Sir, in response to the question posed in Dr Harrison's letter,1 it may be that the recent publications, quoted here, have answered it already.
'There are no guidelines based on robust evidence, clinical management of the oral complications of BON are based on expert opinion'. 2
It is suggested in the meantime we follow protocols relating to osteoradionecrosis (ORN). One such recent publication gives some simple and useful guidance.3 The advice given by Marx4 would also still appear to stand:
'Treatment of established cases is recommended to begin with an identification that palliation and control of osteomyelitis are the primary goals. Control and limitation of progression has been obtained in most cases with long term or intermittent courses of penicillin-type antibiotics (erythromycins or tetracyclines if penicillin contra-indicated), Chlorhexidine mouthwash and periodic minor debridement of soft-textured sequestrating bone and wound irrigation.'
Hyperbaric oxygen (HO) is used as part of a preventative regime in cases requiring oral surgery who are at risk of developing ORN, for example given pre and post extraction of mandibular molars. The effectiveness of HO when used as an adjunct in the treatment of established (overt) ORN has recently proved difficult to support following analysis of a multicentre trial.5 The place of HO in the prevention or treatment of BON is as yet unclear.
Intravenous administered bisphosphonates are more commonly reported in relation to the more aggressive form of the disease,6 but the common oral administered drugs, alendronic acid (Fosamax) and risedronate sodium (Actonel) can also be associated with various levels of the condition. The emphasis at the moment is therefore very much prevention rather than cure.
Intravenous drugs Prior to therapy the highest level of oral health should be achieved.7 During and after IV administration of the drug patients should receive regular oral examinations. Symptoms of oral pain should be explored urgently. If an extraction is considered to be unavoidable or other signs of BON present, then communication with your oral surgery/oral maxillofacial colleagues may be prudent.
Oral administered drugs These appear to be less toxic, the incidence of BON to be lower and the time to presentation of disease later than with IV drugs. The cessation of the drug in conjunction with the previously mentioned regimen hopefully will lead to resolution. However, the bone may take up to a year to return to such a state when it can more effectively resist infection. Close monitoring of all affected cases is advised long term.
The bisphosphonates are very useful drugs and are being used more and more for a number of conditions. Because of the oral side effects and complications associated with these drugs they are very much of relevance to dentistry. If our patients are receiving these drugs we need to know about it.
I hope this is of interest and some use.
References
Harrison Z . Treating osteonecrosis. Br Dent J 2006; 200: 242–243.
Migliorati CA, Casiglia J, Epstein J et al. Managing the care of patients with bisphosphonate-associated osteonecrosis: an American Academy of Oral Medicine position paper. Am Dent Assoc 2005; 136: 1658–1668.
Kanatas AN, Rogers SN, Martin MV . A practical guide for patients undergoing exodontia following radiotherapy to the oral cavity. Dent Update 2002; 29: 498–503.
Marx RE . Pamidronate (Aredia) and zoledronate (Zometa) induced avascular necrosis of the jaws: a growing epidemic. J Oral Maxillofac Surg 2003; 61: 1115–1117.
Annane D et al. Hyperbaric oxygen therapy for radionecrosis of the jaw: a randomized, placebo-controlled, double-blind trial from the ORN96 study group. J Clin Oncol 2004; 22: 4893–4900.
Bagan JV et al. Jaw osteonecrosis associated with bisphosphonates: Multiple exposed areas and its relationship to teeth extractions. Study of 20 cases. Oral Oncol 2006; 42: 327–329.
Melo MD, Obeid G . Osteonecrosis of the jaws in patients with a history of receiving bisphosphonate therapy: strategies for prevention and early recognition. J Am Dent Assoc 2005; 136: 1675–1681.
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Malden, N. Of relevance to dentistry. Br Dent J 200, 475 (2006). https://doi.org/10.1038/sj.bdj.4813574
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DOI: https://doi.org/10.1038/sj.bdj.4813574