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The incidence of medication-related osteonecrosis of the jaw following tooth extraction in patients prescribed oral bisphosphonates

British Dental Journal (2021)Cite this article

Abstract

Aims To determine the incidence of medication-related osteonecrosis of the jaw in patients prescribed oral bisphosphonate medication following dental extraction in a dedicated clinic within the Department of Oral Surgery of King's College Hospital. The effect of factors such as sex, duration of therapy, medical comorbidities and site of extraction, which have previously been reported to significantly affect the risk of developing osteonecrosis of the jaw, was also examined.

Materials and methods Data were gathered from the dental records of patients who had extractions over an eight-year period and were included in this retrospective study. Patients with previous or current exposure to intravenous bisphosphonates, denosumab, novel-targeted chemotherapies used in the oncology setting or radiotherapy to the head and neck were excluded from this study.

Results The incidence of medication-related osteonecrosis of the jaw following tooth extraction in this group of 652 was 0.8%. A significantly increased risk of developing medication-related osteonecrosis of the jaw was evident in patients prescribed oral bisphosphonates for four years or more (p = 0.02), with an incidence in this group of 1.6%.

Conclusion This study demonstrates that, following dental extraction, patients who are prescribed oral bisphosphonates are at risk of developing medication-related osteonecrosis of the jaw and that this risk increases significantly when the patient has been taking the bisphosphonate for four years or more.

Key points

  • Highlights the low incidence of MRONJ following dental extractions in patients taking oral bisphosphonates.

  • Assesses known risk factors of MRONJ and their effect on this patient cohort.

  • Extractions for patients taking oral bisphosphonates, in the absence of further complicating factors, can be carried out safely in primary care.

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References

  1. Drake M T, Clarke B L, Khosla S. Bisphosphonates: mechanism of action and role in clinical practice. Mayo Clin Proc 2008; 83: 1032-1045.

  2. Watts N B. Bisphosphonate treatment of osteoporosis. Clin Geriatr Med 2003; 19: 395-414.

  3. NICE. Early breast cancer (preventing recurrence and improving survival): adjuvant bisphosphonates. 2017. Available at https://www.nice.org.uk/advice/es15/chapter/Key-points (accessed November 2020).

  4. Medicines and Healthcare products Regulatory Agency. Bisphosphonates: Use and Safety. 2014. Available at https://www.gov.uk/government/publications/bisphosphonates-use-and-safety (accessed November 2020).

  5. European Medicines Agency. Assessment report for bisphosphonates containing medicinal products. 2011. Available at https://www.ema.europa.eu/en/documents/referral/assessment-report-bisphosphonates-containing-medicinal-products_en.pdf (accessed November 2020).

  6. Medicines and Healthcare products Regulatory Agency. Bisphosphonates: atypical femoral fractures. 2014. Available at https://www.gov.uk/drug-safety-update/bisphosphonates-atypical-femoral-fractures (accessed November 2020).

  7. Medicines and Healthcare products Regulatory Agency. Bisphosphonates: very rare reports of osteonecrosis of the external auditory canal. 2015. Available at https://www.gov.uk/drug-safety-update/bisphosphonates-very-rare-reports-of-osteonecrosis-of-the-external-auditory-canal (accessed November 2020).

  8. Ruggiero S L, Dodson T B, Fantasia J et al. American Association of Oral and Maxillofacial Surgeons Position Paper on Medication-Related Osteonecrosis of the Jaw - 2014 Update. J Oral Maxillofac Surg 2014; 72: 1938-1956.

  9. Beth-Tasdogan N H, Mayer B, Hussein H, Zolk O. Interventions for managing medication-related osteonecrosis of the jaw. Cochrane Database Syst Rev 2017; DOI: 10.1002/14651858.CD012432.pub2.

  10. King R, Zebic L, Patel V. Deciphering novel chemotherapy and its impact on dentistry. Br Dent J 2020; 228: 415-421.

  11. Schiodt M, Otto S, Fedele S et al. Workshop of European task force on medication-related osteonecrosis of the jaw - Current challenges. Oral Dis 2019; 25: 1815-1821.

  12. Scottish Dental Clinical Effectiveness Programme. Oral health management of patients at risk of medication-related osteonecrosis of the jaw. Dental Clinical Guidance. 2017. Available at https://www.sdcep.org.uk/published-guidance/medication-related-osteonecrosis-of-the-jaw/ (accessed November 2020).

  13. Mavrokokki T, Cheng A, Stein B, Goss A. Nature and Frequency of Bisphosphonate - Associated Osteonecrosis of the Jaws in Australia. J Oral Maxillofac Surg 2007; 65: 415-423.

  14. Jeong H G, Hwang J J, Lee J H, Kim Y H, Na J Y, Han S S. Risk factors of osteonecrosis of the jaw after tooth extraction in osteoporotic patients on oral bisphosphonates. Imaging Sci Dent 2017; 47: 45-50.

  15. Taylor T, Bryant C, Popat S. A study of 225 patients on bisphosphonates presenting to the bisphosphonate clinic at King's College Hospital. Br Dent J 2013; DOI: 10.1038/sj.bdj.2013.327.

  16. Shudo A, Kishimoto H, Takaoka K, Noguchi K. Long-term oral bisphosphonates delay healing after tooth extraction: a single institutional prospective study. Osteoporos Int 2018; 29: 2315-2321.

  17. Gaudin E, Seidel L, Bacevic M, Rompen E, Lambert F. Occurrence and risk indicators of medication-related osteonecrosis of the jaw after dental extraction: A systematic review and meta-analysis. J Clin Periodontol 2015; 42: 922-932.

  18. Mozzati M, Arata V, Gallesio G. Tooth extraction in osteoporotic patients taking oral bisphosphonates. Osteoporos Int 2013; 24: 1707-1712.

  19. Kunchur R, Need A, Hughes T, Goss A. Clinical investigation of C-terminal crosslinking telopeptide test in prevention and management of bisphosphonate-associated osteonecrosis of the jaws. J Oral Maxillofac Surg 2009; 67: 1167-1173.

  20. Hasegawa T, Kawakita A, Ueda N et al. A multicentre retrospective study of the risk factors associated with medication-related osteonecrosis of the jaw after tooth extraction in patients receiving oral bisphosphonate therapy: can primary wound closure and a drug holiday really prevent MRONJ? Osteoporos Int 2017; 28: 2465-2473.

  21. Dodson T B. The Frequency of Medication-related Osteonecrosis of the Jaw and its Associated Risk Factors. Oral Maxillofac Surg Clin North Am 2015; 27: 509-516.

  22. Chiu W Y, Yang W S, Chien J Y, Lee J J, Tsai K S. The influence of alendronate and tooth extraction on the incidence of osteonecrosis of the jaw among osteoporotic subjects. PLoS One 2018; DOI: 10.1371/journal.pone.0196419.

  23. Bagan J V, Jimenez Y, Murillo J 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.

  24. McGowan K, Ware R S, Acton C, Ivanovski S, Johnson N W. Both non-surgical dental treatment and extractions increase the risk of medication-related osteonecrosis of the jaw: case-control study. Clin Oral Investig 2019; 23: 3967-3975.

  25. Khosla S, Burr D, Cauley J et al. Bisphosphonate-associated osteonecrosis of the jaw: report of a task force of the American Society for Bone and Mineral Research. J Bone Miner Res 2007; 22: 1479-1491.

  26. Lo J C, O'Ryan F S, Gordon N P et al. Prevalence of osteonecrosis of the jaw in patients with oral bisphosphonate exposure. J Oral Maxillofac Surg 2010; 68: 243-253.

  27. Saad F, Brown J E, Van Poznak C et al. Incidence, risk factors, and outcomes of osteonecrosis of the jaw: integrated analysis from three blinded active-controlled phase III trials in cancer patients with bone metastases. Ann Oncol 2012; 23: 1341-1347.

  28. Nicolatou-Galitis O, Schiødt M, Mendes R A et al. Medication-related osteonecrosis of the jaw: definition and best practice for prevention, diagnosis, and treatment. Oral Surg Oral Med Oral Pathol Oral Radiol 2019; 127: 117-135.

  29. Ulmner M, Jarnbring F, Törring O. Osteonecrosis of the jaw in Sweden associated with the oral use of bisphosphonate. J Oral Maxillofac Surg 2014; 72: 76-82.

  30. Fleisher K E, Kontio R, Otto S. Antiresorptive drug-related osteonecrosis of the jaw (ARONJ) - a guide to research. Switzerland: AO Foundation, 2016.

  31. Tanna N, Steel C, Stagnell S, Bailey E. Awareness of medication related osteonecrosis of the jaws (MRONJ) among general dental practitioners. Br Dent J 2017; 222: 121-125.

  32. Bermúdez-Bejarano E B, Serrera-Figallo M Á, Gutiérrez-Corrales A et al. Prophylaxis and antibiotic therapy in management protocols of patients treated with oral and intravenous bisphosphonates. J Clin Exp Dent 2017; DOI: 10.4317/jced.53372.

  33. Hellstein J W, Adler R A, Edwards B et al. Managing the care of patients receiving antiresorptive therapy for prevention and treatment of osteoporosis: executive summary of recommendations from the American Dental Association Council on Scientific Affairs. J Am Dent Assoc 2011; 142: 1243-1251.

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Authors and Affiliations

  1. Specialty Doctor in Oral Surgery, King´s College Hospital, London, SE5 9RS, UK

    Elizabeth Barry, Talli Taylor & Umar Hamid

  2. Consultant in Oral Surgery, King´s College Hospital, London, SE5 9RS, UK

    Jashme Patel & Cathy Bryant

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  1. Elizabeth Barry
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Correspondence to Elizabeth Barry.

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Barry, E., Taylor, T., Patel, J. et al. The incidence of medication-related osteonecrosis of the jaw following tooth extraction in patients prescribed oral bisphosphonates. Br Dent J (2021). https://doi.org/10.1038/s41415-021-3620-9

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