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| Bis-Phosphonates & Osteo-Necrosis of the Jaw ('Dead Jaw Syndrome') |
Bis-Phosphonate medications are widely used in the
treatment of bone diseases including osteoporosis and
Paget’s disease and in some cancers. They are used in
low oral doses to treat osteoporosis and to prevent
fractures.
They are used in high IV (intravenous) doses in cancer to
prevent complications when it spreads to bone. They have
been used for over 10 years.
Bis-Phosphonates reduce the risk of fractures (broken
bones) by about 50%. As up to 30% of patients can die in
the first 12 months after a hip fracture, bis-phosphonates
are likely to reduce the numbers of deaths associated with
this and other fractures due to osteoporosis.
These benefits outweigh the risk of side effects of bis-
phosphonates, which are minimal. Osteo-Necrosis of the
jaw (ONJ) is a very rare side-effect of bis-phosphonates.
However, you should be aware of this rare but potentially
serious association of bis-phosphonate treatment and take
appropriate measures to help prevent it.
What is Osteo-Necrosis of the Jaw ('Dead Jaw
Syndrome')?
Osteo-Necrosis means death of bone. Osteo-Necrosis of
the Jaw (ONJ) is defined as an area of exposed bone (not
covered by gum) in the jaw region that does not heal within
8 weeks of identification. The exact cause of BONJ is
currently unknown.
What is the risk of developing this complication?
The risk of developing bis-phosphonate-associated ONJ
ranges between 1/10,000 to 1/100,000 for patients taking
oral bis-phosphonate for treatment of osteoporosis or
Paget’s disease. The risk is much higher, ranging between
1% and 10%, for patients with cancers on high IV doses.
What are the risk factors for Bis-phosphonate-associated
ONJ?
What are the symptoms of BONJ?
These symptoms may occur spontaneously or more often,
following tooth extraction.
treatment of bone diseases including osteoporosis and
Paget’s disease and in some cancers. They are used in
low oral doses to treat osteoporosis and to prevent
fractures.
They are used in high IV (intravenous) doses in cancer to
prevent complications when it spreads to bone. They have
been used for over 10 years.
Bis-Phosphonates reduce the risk of fractures (broken
bones) by about 50%. As up to 30% of patients can die in
the first 12 months after a hip fracture, bis-phosphonates
are likely to reduce the numbers of deaths associated with
this and other fractures due to osteoporosis.
These benefits outweigh the risk of side effects of bis-
phosphonates, which are minimal. Osteo-Necrosis of the
jaw (ONJ) is a very rare side-effect of bis-phosphonates.
However, you should be aware of this rare but potentially
serious association of bis-phosphonate treatment and take
appropriate measures to help prevent it.
What is Osteo-Necrosis of the Jaw ('Dead Jaw
Syndrome')?
Osteo-Necrosis means death of bone. Osteo-Necrosis of
the Jaw (ONJ) is defined as an area of exposed bone (not
covered by gum) in the jaw region that does not heal within
8 weeks of identification. The exact cause of BONJ is
currently unknown.
What is the risk of developing this complication?
The risk of developing bis-phosphonate-associated ONJ
ranges between 1/10,000 to 1/100,000 for patients taking
oral bis-phosphonate for treatment of osteoporosis or
Paget’s disease. The risk is much higher, ranging between
1% and 10%, for patients with cancers on high IV doses.
What are the risk factors for Bis-phosphonate-associated
ONJ?
- Use of high-dose IV bis-phosphonate
- Longer duration of treatment with bis-phosphonate
- Steroid use (Prednisolone, Dexamethasone etc.)
- Alcohol abuse and tobacco use
- People suffering from cancer
- Poor dental hygiene and those who undergo a dental
procedure such as dental extraction - Diabetes mellitus
What are the symptoms of BONJ?
- Severe jaw pain
- Numbness of the jaw
- Swelling and infection of the jaw region
- Loosening of teeth and exposed bone
These symptoms may occur spontaneously or more often,
following tooth extraction.
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| Extensive stage III BONJ of the mandible in a patient treated with intravenous bisphosphonate therapy |
What should I do to minimize the risk of BONJ?
Can BONJ be treated?
There is no cure for BONJ to date.
Stopping bis-phosphonates may not alter the progression
of the disease. You should therefore discuss with your
doctor whether or not it is appropriate for you to cease bis-
phosphonates.
What are the common bis-phosphonates used in
treatment of osteoporosis & cancer?
Alendronate (Fosamax, Fosamax plus, Alendro) and
Risedronate (Actonel, Actonel Combi) are most often used
for osteoporosis treatment in oral form. Pamidronate
(Aredia, Pamisol) and Zolendronic Acid (Zometa) are
given by IV dose in cancer.
Note: Intravenous or IV means that a medication is
injected directly into the vein
Important Points
The main risk group for BONJ are patients on IV doses
who have CANCER — NOT patients on oral doses for
osteoporosis.
The overall benefits of oral bis-phosphonates in preventing
complications (including death) from minimal trauma
fractures due to osteoporosis generally far outweigh the
risk of developing BONJ.
Useful Websites:
www.jr2.ox.ac.uk/bandolier/band149/b149-3.html
http://jada.ada.org/cgi/content/full/137/8/1144
http://www.ada.org/prof/resources/topics/osteonecrosis
http://www.thesurgeon.
net/site/CMD=ORA/ArticleID=978958af-b0a5-4d7a-8999-
f60101779f56/0/default.aspx
Useful Articles:
Dental Update 2006 - BONJ - A Guide for the GDP
Journal of American Dental Association 2006 - American
Dental Association Report - Dental Management of
Patients receiving oral bisphosphonate therapy
British Dental Journal 2007 - Bisphosphonate
osteonecrosis of the jaws; an increasing problem for the
dental practitioner
Dental Update 2008 - Recent Recommendations on BONJ
Journal of Rheumatology 2008 - Guidelines for
bisphosphonate-associated osteonecrosis of the jaw
British Dental Journal 2009 - Dental extractions and
bisphosphonates - the assessment, consent and
management, a proposed algorithm
British Medical Journal 2009 - Battle over Fosamax bursts
into court
British Medical Journal 2010 - Osteonecrosis of the Jaw
and Bisphosphonates - Low Doses for Osteoporosis seem
to be safe
- Inform your dentist that you are taking bis-
phosphonates especially if you plan to have a dental
procedure - Maintain good oral hygiene, attend regular dental
visits and report any oral problems to your dentist. - If you are planning to take bis-phosphonates for
cancer, you should have a dental evaluation prior to
starting the medication and then every 6 to 12 months
or as directed by your dentist. - Discuss possible side-effects with your GP
Can BONJ be treated?
There is no cure for BONJ to date.
Stopping bis-phosphonates may not alter the progression
of the disease. You should therefore discuss with your
doctor whether or not it is appropriate for you to cease bis-
phosphonates.
What are the common bis-phosphonates used in
treatment of osteoporosis & cancer?
Alendronate (Fosamax, Fosamax plus, Alendro) and
Risedronate (Actonel, Actonel Combi) are most often used
for osteoporosis treatment in oral form. Pamidronate
(Aredia, Pamisol) and Zolendronic Acid (Zometa) are
given by IV dose in cancer.
Note: Intravenous or IV means that a medication is
injected directly into the vein
Important Points
The main risk group for BONJ are patients on IV doses
who have CANCER — NOT patients on oral doses for
osteoporosis.
The overall benefits of oral bis-phosphonates in preventing
complications (including death) from minimal trauma
fractures due to osteoporosis generally far outweigh the
risk of developing BONJ.
Useful Websites:
www.jr2.ox.ac.uk/bandolier/band149/b149-3.html
http://jada.ada.org/cgi/content/full/137/8/1144
http://www.ada.org/prof/resources/topics/osteonecrosis
http://www.thesurgeon.
net/site/CMD=ORA/ArticleID=978958af-b0a5-4d7a-8999-
f60101779f56/0/default.aspx
Useful Articles:
Dental Update 2006 - BONJ - A Guide for the GDP
Journal of American Dental Association 2006 - American
Dental Association Report - Dental Management of
Patients receiving oral bisphosphonate therapy
British Dental Journal 2007 - Bisphosphonate
osteonecrosis of the jaws; an increasing problem for the
dental practitioner
Dental Update 2008 - Recent Recommendations on BONJ
Journal of Rheumatology 2008 - Guidelines for
bisphosphonate-associated osteonecrosis of the jaw
British Dental Journal 2009 - Dental extractions and
bisphosphonates - the assessment, consent and
management, a proposed algorithm
British Medical Journal 2009 - Battle over Fosamax bursts
into court
British Medical Journal 2010 - Osteonecrosis of the Jaw
and Bisphosphonates - Low Doses for Osteoporosis seem
to be safe
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| Exposed necrotic bone in the anterior left maxilla related to use of Bisphosphonates |
| Stage I Bisphosphate-related Osteo-Necrosis of the Jaw (BONJ) of the right mylohyoid ridge area |