRONJ was significantly higher for patients with rheumatism and recent dental manipulations. Furthermore, the number of previous bisphosphonate rotations, the duration of bisphosphonate therapy, and the type and cumulative dose of bisphosphonate used were associated with the incidence of BRONJ.

CONCLUSION

Our study is the first to determine the risk of BRONJ in a homogeneous group of multiple myeloma patients treated with high-dose chemotherapy and ASCT.

Clinical treatment outcomes for 40 patients with bisphosphonates-related osteonecrosis of the jaws

BACKGROUND/PURPOSE

Bisphosphonates (BPs) are used to treat osteoporosis and bone metastases from malignancy. They may result in BPs-related osteonecrosis of the jaws (BRONJ) in a subset of patients receiving BPs. This study examined whether conservative or aggressive surgical approach could result in successful treatment of BRONJ lesions and assessed whether concomitant steroid administration or tobacco smoking habit might hinder the remission of BRONJ lesions.

METHODS

The 40 BRONJ patients were evenly divided into four different groups. Group 1 contained 10 patients with concomitant corticosteroid medication but without smoking habit. Group 2 contained 10 patients with smoking habit but without concomitant corticosteroid medication. Groups 3 and 4 each consisted of 10 patients without concomitant corticosteroid medication and smoking habit. To avoid bias, each group contained equal number of patients with different stages of BRONJ. Patients in Groups 1, 2, and 3 received conservative treatment, including antibiotic coverage, antibacterial solution irrigation, and minor surgical debridement. Patients in Group 4 were treated with aggressive surgical excision of necrotic bone segment.

RESULTS

The mean duration to achieve complete remission of BRONJ lesion was 19.7±0.6, 18.2±0.5, 13.0±1.0, and 7.6±1.1 months for patients in Groups 1, 2, 3 and 4, respectively. Student's t-test showed significant differences in the mean duration to achieve complete remission of BRONJ lesion between Groups 1 and 3, between Groups 2 and 3, between Groups 3 and 4, between Groups 1 and 4, and between Groups 2 and 4 (all p values < 0.001).

CONCLUSION

Although both conservative and aggressive surgical approaches can result in successful treatment of BRONJ lesions, aggressive surgical treatment needs a shorter mean duration to achieve complete remission of BRONJ lesion than conservative treatment. Concomitant corticosteroid administration or tobacco smoking may prolong the duration for complete remission of BRONJ lesion.

Incidence, risk factors, and outcomes of osteonecrosis of the jaw: integrated analysis from three blinded active-controlled phase III trials in cancer patients with bone metastases

BACKGROUND

Osteonecrosis of the jaw (ONJ) has been reported in patients receiving bisphosphonates for metastatic bone disease. ONJ incidence, risk factors, and outcomes were evaluated in a combined analysis of three phase III trials in patients with metastatic bone disease receiving antiresorptive therapies.

PATIENTS AND METHODS

Patients with bone metastases secondary to solid tumors or myeloma were randomly assigned to receive either s.c. denosumab (120 mg) or i.v. zoledronic acid (4 mg) every 4 weeks. On-study oral examinations were conducted by investigators at baseline and every 6 months. Oral adverse events were adjudicated by an independent blinded committee of dental experts.

RESULTS

Of 5723 patients enrolled, 89 (1.6%) patients were determined to have ONJ: 37 (1.3%) received zoledronic acid and 52 (1.8%) received denosumab (P = 0.13). Tooth extraction was reported for 61.8% of patients with ONJ. ONJ treatment was conservative in >95% of patients. As of October 2010, ONJ resolved in 36.0% of patients (29.7% for zoledronic acid and 40.4% for denosumab).

CONCLUSIONS

In this combined analysis of three prospective trials, ONJ was infrequent, management was mostly conservative, and healing occurred in over one-third of the patients. Educating physicians about oral health before and during bone-targeted therapy may help reduce ONJ incidence and improve outcomes.

Bisphosphonate-related osteonecrosis of the jaws--a review

The aim was to evaluate the knowledge about bisphosphonate-related osteonecrosis of the jaws (BRONJ). A bibliographic search in Medline, PubMed and the Cochrane Register of controlled clinical trials was performed between 2003 and 2010 by using the terms bisphosphonate and osteonecrosis of the jaw. The amount of publications per year, the type of journal for publication, and the evidence level of the trial were evaluated. Next to this the incidences and the success of treatment strategies for BRONJ were identified. A total of 671 publications were reviewed. Since 2006 more than 100 publications on BRONJ per year (with an upward trend) have been published, mostly in dental journals. The evidence level could be determined for 176 publications and only one grade Ia study was found. The studies showed a wide variety in design, most of them being retrospective. The incidence of BRONJ is strongly dependent on oral or intravenous application and varies between 0.0% and 27.5%. There is no scientific data to sufficiently support any specific treatment protocol for the management of BRONJ. Further clinical studies are needed to evaluate the incidence and treatment strategies at a higher level of evidence. Therefore uniform study protocols would be favourable.

The impact of bisphosphonates on oral health: lessons from the past and opportunities for the future

Osteonecrosis of the jaw (ONJ), a challenging medical condition seen primarily among intravenous bisphosphonate (BP) users, is characterized by exposed necrotic bone that persists for more than eight weeks. While rare among people with osteoporosis treated with oral BPs, ONJ has captured the public's attention and caused significant distress. For many, the risk-benefit scale has conceptually changed, tipping steeply toward risk, while for others the benefit of increased bone mass still outweighs the possibility of ONJ. While more than seven years have passed since the first cases were published, the scientific and medical communities are not yet ready to address with certainty the issue of causal inference, nor do they have any concrete recommendations for risk assessment or management of ONJ. Equally important, the dental literature has been skewed by the perceived risk associated with prolonged use of BPs and has neglected to explore how the antiosteoclastic activity of BPs may be utilized to improve dental outcomes. This article reviews critically the current state of knowledge about the impact of bisphosphonates on oral health. Using the principles of epidemiology, the article identifies scientific gains, research challenges, and future research opportunities on the topic.

Bisphosphonate-associated Osteonecrosis of the Jaw in Ontario: A Survey of Oral and Maxillofacial Surgeons

Objective.

Osteonecrosis of the jaw (ONJ) in association with use of bisphosphonate (BP) has been described primarily in cancer patients receiving high-dose intravenous BP. The frequency of the condition in patients with osteoporosis appears to be low. We evaluated the frequency of BP-associated ONJ in Ontario in the cancer population and in those receiving BP for osteoporosis and metabolic bone disease.

Methods.

A survey developed by representatives of the Ontario Society of Oral and Maxillofacial Surgeons was mailed to Ontario oral and maxillofacial surgeons (OMFS) in December 2006, asking oral surgeons to provide information on cases of ONJ seen in the previous 3 calendar years (2004 to 2006). OMFS were subsequently contacted by telephone if they had not responded or if they had reported cases of ONJ. The frequency of ONJ in association with BP use was estimated from the number of patients with filled prescriptions for BP in Ontario between 2004 and 2006. The cumulative incidence of ONJ was calculated separately for patients using intravenous (IV) BP for cancer treatment and for patients using oral or IV BP for osteoporosis or other metabolic bone disease.

Results.

Between 2004 and 2006, 32 ONJ cases were identified. Nineteen patients received IV BP for cancer treatment and 13 patients received oral or IV BP for osteoporosis or metabolic bone disease. Over a 3-year period the cumulative incidence of BP-associated ONJ was 0.442% of cancer patient observations (442 per 100,000) and 0.001% of osteoporosis or other metabolic bone disease observations (1.04 per 100,000). The relative risk of low dose IV/oral BP-associated ONJ was 0.002 (95% CI 0.001, 0.005) compared to high-dose IV BP. Other risk factors for ONJ were present in all cases in whom detailed assessment was available. The median duration of exposure to BP was 42 months (range 36 to 120 mo) and 42 months (range 11 to 79 mo) in osteoporosis patients and cancer patients, respectively.

Conclusion.

Over a 3-year period, the cumulative incidence for BP-associated ONJ was 0.442% of cancer patient observations (442 per 100,000) and 0.001% of osteoporosis or metabolic bone disease observations (1.04 per 100,000). This study provides an approximate frequency of BP-associated ONJ in Canada. These data need to be quantified prospectively with accurate assessment of coexisting risk factors.

Quality of life implications of bisphosphonate-associated osteonecrosis of the jaw

PURPOSE

Potentially debilitating, osteonecrosis of the jaw (ONJ) is an emerging complication of bisphosphonates. However, its effect on quality of life (QoL) is unknown. We determined the ONJ-related QoL decline in a cancer patient cohort.

PATIENTS AND METHODS

Thirty-four cancer patients with bisphosphonate-associated ONJ completed a telephone survey (October 2007 through May 2008). The Oral Health Impact Profile 14 (OHIP) retrospectively assessed participant oral health-related QoL before and after ONJ. Standardized ONJ descriptions were developed in a multidisciplinary, iterative process and were evaluated with three frequently used preference-based QoL measurement methods on a 0 (death) to 1 (perfect health) scale: Visual Analogue Scale (VAS), Time Trade-Off (TTO), and EQ-5D.

RESULTS

ONJ significantly (p < .001) increased OHIP scores (worse QoL) for additive (3.56-16.53) and weighted (7.0-17.5) methods. Seven individual OHIP items significantly increased (Bonferroni correction p < .0035): pain, eating discomfort, self-consciousness, unsatisfactory diet, interrupted meals, irritability, and decreased life satisfaction. Mean preference-based QoL values significantly decreased (p < .001) with worsening ONJ stage (VAS, TTO, and EQ-5D): no ONJ (0.76, 0.86, 0.82), ONJ stage 1 (0.69, 0.82, 0.78), ONJ stage 2 (0.51, 0.67, 0.55), and ONJ stage 3 (0.37, 0.61, 0.32). As ONJ worsened, EQ-5D domain scores significantly increased (p < .001). Pain/discomfort and anxiety/depression contributed most to declining QoL.

CONCLUSIONS

ONJ significantly affects QoL, a detriment that increases with worsening ONJ. QoL impairments for ONJ stages 2 and 3 are similar to other treatment side effects that influence decision-making. Bisphosphonate-associated ONJ QoL is an important consideration for patients, clinicians, and policy makers.

Effects of alendronate on bone healing after tooth extraction in rats

OBJECTIVES

Tooth extraction has been identified as an important risk factor for bisphosphonate-induced osteonecrosis of the jaw. Therefore, the main goal of this study was to determine the effects of alendronate on healing of the extraction socket and on interdental alveolar bone after tooth extraction in rats.

MATERIALS AND METHODS

Animals were injected subcutaneously with vehicle or alendronate for 3-4 weeks before the first mandibular molar was extracted and these treatments were continued during post-extraction periods of 10, 21, 35 and 70 days. Mandibles were processed to evaluate healing of the extraction socket and adjacent alveolar bone by assessing bone formation, bone resorption and vascularity by histomorphometric techniques.

RESULTS

Alendronate decreased new woven bone formation, blood vessel area, perimeter and number in the extraction socket at 10 days postextraction, but not at later time points. Furthermore, alendronate-treated rats had increased interdental alveolar bone volume and height only at 10 days postextraction. In addition, a 2.5-fold increase in the percentage of empty osteocyte lacunae was found in alveolar bone of alendronate-treated rats only at 10 days postextraction.

CONCLUSIONS

Alendronate transiently decreases bone formation and vascularity in the extraction socket and delays the removal of interdental alveolar bone after tooth extraction in rats.

A review of the clinical implications of bisphosphonates in dentistry

Bisphosphonates are drugs that suppress bone turnover and are commonly prescribed to prevent skeletal related events in malignancy and for benign bone diseases such as osteoporosis. Bisphosphonate associated jaw osteonecrosis (ONJ) is a potentially debilitating, yet poorly understood condition. A literature review was undertaken to review the dental clinical implications of bisphosphonates. The present paper briefly describes the postulated pathophysiology of ONJ and conditions with similar clinical presentations. The implications of bisphosphonates for implantology, periodontology, orthodontics and endodontics are reviewed. Whilst bisphosphonates have potential positive applications in some clinical settings, periodontology particularly, further clinical research is limited by the risk of ONJ. Prevention and management are reviewed, including guidelines for reducing cumulative intravenous bisphosphonate dose, cessation of bisphosphonates prior to invasive dental treatment or after ONJ development, and the use of serum beta-CTX-1 in assessing risk. In the context of substantial uncertainty, the implications of bisphosphonate use in the dental clinical setting are still being determined.

A SNP in CYP2C8 is not associated with the development of bisphosphonate-related osteonecrosis of the jaw in men with castrate-resistant prostate cancer

A single nucleotide polymorphism (SNP) in CYP2C8 (rs1934951), was previously identified in a genome-wide association study as a risk factor for the development of osteonecrosis of the jaw (ONJ) in patients receiving bisphosphonates (BPs) for multiple myeloma. To determine if the same SNP is also associated with the development of ONJ in men receiving BPs for bone metastases from prostate cancer, we genotyped 100 men with castrate-resistant prostate cancer treated with bisphosphonates for bone metastases, 17 of whom developed ONJ. Important clinical characteristics, including type and duration of bisphosphonate therapy, were consistent among those who developed ONJ and those who did not. We found no significant correlation between the variant allele and the development of ONJ (OR = 0.63, 95% CI: 0.165-2.42, P > 0.47). This intronic SNP in CYP2C8 (rs1934951) does not seem to be a risk factor for the development of bisphosphonate-related ONJ in men with prostate cancer. It is important to note that this is only the second study to investigate the genetics associated with BP-related ONJ and the first to do so in men with prostate cancer. More studies are needed to identify genetic risk factors that may predict the development of this important clinical condition.

Angiogenic suppression of osteoclasts may play a role in developing bisphosphonate-related osteonecrosis of the jaw

Since it was firstly reported in 2003, a large number of cases have been published concerning bisphosphonate-related osteonecrosis of the jaw (BRONJ). It has generated great interest in the medical and research communities yet remains an enigma, given its unknown pathogenesis. Many hypotheses concerning the underlying pathophysiology are discussed, including two most popular hypotheses: bone remodeling suppression and angiogenesis suppression, but none of them could explain all the unique characters of BRONJ. Bisphosphonates are potent osteoclast inhibitors, and recent studies revealed that osteoclasts were important for bone angiogenesis. Therefore, we hypothesize that bisphosphonates could inhibit osteoclast stimulation of angiogenesis, which plays an important role in developing BRONJ. Our hypothesis could help to explain some unintelligible characters of BRONJ, and deserves further studies.

How patients' lack of knowledge about oral bisphosphonates can interfere with medical and dental care

BACKGROUND

Oral bisphosphonate use has been associated with a small risk of developing oral osteonecrosis that occurs spontaneously or after the patient has undergone dental surgery. The authors conducted a study to determine whether patients taking bisphosphonates had knowledge about the medical indication for the therapy and the duration of treatment, as well as whether they had been educated by their physicians about possible adverse reactions.

METHODS

From June 2008 through April 2009, people seeking routine care in a dental clinic and who were being treated with bisphosphonates were invited to participate in the study. The participants were asked questions involving knowledge about the medical indications related to their taking bisphosphonates, the duration of their therapy and whether they had been educated about possible adverse reactions.

RESULTS

The authors interviewed 73 participants; 84 percent stated they knew why they were receiving bisphosphonate therapy. However, 80 percent said they were unsure about the duration of therapy, and 82 percent could not recall if they had been told about the risk of experiencing adverse reactions, including oral osteonecrosis, by their physicians.

CONCLUSION

People taking bisphosphonates may be unfamiliar with the drug and its possible adverse oral side effects.

CLINICAL IMPLICATIONS

Dentists should be prepared to educate patients about the risks of developing oral complications resulting from bisphosphonate use and the need for appropriate dental care. Questions regarding discontinuation of bisphosphonate therapy should be answered by the physician.

Prevalence of bisphosphonate associated osteonecrosis of the jaws in multiple myeloma patients

BACKGROUND

Bisphosphonate-associated osteonecrosis of the jaws (BP-ONJ) is an adverse effect of bisphosphonate treatment with varying reported incidence rates.

METHODS

In two neighboring German cities, prevalence and additional factors of the development of BP-ONJ in multiple myeloma patients with bisphosphonates therapy were recorded using a retrospective (RS) and cross-sectional study (CSS) design. For the RS, all patients treated from Jan. 2000--Feb. 2006 were contacted by letter. In the CSS, all patients treated from Oct. 2006--Mar. 2008 had a physical and dental examination. Additionally, a literature review was conducted to evaluate all articles reporting on BP-ONJ prevalence. PubMed search terms were: bisphosphonat, diphosphonate, osteonecrosis, prevalence and incidence.

RESULTS

In the RS, data from 81 of 161 patients could be obtained; four patients (4.9%) developed BP-ONJ. In the CSS, 16 of 78 patients (20.5%) developed BP-ONJ. All patients with BP-ONJ had received zoledronate; 12 of these had had additional bisphosphonates. All except one had an additional trigger factor (tooth extraction [n = 14], dental surgical procedure [n = 2], sharp mylohyoid ridge [n = 3]).

CONCLUSION

The prevalence of BP-ONJ may have been underestimated to date. The oral examination of all patients in this CSS might explain the higher prevalence, since even early asymptomatic stages of BP-ONJ and previously unnoticed symptomatic BP-ONJ were recorded. Since nearly all patients with BP-ONJ had an additional trigger factor, oral hygiene and dental care might help to reduce BP-ONJ incidence.

A systematic review of bisphosphonate osteonecrosis (BON) in cancer

PURPOSE

This systematic review aims to examine the prevalence of bisphosphonate osteonecrosis (BON) in the cancer population, prevention and treatment protocols, and quality of life issues.

METHODS

A search of MEDLINE/PubMed and EMBASE form October 2003 to December 31, 2008 was conducted with the objective of identifying publications that contained original data regarding BON.

RESULTS

A total of 28 publications fulfilled inclusion criteria, but only 22 were used for prevalence analysis. No randomized controlled clinical trials, meta-analysis, or quality of life papers were found that contained information regarding either prevalence or treatment protocols for the management of BON. The overall weighted prevalence of BON included a sample of 39,124 patients with a mean weighted prevalence of 6.1%. The weighted prevalence was 13.3% for studies with documented follow-up with a sample size of 927 individuals. The weighted prevalence in studies with undocumented follow-up was 0.7% in a sample of 8,829 chart reviews. Epidemiological studies evaluated a total of 29,368 individual records, and the weighted BON prevalence was 1.2%.

CONCLUSIONS

High-quality studies are needed to accurately characterize the prevalence of BON, and to determine effective treatment protocols.