Osteonecrosis of the jaws is associated with high-dose bisphosphonate treatment in patients with cancer

Abstract

Systematic review conclusion. Osteonecrosis of the jaw (ONJ) is associated with a high dose and duration of bisphosphonate (BP) treatment in patients with cancer, but there is insufficient evidence to link low-dose BP therapy with ONJ in patients with osteoporosis.Critical summary assessment. Although this systematic review suggested that ONJ is linked only to high-dose BP treatment in patients with cancer, studies published after this review have reported low incidences of ONJ during low-dose BP therapy in patients with osteoporosis, which warrants vigilance.Evidence quality rating. Limited. Systematic review conclusion. Osteonecrosis of the jaw (ONJ) is associated with a high dose and duration of bisphosphonate (BP) treatment in patients with cancer, but there is insufficient evidence to link low-dose BP therapy with ONJ in patients with osteoporosis. Critical summary assessment. Although this systematic review suggested that ONJ is linked only to high-dose BP treatment in patients with cancer, studies published after this review have reported low incidences of ONJ during low-dose BP therapy in patients with osteoporosis, which warrants vigilance. Evidence quality rating. Limited. In patients with cancer or osteoporosis, is bisphosphonate (BP) therapy associated with osteonecrosis of the jaw (ONJ)? This systematic review involved the use of two electronic databases to search for studies up to February 2008. The authors searched the Cochrane database for systematic reviews, abstracts of the American Society of Clinical Oncology and American Society of Hematology, and the bibliographies of key published articles. They also communicated with relevant experts and pharmaceutical companies. The authors followed a defined protocol, with two independent authors assessing study design and extracting data. Disagreements were resolved by means of consensus or consultation with a third reviewer. The systematic review addressed six areas of interest related to BP-associated ONJ: diagnostic features;incidence and prevalence;risk factors;prevention;staging;treatment. The authors excluded studies that did not address these topics. The authors reviewed five studies—two prospective cohort and three retrospective (2,659 patients total)—as well as a survey to evaluate ONJ incidence in patients with cancer who were receiving BP treatment. ONJ appeared to depend on the dose and duration of therapy, with an estimated incidence of 1 to 12 percent at 36 months of BP exposure. For patients with osteoporosis, the authors reviewed two retrospective studies and one survey, and they did not find an association between ONJ and low-dose BP therapy. The incidence of ONJ in the general population is not known. ONJ is associated primarily with high-dose BP therapy in patients with cancer. Insufficient evidence exists to confirm a link between ONJ and low-dose BP treatment for osteoporosis. Prevention and treatment strategies are based on expert opinion and focus on maintaining good oral hygiene and on conservative surgical intervention. A higher level of evidence is needed to establish any diagnosis, incidence, risk factors, prevention, staging and treatment of ONJ associated with the dose and duration of BP treatment.