Surgical-Dentistry.Info
Bis-Phosphonates &
Osteo-Necrosis of the Jaw
('Dead Jaw Syndrome')
Bis-Phosphonate medications are widely used in the
treatment of bone diseases including
osteoporosis and
Paget’s disease and in some cancers.  They are used in
low oral doses to treat
osteoporosis and to prevent
fractures.

They are used in high
IV (intravenous) doses in cancer to
prevent complications when it spreads to bone.  They have
been used for over 10 years.

Bis-Phosphonates reduce the risk of fractures (broken
bones) by about 50%.  As up to 30% of patients can die in
the first 12 months after a hip fracture,
bis-phosphonates
are likely to reduce the numbers of deaths associated with
this and other fractures due to
osteoporosis.

These benefits outweigh the risk of side effects of
bis-
phosphonates
, which are minimal.  Osteo-Necrosis of the
jaw
(ONJ) is a very rare side-effect of bis-phosphonates.

However, you should be aware of this rare but potentially
serious association of
bis-phosphonate treatment and take
appropriate measures to help prevent it.


What is Osteo-Necrosis of the Jaw ('Dead Jaw
Syndrome
')?

Osteo-Necrosis means death of bone.  Osteo-Necrosis of
the Jaw
(ONJ) is defined as an area of exposed bone (not
covered by gum) in the jaw region that does not heal within
8 weeks of identification.  The exact cause of
ONJ is
currently unknown.


What is the risk of developing this complication?

The risk of developing bis-phosphonate-associated ONJ
ranges between 1/10,000 to 1/100,000 for patients taking
oral
bis-phosphonate for treatment of osteoporosis or
Paget’s disease.  The risk is much higher, ranging between
1% and 10%, for patients with cancers on high IV doses.


What are the risk factors for bis-phosphonate-associated
ONJ?

  • Use of high-dose IV bis-phosphonate
  • Longer duration of treatment with bis-phosphonate
  • Steroid use (Prednisolone, Dexamethasone etc.)
  • Alcohol abuse and tobacco use
  • People suffering from cancer
  • Poor dental hygiene and those who undergo a dental
    procedure such as dental extraction
  • Diabetes mellitus


What are the symptoms of ONJ?

  • Severe jaw pain
  • Numbness of the jaw
  • Swelling and infection of the jaw region
  • Loosening of teeth and exposed bone

These symptoms may occur spontaneously or more often,
following tooth extraction.
Photo & X-Ray (of the same mouth) showing the
sequestration of bone in the right upper jaw
What should I do to minimize the risk of ONJ?
  • Inform your dentist that you are taking bis-
    phosphonates especially if you plan to have a dental
    procedure
  • Maintain good oral hygiene, attend regular dental
    visits and report any oral problems to your dentist.
  • If you are planning to take bis-phosphonates for
    cancer, you should have a dental evaluation prior to
    starting the medication and then every 6 to 12 months
    or as directed by your dentist.
  • Discuss possible side-effects with your GP


Can ONJ be treated?

There is no cure for ONJ to date.

Stopping
bis-phosphonates may not alter the progression
of the disease.  You should therefore discuss with your
doctor whether or not it is appropriate for you to cease
bis-
phosphonates
.


What are the common bis-phosphonates used in
treatment of
osteoporosis & cancer?

Alendronate (Fosamax, Fosamax plus, Alendro) and
Risedronate (Actonel, Actonel Combi) are most often used
for
osteoporosis treatment in oral form.  Pamidronate
(
Aredia, Pamisol) and Zolendronic Acid (Zometa) are
given by IV dose in cancer.

Note:
Intravenous or IV means that a medication is
injected directly into the vein


Important Points

The main risk group for ONJ are patients on IV doses who
have CANCER — NOT patients on oral doses for
osteoporosis.

The overall benefits of oral
bis-phosphonates in preventing
complications (including death) from minimal trauma
fractures due to
osteoporosis generally far outweigh the
risk of developing
ONJ.


Useful Websites:

www.jr2.ox.ac.uk/bandolier/band149/b149-3.html

http://jada.ada.org/cgi/content/full/137/8/1144

http://www.ada.org/prof/resources/topics/osteonecrosis

http://www.thesurgeon.
net/site/CMD=ORA/ArticleID=978958af-b0a5-4d7a-8999-
f60101779f56/0/default.aspx


Useful Articles:

Dental Update 2006 - BONJ - A Guide for the GDP

Journal of American Dental Association 2006 - American
Dental Association Report - Dental Management of
Patients receiving oral bisphosphonate therapy

British Dental Journal 2007 - Bisphosphonate
osteonecrosis of the jaws; an increasing problem for the
dental practitioner

Dental Update 2008 - Recent Recommendations on BONJ

Journal of Rheumatology 2008 - Guidelines for
bisphosphonate-associated osteonecrosis of the jaw

British Dental Journal 2009 - Dental extractions and
bisphosphonates - the assessment, consent and
management, a proposed algorithm

British Medical Journal 2009 - Battle over Fosamax bursts
into court
Please click here to send any comments via email.