Patient Information
Bisphosphonate Patients
Osteonecrosis of the Jaw (ONJ) can occur when the blood supply to the upper and lower jaws is compromised and by a problem with the bone’s ability to regrow. When the ability to remodel and grow new bone is impaired, blood flow through the bone can be reduced or stopped. This results in bone loss, bone spurs and breaking loose of pieces of dead bone. The soft tissues around that bone and within the bone itself, which depend on that blood flow for health, also begin to die (or fail to heal).
Some researchers suggest that bisphosphonate drugs lessen the body’s ability to resorb bone, the process that naturally takes place in order to allow the formation of new bone cells. Bisphosphonate Related Osteonecrosis of the Jaw (BRONJ) occurs when patients taking bisphosphonate drugs have exposed dead bone that persists for more than eight weeks.
Most patients diagnosed with BRONJ have taken intravenous (IV) bisphosphonates for cancer, although cases have been reported in post-menopausal women on oral bisphosphonates.
BRONJ Primary risk factors
- Underlying malignancy - multiple myeloma, breast cancer
- Bisphosphonate therapy potency, dose and duration
- Intravenous more common than oral bisphosphonates
- Corticosteroids
- Chemotherapy, radiotherapy
- Tooth extraction & other dental surgery (especially involving bone)
- Periodontal and dental abscesses
- Edentulous areas
- Trauma/denture sores
Patient may be at INCREASED risk for BRONJ when there are multiple, primary risk factors, including:
- Necessary, guided bone regeneration
- More than 3 years of oral bisphosphonate therapy
Dental Treatment & Care Before & During Bisphosphonate Therapy
For patients currently on or about to start bisphosphonate therapy, there are various recommended dental treatments and actions. Please consult with your doctor, dentist, and/or oral surgeon for the most suitable course of dental treatment for you.
Before & During Oral Bisphosphonate Therapy
(Actonel, Boniva, Fosamax)
A complete dental evaluation is recommended before starting oral bisphosphonate therapy. Current data indicates that there is a low risk of developing BRONJ for patients taking oral bisphosphonates. Most dental procedures will be safe.
Patients can reduce the risk of developing BRONJ with good oral hygiene and regular dental care. However, the concern (as with IV bisphosphonates) is that with more women aging and taking oral bisphosphonates for longer periods of time to treat osteoporosis, more cases of BRONJ may develop.
Consult with your dentist and/or oral surgeon regarding any dental treatment needed, any associated risks, and any alternative treatments available.
Before & During IV Bisphosphonate Therapy
(Aredia, Zometa)
A comprehensive oral examination is recommended prior to treatment with an IV bisphosphonate. Non-restorable teeth should be extracted and any other invasive dental procedure should be completed prior to IV bisphosphonate therapy begins. Dental treatment is aimed at eliminating infections and preventing the need for invasive dental procedures while on IV bisphosphonate therapy to reduce the risk of developing BRONJ.
While taking IV bisphosphonate drugs, maintaining good oral hygiene to reduce the risk of infection is important for patients on IV bisphosphonates. Dentures should be examined to ensure proper fit. Routine dental cleanings should be performed with care, avoiding soft tissue injury. Continue regular dental office visits (as frequent as 3-4 months) for hard and soft tissue assessment.
Consult with your treating physician, dentist and/or oral surgeon regarding any dental treatment needed, any associated risks, and any alternative treatments available.
Patients with BRONJ.
For patients with BRONJ, the recommended dental treatment is in the form of non-surgical treatments directed towards eliminating or controlling pain & preventing the progression of exposed bone. Close coordination of dental & oncological care is recommended in making treatment decisions
At this time, stopping IV bisphosphonate therapy (in the short run) has minimal or no apparent benefit regarding BRONJ. However, if systemic conditions permit, long term discontinuation may be beneficial in stabilizing established sites of BRONJ, reducing the risk of new site development and reducing clinical symptoms. The risk and benefits of continuing bisphosphonate therapy should be discussed with the treating oncologist in consultation with the oral and maxillofacial surgeon and patient.