Bisphosphonate’s Effect on Bone Cell Survival and Healing

Abstract

Patients on oral bisphosphonates without bisphosphonate related osteonecrosis of the jaw may safely undergo all routine dental care. Invasive treatment such as extraction or implant placement affords the risk of BRONJ currently believed to be between one in 24,000 per prescription course and to one in 93,000 per patient. While BRONJ is rare in patients taking oral bisphosphonates, its occurrence is often related to invasive dental treatment. Thus, prevention of BRONJ can be sought by optimizing dental health before and during therapy. Extractions and implant placement can be safely done in patients on bisphosphonates. Studies of patients receiving implants indicate a very low risk of either implant loss or BRONJ following implant placement. Consideration toward assessing the product of type one collagen degradation, a biomarker for bone turnover, can be done with CDX assay prior to invasive dental procedure, but the clinical value of this information can not be ascertained at this time. A drug holiday prior to invasive procedure may be considered in consultation with the patient’s prescribing physician. The risk of bisphosphonates withdrawal must be considered along with the potential benefit. Three stages of bisphosphonate related osteonecrosis have been classified by the AAOMS. For each of these three stages, the goal of treatment is to mitigate symptoms of pain and swelling and to decrease the advancement of disease to more severe stages. Reduction of severity to a lower stage is a key goal of treatment. Medical therapy is the hallmark of treatment. Local bacteriocidal agents, most importantly chlohexidine, are used along with removal of bacterial plaque and detritus. Antibiotic therapy in courses of two to three weeks, either orally or parenterally, is designed to address common BRONJ organisms including Actinomyces and Eikinella Corrodens. First line antibiotic of choice is penicillin. Surgical treatment often is necessary. Sequestrectomy of loose bone can be utilized in stage one and two, but removal of fixed exposed bone with rotary instruments or other cutting means is often counterproductive in stage one and two in that further exposed bone may result in yet greater loss of tissue. For stage three patients, resection of affected bone and reconstruction is often necessary. This may include free vascularized tissue transfer. The Japanese Experience With Bisphosphonate-Related Osteonecrosis of the Jaw