1. ONJ (Osteonecrosis of the Jaw) in Bisphosphonate-Treated Cancer Patients

2. Bisphosphonates effectively manage bone complications from cancer
Approved for treatment of malignant bone disease from solid tumors and multiple myeloma
Zoledronic acid (Zometa) is approved for the treatment of any advanced malignancy involving bone

3. ● Common adverse events
- Flu-like symptoms
- Fever
- Myalgias/ Arthralgias
● Uncommon adverse events:
- Renal-function effects
- Osteonecrosis of the jaw

4. ONJ Etiology and pathogenesis are not well characterized
The clinical identification of ONJ is usually made on the basis of visual inspection and/or radiographic appearance

5. Study
Study type
Patients treated with BP, n
Patients with suspected or proven ONJ, n
Frequency %
Hoff et al.MDACC ASCO 2006
Chart review
3,994 29
0.7%
Durie et al
Web-based survey
1,203
152
12.6%
Pozzi et all italian multicenter study
888 16
1.8%
Badros et al
Chart review/observational
340 11
3.2%
Tosi et al. Analysis of Bologna 2002 trial
Retrospective review of trial data base
259 9
3.5%
Dimopoulos et al
202 15
7.4%
Cafro et al
118 14
11.9%

6. Risk Factors for ONJ •Periodontal disease •Dento-alveolar surgery
•Oral trauma
•Corticosteroid therapy
•Immuno-compromised state

7. Recommendations for the Management of ONJ
Prevention of ONJ
• Prior to treatment with bisphosphonates:
– Dental exam with appropriate preventive dentistry
– Remove abscessed teeth, and teeth with poor long-term prognosis
– Educate patients on oral hygiene and signs and symptoms of ONJ

8. • During bisphosphonate treatment
– Seek dental maintenance care at least every 6 months
– Avoid invasive dental procedures if possible

9. • In case of ONJ
– Refer to dental professional as soon as possible
– Reassess benefit/risk of continued bisphosphonate therapy
• No prospective data exist to withhold therapy–Conservative management

10. ONJ Outcomes
• Emerging data indicate that stability / improvement of lesions occurs in the majority of patients with conservative management
– With preventive measures and conservative management, deterioration occurs only in a minority of patients

11. ONJ : personal clinical case
V.H.52 year old man receiving IV Biphosphonate as maintenance therapy for Multiple Myeloma
ONJ healing after 3 months
ONL annual incidence : 1/300. it dropped to 1/7000 by practicing prevention dental care.
ONJ after two years of
Biphosphonate therapy

13. Summary
- ONJ is an uncommon event
- Most patients can be managed conservatively according to guidelines with minimal impact on quality of life
- Ongoing studies will increase the understanding of ONJ…

14. THANK YOU