Bisphosphonate-Related Osteonecrosis of the Jaws. A Severe Side Effect of Bisphosphonate Therapy

Zuzana Janovská

doi:10.14712/18059694.2015.47

Abstract

Bisphosphonates (BP) are potent inhibitors of bone resorption used mainly in the treatment of metastatic bone disease and osteoporosis. By inhibiting bone resorption, they prevent complications as pathological fracture, pain, tumor-induced hypercalcemia. Even though patient's benefit of BP therapy is huge, various side effects may develop. Bisphosphonate-related osteonecrosis of the jaws (BRONJ) is among the most serious ones. Oncologic patients receiving high doses of BP intravenously are at high risk of BRONJ development. BPs impair bone turnover leading to compromised bone healing which may result in the exposure of necrotic bone in the oral cavity frequently following tooth extraction or trauma of the oral mucosa. Frank bone exposure may be complicated by secondary infection leading to osteomyelitis development with various symptoms and radiological findings. In the management of BRONJ, conservative therapy aiming to reduce the symptoms plays the main role. In patients with extensive bone involvement resective surgery may lead to complete recovery, provided that the procedure is correctly indicated. Since the treatment of BRONJ is difficult, prevention is the main goal. Therefore in high risk patients dental preventive measures should be taken prior to bisphosphonate administration. This requires adequate communication between the prescribing physician, the patient and the dentist.

Highlights

Bisphosphonates (BP) are synthetic drugs used in the treatment of bone involvement in various osseous diseases as osteoporosis, multiple myeloma, bone metastasis of solid tumors, osteitis deformans (“Paget’s disease of bone”), primary and secondary hyperparathyroidism, osteogenesis imperfecta, and other conditions that feature bone fragility [6]
High risk patients for Bisphosphonate-related osteonecrosis of the jaws (BRONJ) development are those with malignant disease receiving intravenous BP therapy in high doses and/or with a history of chemotherapy, or concomitant medications of systemic corticosteroids or anti-angiogenic agents
Patients receiving high doses of BP intravenously are at high risk of BRONJ development

Summary

Introduction

Bisphosphonates (BP) are synthetic drugs used in the treatment of bone involvement in various osseous diseases as osteoporosis, multiple myeloma, bone metastasis of solid tumors (with or without hypercalcaemia), osteitis deformans (“Paget’s disease of bone”), primary and secondary hyperparathyroidism, osteogenesis imperfecta, and other conditions that feature bone fragility [6]. In the maxillofacial region lasting for more than 8 weeks in a patient who was receiving bisphosphonate and had not received radiation therapy to craniofacial region [42] This definition doesn’t include so called ‘non-exposed’ variant of BRONJ, where no denuded necrotic bone is exposed, but bone pain, swelling, sinus tract or radiographic abnormality is present [31]. High risk patients for BRONJ development are those with malignant disease receiving intravenous BP therapy in high doses and/or with a history of chemotherapy, or concomitant medications of systemic corticosteroids or anti-angiogenic agents. (See Tab. 2.) The symptoms may include increased tooth mobility, formation of sinus tracts, suppuration and traumatic ulceration of oral mucosa adjacent to exposed bone, mandibular fracture or cervical lymphadenopathy [36]. Specificity of these radiological methods is low and similar findings may be caused by odontogenic infections or bone involvement in multiple myeloma

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Findings

Conclusion