Bisphosphonate-related osteonecrosis of the jaw (BRONJ): run dental management designs and issues in diagnosis

Abstract

Recently, jawbone osteonecrosis has been largely reported as a potential adverse effect of bisphosphonate (BP) administration. Because of the peculiar pharmacokinetic and pharmacodynamic features of the BF (mainly for i.v. administration), their efficacy and large use, some major issues have to be taken into account extendedly both by oncologists and by dentists: 1) therapeutic dental protocol for patients with diagnosis of bisphosphonate-related osteonecrosis of the jaw (BRONJ); 2) dental strategies for patients in former or current i.v. BF treatment and in absence of BRONJ signs; 3) strategies for patients before i.v. BF treatment. Clinical features and guidelines for the management of this condition have been investigated and reported, sometimes with unclear indications; hence, on the basis of the literature and our clinical experience, major end points of this paper are providing our run protocols for the issues above described and, finally, focusing on a crucial, but not extensively investigated point: the early and correct diagnosis of BRONJ versus metastatic jaw lesions in cancer patients.

Medication-Related Osteonecrosis of the Jaws (MRONJ) Induced by Incompatible Complete Removable Denture: A Case Report

“…Patients with full or partial dentures should be examined for areas of mucosal trauma. [19] Gridelli [3] suggested that to use of dentures may increase the risk for MRONJ. Elderly patients are more risky about dental problems than their younger counterparts, therefore this is particularly relevant to elderly patients, most of them are over 40 years old.…”

Effects of Bisphosphonate Administration on Peri-Implant Bone in Vitamin D-Deficient Rats

“…BRONJ occurs at a particularly high frequency in patients using injectable bisphosphonates such as zoledronate. Oral bisphosphonates such as aledronate had been considered to have a low risk [24][25][26] . However, osteonecrosis of the jaw has also been reported in patients using oral bisphosphonates for osteoporosis 27,22) .…”

Dental treatment considerations in the chemotherapy patient

“…In this context, tartar removal can be carried out, with a view to eliminating this source of mechanical and biological irritation. Removable dentures are not contraindicated, though the dentist must be particularly carefully to avoid the development of friction ulcers, and any such lesions must be treated as soon as possible (24,31,32,39). If such ulcers appear, the dentures must be removed, followed by patient control after 7-10 days.…”

“…If extraction proves necessary, the recommendations of the Spanish expert committee should be followed (23): before any surgical intervention, the patient is to be carefully informed of the risks of ONJ, with signing of the corresponding consent document. Different authors recommend the suspension of BP therapy, though there is no evidence that such suspension prevents the development of ONJ, since the half-life of bisphosphonates is extremely long (39). Tooth extraction should be minimally traumatic, with curettage of the socket, cleansing of the surgical bed and suturing of the wound margins.…”

“…Antibiotic prophylaxis is to be provided before and after extraction. Regarding dental implant placement in these patients, the available data are very limited, though all the studies found in the literature speak against such treatment (24,32,(39)(40)(41). Orthodontic treatment in these patients is not recommended, due to the seriousness of their background illness, and due to the important osteoclastic inhibition induced by bisphosphonate therapy, which limits or impedes the bone reabsorption required for dental displacement (41).…”