Osteonecrosis of the Jaw and Antiresorptive Agents in Benign and Malignant Diseases: A Critical Review Organized by the ECTS

Abstract

Context Antiresorptive therapy significantly reduces fracture risk in patients with benign bone disease and skeletal-related events (SREs) in patients with bone metastases. Osteonecrosis of the jaw (ONJ) is a rare, but severe condition, manifested as necrotic bone lesion(-s) of the jaws. ONJ has been linked to the use of potent antiresorptive agents, termed as Medication Related ONJ (MRONJ). Methods A working group of the European Calcified Tissue Society (ECTS) and two experts performed an updated detailed review of existing literature on MRONJ incidence, characteristics, and treatment applied in bone diseases with variable severity of skeletal insult, ranging from osteoporosis to prevention of cancer treatment-induced bone loss and SREs in cancer patients with bone metastases. We aimed to identify the differences in various aspects of MRONJ among these distinct patient categories and provide recommendations on how to mitigate the risk and optimally manage MRONJ in each one of them. Results The risk for MRONJ is much higher in patients with advanced malignancies compared to those with benign bone diseases, because of the higher doses and more frequent administration of antiresorptive agents in individuals with compromised general health, along with co-administration of other medications that predispose to MRONJ. The overall risk for MRONJ is considerably lower than the benefits in all categories of patients. Conclusions The risk for MRONJ largely depends on the underlying bone disease and the relevant antiresorptive regimen applied. Physicians and dentists should keep in mind that the benefits of antiresorptive therapy far outweigh the risk for MRONJ development.

Real-world study of antiresorptive-related osteonecrosis of jaw based on the US food and drug administration adverse event reporting system database

“…Especially the data matched dose frequency. Above all, we agree that there is a strong association between ONJ and the underlying bone disease and antiresorptive regimens used in treating it (Anastasilakis et al, 2022). The risk of ONJ between alendronate, ibandronate, risedronate, and romosozumab in the treatment of osteoporosis differs with gender.…”

“…Especially the data matched dose frequency. Above all, we agree that there is a strong association between ONJ and the underlying bone disease and antiresorptive regimens used in treating it ( Anastasilakis et al, 2022 ).…”

Reply to Potential Issues With the Use of Teriparatide After Denosumab-Related Osteonecrosis of the Jaw

“…A critical review organized by the European Calcified Tissue Society (ECTS)in2022 stated that the questionof whether to stop or continue a bone-modifying agent should be carefully considered in patients with ONJ. (6) In other words, decisions regarding further treatment of osteoporosis should be made on a case-by-case basis, depending on several individual factors. In our personal experience, denosumab can often be continued even if ONJ has occurred.…”

Response to Letter to the Editor From Taguchi: “Osteonecrosis of the Jaw and Antiresorptive Agents in Benign and Malignant Diseases: A Critical Review Organized by the ECTS”

“…We read the letter of Dr. Taguchi ( 1 ) about our article ( 2 ) with interest. Teeth and bones have some commonalities, such as containing large amounts of calcium and being the hardest substances in human body.…”

“…The notion that osteoporosis itself may be an important risk factor for developing ONJ is intriguing despite the limited and mostly indirect evidence to support it. Since periodontal disease increases the risk for ONJ ( 2 ) and is more common in osteoporotic patients ( 1 ), this could be the link between the 2 conditions. Even so, this would by no means indicate that osteoporosis should not be treated for fracture prevention.…”