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

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.

Characteristics of implant failures in patients with a history of oral bisphosphonate therapy

PURPOSE

This study examines the pattern of implant failures reported in a large cohort of patients who received oral bisphosphonate therapy.

MATERIALS AND METHODS

A total of 8,572 individuals who received oral bisphosphonate drugs returned a dental survey that obtained information pertaining to implant placement and related complications. Among the 589 individuals reporting dental implants, 16 reported implant failures that were verified by dental records. Implant placement, timing of failure, and bisphosphonate duration were ascertained to determine the characteristics of implant loss in the setting of oral bisphosphonate exposure.

RESULTS

Among the 16 patients (all women, aged 70.2 +/- 7.6 yrs) there were 26 implant failures; 8 had failure of 12 implants in the maxilla and 9 had failure of 14 implants in the mandible. Early failure (<or=1 yr after placement) was experienced by 8 patients (8 implants), whereas late failures (>1 yr after placement) occurred in 10 patients (18 implants); 2 patients had both early and late failures.

CONCLUSIONS

Overall, few patients reported implant failures. However, among these, there were more late than early failures and a slightly higher proportion of failures in the mandible versus the maxilla. Further studies should investigate the role of chronic bisphosphonate therapy in implant survival and long-term implant osseointegration.

Prevalence of osteonecrosis of the jaw in patients with oral bisphosphonate exposure

PURPOSE

Osteonecrosis of the jaw (ONJ) is a serious complication associated with bisphosphonate therapy, but its epidemiology in the setting of oral bisphosphonate therapy is poorly understood. The present study examined the prevalence of ONJ in patients receiving chronic oral bisphosphonate therapy.

MATERIALS AND METHODS

We mailed a survey to 13,946 members who had received chronic oral bisphosphonate therapy as of 2006 within a large integrated health care delivery system in Northern California. Respondents who reported ONJ, exposed bone or gingival sores, moderate periodontal disease, persistent symptoms, or complications after dental procedures were invited for examination or to have their dental records reviewed. ONJ was defined as exposed bone (of >8 weeks' duration) in the maxillofacial region in the absence of previous radiotherapy.

RESULTS

Of the 8,572 survey respondents (71 +/- 9 years, 93% women), 2,159 (25%) reported pertinent dental symptoms. Of these 2,159 patients, 1,005 were examined and an additional 536 provided dental records. Nine ONJ cases were identified, representing a prevalence of 0.10% (95% confidence interval 0.05% to 0.20%) among the survey respondents. Of the 9 cases, 5 had occurred spontaneously (3 in palatal tori) and 4 occurred in previous extraction sites. An additional 3 patients had mandibular osteomyelitis (2 after extraction and 1 with implant failure) but without exposed bone. Finally, 7 other patients had bone exposure that did not fulfill the criteria for ONJ.

CONCLUSIONS

ONJ occurred in 1 of 952 survey respondents with oral bisphosphonate exposure (minimum prevalence of 1 in 1,537 of the entire mailed cohort). A similar number had select features concerning for ONJ that did not meet the criteria. The results of the present study provide important data on the spectrum of jaw complications among patients with oral bisphosphonate exposure.

Bisphosphonate-induced osteonecrosis of the jaw: a medical enigma?

Bisphosphonates are used for the standard of care of patients with skeletal metastases and hypocalcemia of malignancy. Bisphosphonate-induced osteonecrosis (BION) is a serious complication. Clinically, BION presents as an area of exposed alveolar bone that occurs spontaneously or becomes evident following an invasive surgical procedure such as extraction of a tooth, periodontal surgery, apicoectomy, or oral implant placement. The mechanism by which bisphosphonates cause osteonecrosis is uncertain. There are no controlled trials to show a direct cause-effect relationship between bisphosphonates and osteonecrosis of the jaw. Oral bisphosphonate-induced necrosis is a rare clinical entity, less frequent, less aggressive, more predictable, and more responsive to treatment than IV forms of bisphosphonate-related osteonecrosis of the jaw. However, there have been reports of this complication with the less potent oral forms of bisphosphonates (0.007% to 0.01%). The morbidity of osteonecrosis of the jaw induced by IV bisphosphonates is significant, so prevention should receive prime importance. Patients should receive prophylactic dental examinations, and any necessary dental treatment before starting bisphosphonate therapy. Good communication among dentists, oral surgeons, physicians, and oncologists is of vital importance in providing care of these patients.

Surgical management of metastatic bone disease

Metastatic bone disease is a major contributor to the deterioration of the quality of life of patients with cancer; it causes pain, impending and actual pathological fractures, and loss of function and may also be associated with considerable metabolic alterations. Operative treatment may be required for an impending or existing fracture and intractable pain. The goals of surgery are to provide local tumor control and allow immediate weight-bearing and function. Radiation therapy is often indicated postoperatively. Detailed preoperative evaluation is required to assess the local extent of bone destruction and soft-tissue involvement, involvement of other skeletal sites, and the overall medical and oncological status.