1. Algorithm for Clinical Treatment of Bisphosphonate related Osteonecrosis of the Jaw (BRONJ) ABSTRACT Patricia Lukasavage, DDS**; David Telles, DDS*; William Flick DDS, MS ¥ ; Gene Sbalchiero DDS Ұ INTRODUCTION Objective Case Reports Acknowledgements Dr. Tarkan Sidal*** – for photos of various cases Case #1 – Superficial debridement, long term chlorhexidine rinse and antibiotic treatment [PenVK 500 mg x 6 months] 68 yo Caucasian with history of Breast CA, Zolendronate (Zometa) x 1 yr, mandibular anterior extractions, history of debridements x 4 Case #2 Chlorhexidine rinse, Long term antibiotic treatment (Amoxicillin/Metronidazole) [for approx. 4 months], sequestrectomy of exposed bone under local anesthesia 60 yo African American female with Multiple Myeloma on IV Pamidronate, had #19 removed in 2005, painful, infected, exposed bone To demonstrate an algorithm for treatment of BRONJ that dental professionals can utilize when faced with this side effect of oral and intravenous bisphosphonates based upon clinical presentation and symptoms. Ұ Department Head of Oral and Maxillofacial Surgery, College of Dentistry, University of Illinois-Chicago, Chicago, IL ¥ Clinical Instructor of Oral and Maxillofacial Surgery, College of Dentistry, University of Illinois-Chicago, Chicago, IL, * Intern for the department of Oral and Maxillofacial Surgery, College of Dentistry, University of Illinois-Chicago, Chicago, IL, USA ** 3 rd year resident for the department of Oral and Maxillofacial Surgery, College of Dentistry, University of Illinois-Chicago, Chicago, IL ***4 th year resident/chief for the department Head of Oral and Maxillofacial Surgery, College of Dentistry, University of Illinois-Chicago, Chicago, IL, USA Case #4 - Treatment Extended course of Penicillin of approx 6 months, Peridex rinse, Long term follow-up. 70 yo hispanic female w/ h/o Breast CA, secondary metastases to spine, on Zolendronate >1 year She presented 3 months status post extraction of dentition in upper right quadrant with a chief complaint of a non-healing wound and inability to wear prosthesis Discussion Several cases of BRONJ will be presented with their clinical symptoms and manifestations as well as the treatment modalities utilized. Success of a given treatment was determined as resolution of patient’s clinical complaints and symptoms, not necessarily the resolution of the drug-related osteonecrosis itself. Uses of bisphosphonates 1 - Inhibition of bone resorption 6 - Osteolytic disease (Paget’s, Multiple Myeloma) - Metastatic bone disease - Hypercalcemia associated with malignancy - Osteoporosis - Anti-tumor activity (Rosen, Theriault et.al. 2001) Mechanism of Action - Effects on osteoclasts- Precursor cells, cytoskeleton, apoptosis 4 (, Hughes et.al. 1995) - Anti-angiogenesis - Zometa study 8 Intravenous vs. Oral - Ruggiero et. al. (2004) study - 63 cases oral osteonecrosis (56 on IV treatment, 7 on oral treatment) 7 Conclusion Case #3 - Oral hygiene, Chlorhexidine gluconate mouth rinse and on long term follow up 88 yo Caucasian female, lymphoma, Zolendronate IV, multiple extractions and debridement by private dentist, currently not painful References Case #5 – Surgical Debridement with Buccal fat pad advancement, primary closure, Long term pen vk, Chlorhexidine gluconate rinse 2x/day 61 yo HF, on IV Zometa 1 time per month for multiple myeloma. The pt developed BRONJ in lower right quadrant secondary to extractions performed by a private dentist. The patient experienced pain and bleeding of gums x 3-4 months after dental procedure of removal of root fragment/bone in lower right side. Afterwards, patient developed this problem on lower right quadrant, the area of necrosis became slowly worse and as a result the patient developed numbness in lower right jaw, lip and face (V3 distribution) about 3 months prior to presentation to UIC. Level of numbness at initial presentation was unchanged from initial development 3 months prior.