Osteonecrosis of the Jaw

In 2003 Marx reported a connection between bisphosphonates and osteonecrosis of the jaw. Since then over a dozen series of cases has been reported. This is a serious complication.

Features

• Bone under the teeth is exposed, often painfully
• Swelling and loosening of teeth may be seen
• Attempts at surgical correction make lesions worse
• Most cases follow dental procedure such as tooth extraction
• Many cases are complicated by infection
• Occurs mainly in patients with cancer after prolonged therapy

This photograph is courtesy of Dr. Sook-Bin Woo from Oral Medicine at the Brigham and Women's Hospital in Boston. The patient had myeloma and was on zoledronic acid. The exposed, necrotic bone can be seen. Click on image to see enlargement

These charts are from a review of 119 patients by Marx RE that included 76 consecutive individuals referred to the University of Miami and 43 other cases contributed by colleagues. Note that he saw a few cases in patients with osteoporosis who were treated with oral bisphosphonates. This has been seen in several of the case series, but the incidence in ordinary osteoporosis is very low.

This graph shows the incidence of jaw osteonecrosis in patients with cancer who were treated with bisphosphonates. The authors propectively followed patients who were treated since 1997. Overall the incidence was 7.7% in those treated from 3 to 4 years. The graph shows the percentage of patients taking bisphosphonates who developed this. Numbers above the points are the actual number of patients for each time interval of exposure.

Bamias A. Osteonecrosis of the jaw in cancer after treatment with bisphosphonates: incidence and risk factors. J Clin Oncol 2005;23(34):8580-7.

Links to other information about jaw osteonecrosis

The FDA website includes a expert panel recommendation about this subject, which was convened by the pharmaceutical company. Additionally, letters have been sent to dentists in the USA, and the package insert has been modified to include this side effect.

The American Dental Association has recently added information about jaw osteonecrosis.

A review with guidelines was just published by Ruggiero and colleagues.

References

Bagan JV. Jaw osteonecrosis associated with bisphosphonates: Multiple exposed areas and its relationship to teeth extractions. Study of 20 cases. Oral Oncol 2005.

Bagan JV. Avascular jaw osteonecrosis in association with cancer chemotherapy: series of 10 cases. J Oral Pathol Med 2005;34(2):120-3.

Bamias A. Osteonecrosis of the jaw in cancer after treatment with bisphosphonates: incidence and risk factors. J Clin Oncol 2005;23(34):8580-7.

Durie BG. Osteonecrosis of the jaw and bisphosphonates. N Engl J Med 2005;353(1):99-102; discussion 99-.

Ficarra G. Osteonecrosis of the jaws in periodontal patients with a history of bisphosphonates treatment. J Clin Periodontol 2005;32(11):1123-8.

Gralow J. Evolving role of bisphosphonates in women undergoing treatment for localized and advanced breast cancer. Clin Breast Cancer 2005;5 Suppl(2):S54-62.

Maerevoet M. Osteonecrosis of the jaw and bisphosphonates. N Engl J Med 2005;353(1):99-102.

Markiewicz MR. Bisphosphonate-associated osteonecrosis of the jaws: a review of current knowledge. J Am Dent Assoc 2005;136(12):1669-74.

Marx RE. Pamidronate (Aredia) and zoledronate (Zometa) induced avascular necrosis of the jaws: a growing epidemic. J Oral Maxillofac Surg 2003;61(9):1115-7.

Marx RE. Bisphosphonate-induced exposed bone (osteonecrosis/osteopetrosis) of the jaws: risk factors, recognition, prevention, and treatment. J Oral Maxillofac Surg 2005;63(11):1567-75.

Melo MD. Osteonecrosis of the jaws in patients with a history of receiving bisphosphonate therapy: strategies for prevention and early recognition. J Am Dent Assoc 2005;136(12):1675-81.

Migliorati CA. Bisphosphanates and oral cavity avascular bone necrosis. J Clin Oncol 2003;21(22):4253-4.

Migliorati CA. Managing the care of patients with bisphosphonate-associated osteonecrosis: an American Academy of Oral Medicine position paper. J Am Dent Assoc 2005;136(12):1658-68.

Migliorati CA. Bisphosphonate-associated osteonecrosis of mandibular and maxillary bone: an emerging oral complication of supportive cancer therapy. Cancer 2005;104(1):83-93.

Ruggiero SL. Osteonecrosis of the jaws associated with the use of bisphosphonates: a review of 63 cases. J Oral Maxillofac Surg 2004;62(5):527-34.

Ruggiero SL. Practical guidelines for the prevention, diagnosis and treatment of osteonecrosis of the jaw in patients with cancer. J Oncology Practice 2006;2(1):7-14.

Wang J. Osteonecrosis of the jaws associated with cancer chemotherapy. J Oral Maxillofac Surg 2003;61(9):1104-7.

Woo SB. Osteonecrosis of the jaw and bisphosphonates. N Engl J Med 2005;353(1):99-102.

Zarychanski R. Osteonecrosis of the jaw associated with pamidronate therapy. Am J Hematol 2006;81(1):73-5.