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Bisphosphonate-Related Osteonecrosis of the Jaw Treatment & Management

  • Author: Remy H Blanchaert, Jr, DDS, MD; Chief Editor: Arlen D Meyers, MD, MBA  more...
 
Updated: Feb 26, 2015
 

Medical Therapy

Nonsurgical management of bisphosphonate-related osteonecrosis of the jaw (BRONJ) may consist of the following:

  • Antimicrobial rinses
  • Systemic antibiotics
  • Systemic or topical antifungals
  • Discontinuation of bisphosphonate therapy
  • No dental therapy or minimally invasive dental therapy (ie, root canal therapy instead of extraction)
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Surgical Therapy

Surgical intervention for bisphosphonate-related osteonecrosis of the jaw (BRONJ) remains limited because of the impaired ability of the bone to heal. Because no long-term or controlled studies on the management of bisphosphonate-related osteonecrosis of the jaw (BRONJ) have been published, the article from AAOMS, which is based on the consensus of a panel discussion, is the best available guide to therapy.[3] The suggested treatment of bisphosphonate-related osteonecrosis of the jaw (BRONJ) is determined by the patient’s classification according to the stages described below.

Stage I is as follows:

  • Antimicrobial rinses (ie, chlorhexidine 0.12%)
  • No surgical intervention

Stage II is as follows:

  • Antimicrobial rinses (ie, chlorhexidine 0.12%)
  • Systemic antibiotics or antifungals (infections may exacerbate BRONJ)
  • Analgesics

Stage III is as follows:

  • Antimicrobial rinses (ie, chlorhexidine 0.12%)
  • Systemic antibiotics or antifungals (infections may exacerbate BRONJ)
  • Analgesics
  • Surgical debridement or resection
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Outcome and Prognosis

Long-term data are not available concerning the appropriate management of bisphosphonate-related osteonecrosis of the jaw (BRONJ). Traditional reconstructive efforts are generally not recommended by most experts. The role of adjunctive procedures (ie, hyperbaric oxygen [HBO]) and vascularized tissue transfers in the reconstructive management of bisphosphonate-related osteonecrosis of the jaw (BRONJ) have yet to be elucidated.

A study by Hinson et al indicated that stopping bisphosphonate therapy before or at the start of treatment for bisphosphonate-related osteonecrosis of the jaw (BRONJ) permits faster resolution of maxillofacial symptoms than does discontinuing bisphosphonate use during or continuing it throughout osteonecrosis management. The study, of 84 patients, found that the median time to resolution of osteonecrosis symptoms in patients who halted bisphosphonate therapy before or at the initiation of treatment was 3 and 6 months, respectively, compared with 12 months for patients who remained on bisphosphonate during jaw treatment.[11]

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Future and Controversies

The wide use of oral bisphosphonates and their role in bisphosphonate-related osteonecrosis of the jaw (BRONJ) have yet to be completely determined. Long-term studies identifying the patients who are at risk for this disease process are still pending.

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Contributor Information and Disclosures
Author

Remy H Blanchaert, Jr, DDS, MD Private Practice

Remy H Blanchaert, Jr, DDS, MD is a member of the following medical societies: American Association of Oral and Maxillofacial Surgeons, American Dental Association, American Medical Association

Disclosure: Nothing to disclose.

Coauthor(s)

Christopher M Harris, MD, DMD Residency Program Director, Department of Oral and Maxillofacial Surgery, Maxillofacial Tumor and Reconstruction, Naval Medical Center Portsmouth

Christopher M Harris, MD, DMD is a member of the following medical societies: American Association of Oral and Maxillofacial Surgeons, American Dental Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Robert M Kellman, MD Professor and Chair, Department of Otolaryngology and Communication Sciences, State University of New York Upstate Medical University

Robert M Kellman, MD is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Head and Neck Society, American Rhinologic Society, Triological Society, American Neurotology Society, American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, American Medical Association, Medical Society of the State of New York

Disclosure: Nothing to disclose.

Chief Editor

Arlen D Meyers, MD, MBA Professor of Otolaryngology, Dentistry, and Engineering, University of Colorado School of Medicine

Arlen D Meyers, MD, MBA is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, American Head and Neck Society

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Cerescan;RxRevu;SymbiaAllergySolutions<br/>Received income in an amount equal to or greater than $250 from: Symbia<br/>Received from Allergy Solutions, Inc for board membership; Received honoraria from RxRevu for chief medical editor; Received salary from Medvoy for founder and president; Received consulting fee from Corvectra for senior medical advisor; Received ownership interest from Cerescan for consulting; Received consulting fee from Essiahealth for advisor; Received consulting fee from Carespan for advisor; Received consulting fee from Covidien for consulting.

References
  1. [Guideline] AAOMS. Position Paper: Medication-Related Osteonecrosis of the Jaw—2014 Update. American Association of Oral and Maxillofacial Surgeons. Available at https://www.aaoms.org/docs/position_papers/mronj_position_paper.pdf?pdf=MRONJ-Position-Paper. Accessed: Feb 26 2015.

  2. American Dental Association. Report of the Council of Scientific Affairs. Expert panel recommendations: Dental management of patients on oral bisphosphonate therapy. American Dental Association. June 2006. [Full Text].

  3. AAOMS. American Association of Oral and Maxillofacial Surgeons position paper on bisphosphonate-related osteonecrosis of the jaws. J Oral Maxillofac Surg. 2007 Mar. 65(3):369-76. [Medline].

  4. Bamias A, Kastritis E, Bamia C, et al. Osteonecrosis of the jaw in cancer after treatment with bisphosphonates: incidence and risk factors. J Clin Oncol. 2005 Dec 1. 23(34):8580-7. [Medline].

  5. Mavrokokki T, Cheng A, Stein B, et al. Nature and frequency of bisphosphonate-associated osteonecrosis of the jaws in Australia. J Oral Maxillofac Surg. 2007 Mar. 65(3):415-23. [Medline].

  6. Khan AA, Sandor GK, Dore E, Morrison AD, Alsahli M, Amin F, et al. Bisphosphonate associated osteonecrosis of the jaw. J Rheumatol. 2009 Mar. 36(3):478-90. [Medline].

  7. Fisher JE, Rogers MJ, Halasy JM, et al. Alendronate mechanism of action: geranylgeraniol, an intermediate in the mevalonate pathway, prevents inhibition of osteoclast formation, bone resorption, and kinase activation in vitro. Proc Natl Acad Sci U S A. 1999 Jan 5. 96(1):133-8. [Medline].

  8. Rodan GA, Reszka AA. Bisphosphonate mechanism of action. Curr Mol Med. 2002 Sep. 2(6):571-7. [Medline].

  9. Marx RE, Cillo JE Jr, Ulloa JJ. Oral bisphosphonate-induced osteonecrosis: risk factors, prediction of risk using serum CTX testing, prevention, and treatment. J Oral Maxillofac Surg. 2007 Dec. 65(12):2397-410. [Medline].

  10. Bedogni A, Blandamura S, Lokmic Z, et al. Bisphosphonate-associated jawbone osteonecrosis: a correlation between imaging techniques and histopathology. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2008 Mar. 105(3):358-64. [Medline].

  11. Hinson AM, Siegel ER, Stack BC Jr. Temporal correlation between bisphosphonate termination and symptom resolution in osteonecrosis of the jaw: a pooled case report analysis. J Oral Maxillofac Surg. 2015 Jan. 73(1):53-62. [Medline].

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Exposed, necrotic bone in the left anterior maxilla.
Extensive stage III bisphosphonate-related osteonecrosis of the jaw (BRONJ) of the mandible in a patient treated with intravenous bisphosphonate therapy.
Stage I bisphosphate-related osteonecrosis of the jaw (BRONJ) of the right mylohyoid ridge area.
Bisphosphonate-related osteonecrosis of the jaw (BRONJ) of the right mandible. Note the moth-eaten appearance of the right mandibular angle area and unhealed extraction socket.
 
 
 
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