1. Osteonecrosis of the Jaw influenced by Bisphosphonates Presented By: Manessah Cox, Student Anna Nguyen, Student

2. What is osteonecrosis of the jaw (ONJ)?  Described as the persistence of exposed bone in the oral cavity.  Results in loss of viability due to lack of blood supply.  Jaw bone is “starving”.

3. Bisphosphonates  Alendronate, Ibandronate, Risedronate, Zoledronic acid.  Can be oral or intravenously administered.  Antiresorptive Meds: they slow or stop the natural process that dissolves bone tissue.  They can prevent osteoporosis if already developed. It can slow rate of bone thinning.  USES: Prevention/treatment of osteopenia and osteoporosis.  Osteonecrosis of the Jaw (ONJ) is a condition found in patients who received IV and oral forms of bisphosphonates.

4. Purpose:  To become aware of the disease and correct procedures/instructions to present to the patient  Systemic antibiotic premedication should be prescribed immediately prior to debridement of the ONJ site and followed for 10 to 14 days post- debridement.  To provide correct patient education for patients with ONJ  Chlorhexidine mouth rinses should be prescribed for twice daily use.  Meticulous oral hygiene must be emphasized.  Any sharp, ill fitting prosthodontics appliances The site should be debrided and monitored every 2-3 weeks until the site is healed.

5. ONJ and Bisphosphonates  ONJ is uncommon but can have severe adverse effects.  It is hypothesized that the bisphosphonates lead to a possible accumulation of micro-damage which can lead to micro-fractures.  Additional trauma, infection, periodontal disease, and chemotherapy increases chances of getting ONJ.

6. Susceptibility to the disease  Women/men  Cancer patients receiving high doses of intravenous bisphosphonates

7. Clinical Signs and Prevention  Intraoral lesions with areas of exposed yellow-white hard bone.  Ulcers  Severe, abnormal Radiolucencies  Prevention: maintain optimum oral health before any bisphosphonate treatment. (Complete dental exam, completing any traumatic treatment including extractions.  Regular 6 month recall  Patients taking bisphosphonates should avoid alcohol and tobacco.

8. Treatment and Maintenance  The best treatment is prevention. Before a patient is placed on an IV bisphosphonate:  Once developed there is no effective therapy.  Antibiotics (Topical)  Chlorhexidine gluconate rinses.  The further use of bisphosphonates should be discussed with physician/oncologist.  A full dental clearance should be performed using appropriate diagnostic information.  Periodontal debridement (scaling/root planning/periodontal surgery) should be performed as needed  Restorative dentistry should be performed to eliminate caries.  Teeth with poor or hopeless prognoses should be extracted.  The patient needs to be on a tightly managed maintenance program that includes continued oral hygiene reinforcement and education on the oral risks of IV bisphosphonate therapy.

9. Should patients discontinue use of bisphosphonates if osteonecrosis is diagnosed?  Discontinuing therapy must be discussed with the patient’s oncologist or primary physician.  To date, scientific evidence does not support the discontinuation of bisphosphonate therapy to improve soft or osseous tissue healing. The half-life of IV bisphosphonates is years in duration and the medication itself deposits in the bone matrix.  Further research is needed to provide clinical guidelines.

10. Dental Considerations  Maintain good oral health before the start of bisphosphonate treatment so any invasive dental procedures are not needed.  If a dental procedure (teeth extraction, etc.) is needed, try to do it before start of treatment.

11. Suggested Staging and Management of Osteonecrosis of the Jaw Stage (Frequency)Defining FeaturesManagement by Stage Stage I (-30%)Bare bone in oral cavity; no infection; often asymptomatic Chlorhexidine mouth rinse twice daily. Stage II (-40%)Bare bone in oral cavity; soft-tissue infection present; usually symptomatic Chlorhexidine rinse twice daily; PRN; antibiotic for infection and medication for pain Stage III (-20%)Extensive bare bone in oral cavity; extensive soft- tissue infection Conservative soft-tissue debridement to clear necrotic soft tissue Chlorhexidine rinse twice daily; PRN: antibiotic for infection and medication for pain Stage IV (-10%)Extensive bare bone in oral cavity; extensive soft- tissue infection with hard- tissue involvement Conservative soft- and hard- tissue debridement to clear necrotic tissue and establish blood flow Chlorhexidine rinse twice daily; PRN: antibiotic for infection and medication for pain

12. Benefits vs. Risk of taking Bisphosphonates  If you’re at significant risk at breaking bones and you can reduce risk by taking bisphosphonates by half.  Bisphosphonates reduces the risk of osteoporosis by half.  That benefit overwhelmingly outweighs the very small risk of getting osteonecrosis of the jaw.  With ONJ, there are factors that will increase your chances of getting this disease while taking these drugs.

13. Reference  Gavrić, M., Antić, S., Jelovac, D. B., Zarev, A. I., Petrović, M. B., Golubović, M., & Antunović,  M. (2014). Osteonecrosis of the jaw as a serious adverse effect of bisphosphonate therapy and its indistinct etiopathogenesis. Vojnosanitetski Pregled: Military Medical & Pharmaceutical Journal Of Serbia & Montenegro, 71(8), 772-776. doi:10.2298/VSP121211025G  Akhtar, N. H., Afzal, M. Z., & Ahmed, A. A. (2011). Osteonecrosis of jaw with the use of  denosumab. Journal Of Cancer Research & Therapeutics, 7(4), 499-500. doi:10.4103/0973- 1482.92020  Miyazaki, H., Nishimatsu, H., Kume, H., Suzuki, M., Fujimura, T., Fukuhara, H., &... Homma,  Y. (2012). Leukopenia as a risk factor for osteonecrosis of the jaw in metastatic prostate cancer treated using zoledronic acid and docetaxel. BJU International, 110(11b), E520-E525. doi:10.1111/j.1464-410X.2012.11205.x  Quispe, D., Shi, R., & Burton, G. (2011). Osteonecrosis of the Jaw in Patients with Metastatic  Breast Cancer: Ethnic and Socio-Economic Aspects. Breast Journal, 17(5), 510-513. doi:10.1111/j.1524-4741.2011.01119.x