Guidelines for the diagnosis of bisphosphonaterelated. Risk factors, prediction of risk using serum ctx testing, prevention, and treatment robert e. Recently, osteonecrosis affecting only the jaw bones, or osteonecrosis of the jaw onj, has been described as a unique complication secondary to bisphosphonate bp therapy and is thought to represent a growing trend. Bisphosphonaterelated osteonecrosis of the jaw bronj is characterized by delayed healing or nonhealing of the bone and soft tissue following an oral surgery procedure such as tooth extraction, dental implant placement, periapical surgery and some periodontal surgeries. To assess the risk and time course of oral bisphosphonateinduced osteonecrosis of the jaws. Bisphosphonaterelated osteonecrosis of the skull base. It may also occur spontaneously without having had any recent. How cancer patients can lower the risk of bisphosphonate.
Bisphosphonate for bone cancer is given intravenously every 2 to 4 weeks. The aim of this paper is to summarize different diagnostic criteria as well as probable aetiopathogenesis of bisphosphonates related osteonecrosis of the jaw. Guidelines for bisphosphonateassociated osteonecrosis of the jaw. Bisphosphonaterelated osteonecrosis of the jaws bronj was first. The prevalence of onj is variable and has been reported to be 1%10% in patients receiving intravenous bisphosphonate treatment for cancer. Bisphosphonateassociated osteonecrosis is a rare clinical entity that is poorly understood. Lack of association between oral bisphophonates and osteonecrosis of the jaw using jaw surgery as a surrogate. Lowdose bisphosphonate use in patients with osteoporosis or other metabolic bone disease has not been causally linked to the development of osteonecrosis of. The impact of osteonecrosis of the jaw on osteoporosis management. Bisphosphonateassociated osteonecrosis of the jaw bon is a rare but serious condition that can cause severe damage to the jaw bone. The risk of bisphosphonate related osteonecrosis of the jaw.
Bon is diagnosed in a patient who dhas an area of exposed jaw bone that persists for more than eight weeks. Diagnostic tissue sampling may exacerbate the process and is. Article bisphosphonate associated osteonecrosis of the jaw. Bisphosphonates are a class of agents used to treat osteoporosis and malignant bone metastases. Bisphosphonate associated osteonecrosis is a rare clinical entity that is poorly understood. Oral bisphosphonate induced osteonecrosis is a rare but real entity that is less frequent, less severe, more predictable, and more responsive to treatment than intravenous bisphosphonate induced osteonecrosis.
Bisphosphonate associated osteonecrosis of the jaw bon is a rare but serious condition that can cause severe damage to the jaw bone. Pdf bisphosphonates bps are boneremodeling inhibitors that are used to manage bone metastases and osteoporosis. This is a smoldering, longterm, destructive process in the jawbone that is often very difficult or impossible to eliminate. Currently, oral bisphosphonates are used widely in the treatment of osteoporosis 10. Medicationrelated osteonecrosis of the jaw wikipedia. Therapy for bisphosphonaterelated osteonecrosis of the jaw. The prevalence of onj associated with osteoporosis, which is typically treated with a less powerful oral bisphosphonate, has been estimated as less than 1 in 100,000 patient treatment years, with a varied reported prevalence between 0. Blue arrows point to a large lytic lesion in the right side of the mandible in a patient who had been on highdose bisphosphonates for multiple myeloma.
Drug related risk factors a bisphosphonate potency. Characteristics of bisphosphonate related osteonecrosis of the jaw bronj. May 16, 20 despite the benefits of these drugs, bisphosphonate related osteonecrosis of the jaw bronj which was first published in the literature in 2003 is a severe side effect of bisphosphonate therapy 47. It may lead to surgical complication in the form of impaired wound healing following oral and maxillofacial surgery, periodontal surgery, or endodontic therapy. Despite these benefits, osteonecrosis of the jaws has. Hyperbaric oxygen in addition to antibiotic therapy is effective for bisphosphonate induced osteonecrosis of the jaw in a patient with multiple myeloma.
It is recommended that you have a good dental exam prior to starting these medications. Bisphosphonate use has been described in children diagnosed with osteogenesis imperfecta oi, fibrous dysplasia, neuromuscular disorders, bone dysplasia, idiopathic juvenile osteoporosis. Download pdf what we know bisphosphonate bp treatment is typically the first medicine used for patients with osteoporosis to slow the breakdown of bone and reduce the chance of fractures. Bisphosphonaterelated osteonecrosis of the jaw rev bras reumatol 2012. It should also be noted that, although less common, the maxilla can also be affected 7. However, the evidence for bronj in paediatric patients is scarce. Decisions to stop or continue bisphosphonate treatment after 5 years 3 years for zoledronate. The patients had exposure of areas of alveolar bone, mostly after oral surgery, eg, mucogingival flap elevation. Surgeons aaoms position paper on bisphosphonate related osteonecrosis of the jaws position paper and approved by the board of trustees in september 2006 1. Feb 26, 2019 please use one of the following formats to cite this article in your essay, paper or report. Guidelines for bisphosphonateassociated osteonecrosis of. Pain from hip or knee osteonecrosis may be worse during weightbearing or walking. The first case reports describing a possible relationship between bisphosphonate therapy and osteonecrosis of the jaw published in the journal of endodontics and the journal of the american dental association termed the phenomenon as bisphosphonateassociated osteonecrosis of the.
Some studies show shortterm bisphosphonate treatment may slow, improve or prevent bone collapse in the hip or knee. Medicationrelated osteonecrosis of the jaw radiology. Bisphosphonateassociated osteonecrosis bon is a rare complication that almost exclusively affects the jaws. Bisphosphonate related osteonecrosis of the skull base aayesha m. Hyperbaric osteonecrosis pdf utility of hyperbaric oxygen in treatment of bisphosphonate related osteonecrosis of the jaws. Osteonecrosis of the jaw in a patient receiving bisphosphonate therapy. Denosumab and zoledronic acid for patients with postmenopausal osteoporosis 5 interventions and comparators one study 17 examined the use of subcutaneous denosumab after oral alendronate compared to continuing on alendronate therapy while another study 18 examined the use of intravenous zoledronic acid after alendronate. Endodontic implications of bisphosphonateassociated. June 2004 background osteonecrosis of the jaws is a rare potential complication in cancer patients receiving radiation, chemotherapy, or other cancer treatment regimens, or in patients with tumorsinfectious embolic events.
Bisphosphonateassociated osteonecrosis of the jaw ncbi. Raj sindwani, md, facs, frcs bisphosphonaterelated osteonecrosis of the jaw bronj is reported in up to 18. Cloudbased multicenter data collection and epidemiologic. Osteonecrosis an early sign of osteonecrosis is local pain in the affected bone or joint. Multiple myeloma and iv bisphosphonate are risk factors. It may lead to surgical complication in the form of impaired wound healing following oral and maxillofacial surgery. Multiple myeloma and iv bisphosphonate are risk factors for. The risk of bisphosphonate related osteonecrosis of the.
Pharmacogenetics of bisphosphonate associated osteonecrosis of the jaw francesca marini1, paolo tonelli2, loredana cavalli1, tiziana cavalli1, laura masi1, alberto falchetti1, maria luisa brandi 1 1department of internal medicine, university of florence, medical school, viale pieraccini 6, 509 florence, italy. Risks of bisphosphonate use fpins clinical inquiries. Bisphosphonate associated osteonecrosis of the jaw. It has been speculated that the medication, especially longterm i. Pharmacogenetics of bisphosphonateassociated osteonecrosis. American association of oral and maxillofacial surgeons. This is alleged to increase the oxygen supply to the body tissue and stop necrosis. The first case reports describing a possible relationship between bisphosphonate therapy and osteonecrosis of the jaw published in the journal of endodontics and the journal of the american dental association termed the phenomenon as bisphosphonate associated osteonecrosis of the jaw or bonj.
Bisphosphonates bps are a class of drugs used to treat osteoporosis and malignant bone metastasis. The position paper was developed by a task force appointed by the board and composed of clinicians with extensive experience in caring for these patients and basic science researchers. Osteonecrosis of the jaw in patients treated with bisphosphonates is a relatively rare but well known complication at maxillofacial units around the world. Antiresorptive agents, especially the bp zoledronic acid or zometa and the nonbp denosumab or xgeva, prolia are used to prevent the spread of cancers to. Medicationrelated osteonecrosis of the jaw mon, mronj is progressive death of the jawbone in a person exposed to a medications known to increase the risk of disease, in the absence of a previous radiation treatment. Nov 16, 2010 bisphosphonate associated osteonecrosis bon is a rare complication that almost exclusively affects the jaws. There is no test to measure onj risk, but some factors are known to raise this risk in very rare. Surgeons aaoms position paper on bisphosphonaterelated osteonecrosis of the jaws position paper and approved by the board of trustees in september 2006 1. The change is justified to accommodate the growing number of osteonecrosis cases involving the maxilla and mandible associated with other antiresorptive denosumab. Osteonecrosis of the jaw in patients with bone metastases treated with bisphosphonates. Bisphosphonates are associated with a small risk of atypical femoral shaft fractures, which increases with duration of use. Canadian consensus practice guidelines for bisphosphonate associated osteonecrosis of the jaw.
Bps show high binding capacity to the bone matrix, especially in sites of active bone metabolism. Given the widespread use of bisphosphonates in clinical practice, even a very low incidence of oral osteonecrosis in bisphosphonate users should be considered a public emergency. Oral bisphosphonate use and the prevalence of osteonecrosis. Bisphosphonates for treatment of osteoporosis expected beneits, potential harms, and drug holidays. Osteonecrosis of the jaw is typically associated with trauma to the jaw tooth extraction, history of malignancy andor infections while on bisphosphonate therapy. Bisphosphonate length of treatment in osteoporosis.
Bisphosphonaterelated osteonecrosis of the jaw onj is characterized by nonhealing exposed bone in the maxillofacial region in patients who have undergone bisphosphonate treatment. Pdf bisphosphonate associated osteonecrosis of the jaw. Axial and coronal computed tomography ct images of the maxillofacial bones figures 2 and 3 demonstrate extensive cortical destruction, osteosclerosis, cortical thickening, and fragmentation of the right maxilla, which extends into the frontal process of the zygomatic bone and pterygoid plates. Medicationrelated osteonecrosis of the jaw mronj, which was first described in 2002, is a relatively uncommon but potentially serious side effect of treatment with osteoclast inhibitors, such as intravenous highpotency bisphosphonates and denosumab, which decrease the risk of skeletalrelated events in patients with cancer and metastatic bone disease. Learningradiology bisphosphonaterelated, osteonecrosis. Zoledronic acid aclasta is a newer bisphosphonate administered intravenously onceyearly. Reclast zolendronic acid is a bisphosphonate infusion that has also become more common. Intravenous regimes are designed to treat the complications of. From the molecular viewpoint, bps are postulated to modulate the function of osteoclasts, reacting with a surface receptor or with an intracellular enzyme. The american society for bone and mineral research defines bronj as an area of exposed bone in the maxillofacial region that has not healed within 8 weeks after identification. The special committee favors the term medicationrelated osteonecrosis of the jaw mronj.
Bisphosphonate use and the risk of adverse jaw outcomes. Among cancer patients receiving highdose intravenous bisphosphonates, osteonecrosis of the jaw is dependent on dose and duration of therapy, 17 20 and has an estimated incidence of 1% to 12%. These cases occurred in patients with cancer receiving highdose intravenous bp. In 2003, the first reports describing osteonecrosis of the jaw onj in patients receiving bisphosphonates bp were published. Since this initial identification, many cases have been reported 811. Most cases are managed by oral surgeons with only a handful of. The underlying etiology is unclear and may be multifactorial. The morning fasting serum cterminal telopeptide bone suppression marker is a. Bisphosphonate related osteonecrosis of the jaw onj is characterized by nonhealing exposed bone in the maxillofacial region in patients who have undergone bisphosphonate treatment. Bisphosphonate related osteonecrosis of the jaw bronj was the initially described entity, but mronj is now the preferred term as other medications besides bisphosphonates have been implicated as etiological agents 5,6. Bisphosphonates are associated with a small risk of osteonecrosis of the. Therapy for bisphosphonaterelated osteonecrosis of the. Raj sindwani, md, facs, frcs bisphosphonate related osteonecrosis of the jaw bronj is reported in up to 18. Endodontic implications of bisphosphonate associated osteonecrosis of the jaws the guidance in this statement is not intended to substitute for a clinicians independent judgment in light of the conditions and needs of a specific patient.
The decision to discontinue oral bisphosphonate drug therapy before dental treatment should be made by you in consultation with your medical doctor. Medicationrelated osteonecrosis of the jaw2014 update. Pdf background bisphosphonates are antiresorptive agents that have been used for more than a decade, for the treatment of metabolic. Bisphosphonaterelated osteonecrosis of the skull base aayesha m. Please use one of the following formats to cite this article in your essay, paper or report. Pharmacogenetics of bisphosphonateassociated osteonecrosis of the jaw francesca marini1, paolo tonelli2, loredana cavalli1, tiziana cavalli1, laura masi1, alberto falchetti1, maria luisa brandi 1 1department of internal medicine, university of florence, medical school, viale pieraccini 6, 509 florence, italy, 2department of odontostomatology, unive rsity of florence, medical. Bisphosphonate related osteonecrosis of the jaw bronj has become an increasingly common complication as the use of these drugs is becoming more widespread in adults. Medicationrelated osteonecrosis of the jaw guidance for the oncology multidisciplinary team 6 mronj in the adjuvant setting the frequency of mronj from oral bisphosphonates in the early breast cancer setting is 0. Oral bisphosphonate related osteonecrosis of the jaw. Pdf bisphosphonateinduced osteonecrosis of the jaw. Bisphosphonate associated osteonecrosis of the jaw the. Bisphosphonateinduced osteonecrosis of the ear canal.
November 20 dentalupdate 733 oralsurgery the risk of bisphosphonaterelated osteonecrosis of the jaw in children. Multiple myeloma and iv bisphosphonate are risk factors for osteonecrosis of the jaw patricia tennis,1 kenneth j rothman,1 rhonda bohn,2 hiangkat tan,2 mary anthony,3 athanosios zavras,4 brian calingaert1 1rti health solutions, research triangle park, nc, united states. Condition bisphosphonates, like alendronate fosamax, description care management tips osteonecrosis of the jaw onj is a condition where the jawbone is exposed and not covered by gums. Bisphosphonate drug holidays can be considered for patients who have persisted with bisphosphonate therapy for 3 to 5 years and for those at low risk of fracture. Since intravenous administration leads to a higher drug exposure than the oral route, osteonecrosis related to oral bisphosphonate therapy is less common than that of related to intravenous forms such as zolendronate which is also more potent than oral bisphosphonates. Osteonecrosis of the jaw and bisphosphonates in cancer. Bon has only been recognized within the past 10 years.