Osteonecrosis of the Jaw from bisphosphonate therapy
Reports of bisphosphonate-associated osteonecrosis of the jaw (BON) associated with the use of Zometa (zolendronic acid) and Aredia (pamidronate) began to surface in 2003. The majority of reported cases have been associated with dental procedures such as tooth extraction; however, less commonly BON appears to occur spontaneously in patients taking these drugs.
Zolendronic acid and pamidronate are intravenous (i.v.) bisphosphonates used to reduce bone pain, hypercalcemia and skeletal complications in patients with multiple myeloma, breast, lung and other cancers and Paget’s disease of bone.
Several cases of BON have also been associated with the use of the oral bisphosphonates, Fosamax (alendronate), Actonel (risedronate) and Boniva (ibandronate), for the treatment of osteoporosis; however, it is not clear if these patients had other conditions that would put them at risk for developing BON.
The table below lists all oral and i.v. bisphosphonates currently on the market in the U.S.
The typical clinical presentation of BON includes pain, soft-tissue swelling and infection, loosening of teeth, drainage, and exposed bone3. These symptoms may occur spontaneously, or more commonly, at the site of previous tooth extraction. Patients may also present with feelings of numbness, heaviness and dysesthesias of the jaw. However, BON may remain asymptomatic for weeks or months, and may only become evident after finding exposed bone in the jaw.
It is important to understand that, based on the information currently available, the risk for developing BON is much higher for cancer patients on i.v. bisphosphonate therapy than the risk for patients on oral bisphosphonate therapy. Therefore, there are different recommendations for dental management of these patients.
For patients on oral bisphosphonate therapy
These panel recommendations focus on conservative surgical procedures, proper sterile technique, appropriate use of oral disinfectants and the principals of effective antibiotic therapy. There is currently no data from clinical trials evaluating dental management of patients on oral bisphosphonate therapy, and therefore, these recommendations are based on expert opinion only. A comprehensive oral evaluation is recommended for all patients about to begin therapy with oral bisphosphonates (or as soon as possible after beginning therapy).
These recommendations do not address treatment of patients on i.v. bisphosphonate therapy or patients with BON. Refer to the information below regarding their treatment.
For patients on i.v. bisphosphonate therapy
The prescribing information for these drugs recommends that cancer patients:
An expert panel convened by Novartis Pharmaceuticals Corporation (the manufacturer of Zometa and Aredia) in 2004, made the following recommendations for prevention, diagnosis and treatment of osteonecrosis of the jaw in patients on i.v. bisphosphonate therapy:
*Thanks to the American Dental Association for information relating to this article
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