OSTEONECROSIS OF THE JAWS- Biphosphonates

 

Potential Preventive Measures Prior to the Initiation of  Bisphosphonate Therapy

  • Suggested preventive dentistry before initiation of chemotherapy, immunotherapy, and/or bisphosphonate therapy may include:
  • Recommend a routine clinical dental exam that may include a panoramic jaw radiograph to detect potential dental and periodontal infections
  • Remove abscessed and nonrestorable teeth and involved periodontal tissues
  • If bisphosphonate therapy can be briefly delayed without the risk of skeletal-related complication, teeth with a poor prognosis or in need of extraction should be extracted and other dental surgeries should be completed prior to the initiation of bisphosphonate therapy.
  • Functional rehabilitation of salvageable dentition, including endodontic therapy
  • Dental prophylaxis, caries control, and stabilizing restorative dental care
  • Examine dentures to ensure proper fit (remove dentures at night)
  • Oral self-care hygiene education
  • Prophylactic antibiotics are not indicated before routine dentistry unless otherwise required for prophylaxis of bacteremia in those patients at risk (eg, those with an indwelling catheter)
  • Avoid any elective jaw procedure that will require bone to heal.
  • Oncologists should perform a brief visual inspection of the oral cavity at baseline and at every follow up visit
  • Avoid any elective jaw procedure that will require bone to heal
  • Educate patients regarding the importance of good dental hygiene and symptom reporting

 

 

Dental Treatment for Patients Currently Receiving Bisphosphonate Therapy

  • Suggest regularly scheduled hard-and soft-tissue oral assessments,  possibly every 3-4 months, depending on risk
  • Maintain excellent oral hygiene to reduce the risk of dental and periodontal infections
  • Check and adjust removable dentures for potential soft-tissue injury, especially tissue overlying bone
  • Perform routine dental cleanings, being sure to avoid soft-tissue injury
  • Aggressively manage dental infections nonsurgically with root canal treatment if possible or with minimal surgical intervention
  • Endodontic (root canal) therapy is preferable to extractions when possible. It may be necessary to carry out coronal amputation with subsequent root canal therapy on retained roots to avoid the need for tooth extraction and, therefore, the potential development of osteonecrosis

 

Clinical Presentation and Diagnosis of Osteonecrosis of the Jaws

  • Typical signs and symptoms include pain, soft-tissue swelling and infection, loosening of the teeth, drainage, and exposed bone, which may occur spontaneously or, more commonly, at the site of previous tooth extraction. Some patients may present with atypical complaints, such as “numbness,” the feeling of a “heavy jaw,” and various dysesthesias
  • Signs and symptoms that may occur before the development of clinical osteonecrosis include a sudden change in the health of periodontal or mucosal tissues, failure of the oral mucosa to heal, undiagnosed oral pain, loose teeth, or soft-tissue infection
  • If osteonecrosis is suspected, panoramic and tomographic imaging may be performed to rule out other etiologies (eg, cysts or impacted teeth). Smaller intraoral films can also be used to demonstrate subtle bone changes
  • Tissue biopsy should be performed only if metastatic disease is suspected. If a biopsy is performed to rule out metastatic tumor, microbial cultures (aerobic and anaerobic) may provide identification of the pathogens causing secondary infections (Note: actinomyces organisms are often seen microscopically or identified upon culture)

 

Potential Risk Factors for the Development of Osteonecrosis of the Jaws

  • Risk factors may include
  • Concomitant therapy with steroids, chemotherapy, and bisphosphonates (in a few instances after short dosing)
  • Dental extraction, infectious disease, and/or trauma
  • Occasionally the concomitant risk factors may not be apparent

 

  • Other risk factors that have been previously identified for osteonecrosis (not limited to the jaws) include
  • Head and neck radiotherapy, chemotherapy, immunotherapy, or other cancer treatment regimens
  • Female gender, coagulopathies infections, periodontal disease, bony exostosis, previous invasive dental procedures, dental prostheses, arthritis, blood dyscrasias, vascular disorders, alcohol abuse, smoking, and malnutrition. Controversially, anesthetics with vasoconstrictors (ie, novocaine) have been reported as potentially contributing to some cases of osteonecrosis