Bisphosphonate Associated Osteonecrosis of the Jaws

[BISPHOSPHONATES ASSOCIATED OSTEONECROSIS OF THE JAWS] Oral Surgery

B i s p h o s p h o n a t e s a s s o c i a t e d o s t e o n e c r o s i s o f t h e J a w s

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This script is combination between Record , 2009 script & the book . We notify you

that's sometimes we write in different way than the doctor spoke and we use the last

year script and the book to get the best similar information. Hope you Enjoy our work.

- Today we're going to talk about osteochemonecrosis and

osteoradionecrosis which mean the effect of chemotherapy or radiotherapy

to bone that may cause necrosis.

Now there are group of drugs called Bisphosphonates , They are potent

inhibitors of osteoclastic activity (thus inhibit bone resorption ), Used in

two forms either IV or oral.

You have to be aware of the condition that may it be on bisphosphonates

either IV or the oral preparation for example any patient who has cancer

and he has bony metastasis is suspected to be on bisphosphonates.

Any patients who has multiple myeloma , Paget's disease , breast cancer

& prostate cancer those cancers they have three Dimensions to

metastasis in to bone .

Usually they are on IV bisphosphonates as pamidronate , Zolendronate

(note : both these 2 drugs are only available as IV preparation) and

others preparation .



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-The patients who have osteoporosis they are taken oral bisphosphonates

and this is a risk factor to cause osteochemonecrosis that's why it's very

common in the exams (international exams) to ask that : patient who

present to you who osteoporotic and he seeking dental implants many

they may think the answer is the quality of bone and something like this

but the answer is the problem that they may be on bisphosphonates. So

we have to take care and follow the guidelines.

So again we have oral preparation and IV preparation .

Patients receiving bisphosphonates intravenously

clearly are more susceptible to Bisphosphonates

associated osteonecrosis of the Jaws (BOJ) than

are those receiving the drug orally.

-Newly they are giving to osteoporotic patients IV preparation only one

dose annually but you have to put in your mind the bisphosphonates

either IV or oral because the guidelines depends on the way that the

patient take medication either oral or IV .

IV preparation related to : cancer , malignancy , bone metastasis , multiple myeloma & Paget's disease .

Oral preparation related to : osteoporosis.

This point is very impotant that the effect last for IV preparation (specially even the patient took decades

IV) 1 year ago or 2 years ago or 20 years ago the effect . decadesand the risk of osteochemonecrosis last for



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-It's a new oral complication seen in patients who have not had any

radiation treatment, and the methods used to treat osteoradionecrosis

do not seem to be effective for the treatment of these lesions what

patients with these lesions have in common is that they are taking a

bisphosphonate medication, usually as an adjunct to chemotherapy for

malignant disease.

- Bisphosphonates associated

osteonecrosis of the Jaws (BOJ) is a

condition of chronically exposed

necrotic bone, painful and often

primarily or secondarily infected

- Exposure either spontaneously or

secondarily to an invasive dental

procedure ( Extraction is the most

common cause of bone exposure )

- Patients complain of halitosis and have

difficulty eating and speaking.

- Clinically, the lesions appear as oral

mucosal ulcerations that expose the

underlying bone and frequently are

extremely painful, The lesions are

persistent and do not respond to

conventional treatment modalities such

as debridement, antibiotic therapy, or

HBO therapy .

What is Bisphosphonates Associated Osteonecrosis of The Bone ?



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Affects the jaws (Mandible > Maxilla).

The most common clinical presentation associated with BOJ is an

ulcer with exposed bone in a patient who has had a dental

extraction. (non healing socket with exposed bone).

In the early stages of oral BOJ no radiographic manifestations

can be seen (Similar to osteoradionecrosis).

Patients may be asymptomatic but may have severe pain

because of the necrotic bone becoming infected secondarily

after it iafter it is exposed to the oral environment.

The most common dental comorbidity in these patients

reportedly is clinically and radiographically apparent

periodoperiodontitis.

Other local factors associated with BOJ are infected teeth,

dental abscesses, previous endodontic treatments, and tori.

Area of exposed bone it has to be for more than 8 weeks



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Similar to the management of patients who will receive radiation

treatment, the dentist should see all patients before intravenous

bisphosphonate therapy begins.

Although a small percentage of patients receiving bisphosphonates have

BON spontaneously, the majority of affected patients experience this

complication following routine dentoalveolar surgery (i. e . , extraction,

Dental implant placement, or apical surgery) Therefore, teeth with a

poor prognosis should be removed before bisphosphonat administration

or as early as possible.

A progressive case of bisphosphonate-

related osteonecrosis of the

mandible. At initial presentation,

areas of bone exposure occurred

along the anterior teeth.

This two photographs are related

to mylohyoid ridges .It's a very

common presentation because it's a

sharp bone ridge and due to trauma

and non healing capacity it will be

expose.(in this case, it's bilateral)



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Stage one :

-Exposed bone , asymptomatic & no infection.

Stage two :

-Exposed bone , pain & clinical evidence of infection

(local infection at the sight of the bone exposure).

Stage three :

- More serious and severe form … when we find that there is a oroantral

fistula, a skin lesion, a pathological fracture, or open into the maxillary

sinus so it is not localized (it's going outside the oral cavity).

Stages of Bisphosphonates Osteonecrosis of The Jaws

Because of the infection not because of the exposed bone we will have painful exposed bone .

Stage one

Stage Two

This X-ray is showing pathologic

fracture at the left side of

mandible. (this x-ray for different

patient than one above).



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Most importantly How to prevent bisphosphonates osteonecrosis of

the jaws ?

Insure dental health before

starting the therapy

how

By extraction of all teeth that have poor prognosis to prevent any

dentoalveolar surgery that may be needed later on.

Invasive procedure 4 to 6 weeks before therapy to insure that the site

is healed completely. this is the duration that is required for complete

healing. So if we have any invasive procedure we have to do it in 4 to 6

weeks before starting the therapy .

Avoidance of extraction and Surgical

treatment during the therapy before 4

to 6 weeks, if we have any surgery we

have to do it before 4 to 6 weeks in

addition to dental care .

Now we will continue with Ahmed Al-Salahi



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-If the patient has osteonecrosis of the jaws due to bisphosohonate, the

management usually by oral maxillofacial Surgeon. until now no

therapeutic modality prove to be successful, actually the English dr's

they said we have to be conservative and just removing minimal amount

which is detached from the tissues, the Americans are aggressive they

are removing more bone, they are trying to do reconstruction , but

actually through many cases that I saw, I go with conservative approach

because usually this drug affect the hole jaw even if you saw small

amount of exposed bone but all the jaw has been affected. usually

during the surgery our indication of how much we remove, we remove

the exposed bone until we reach bleeding bone but usually in these

cases we don't find bleeding bone which is the healthy bone that's why

I am with the conservative approach which is minimal debridement.

- So the idea for this patient to live with his exposed bone but

comfortably Without infections without any problems

So practically we are more conservative , only we are doing minimal

debridement if there are obvious signs of infection we are giving

antibiotics.

-We give antibiotic if the patient has signs of infection, because many

people thinks that BOJ is an infection which is not .If it's painful, it

means that it has an infection but otherwise it's not an infection. So

antibiotic indicated in case of infection overlays the BOJ.



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-If there is obvious signs of infections we give antibiotics (antibiotics not

because there is exposed bone)

-No one knows or expect what could happen if it proceeds or not.

Bisphosohonate is a group of drugs used for treatment of

either patients have cancer or osteoporotic patients. the IV

preparation for cancer patients and the oral preparation for

osteoporotic patients , the risk of osteonecrosis increased with

IV preparation , it's only affect the maxilla & mandible and

usually presents as non healing socket which is painless for

more than 8 weeks. the patient has no history of radio-therapy,

the management is problematic and they are no definite

guidelines for the management of BOJ.

Progression

conclusion



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- ORN is a condition of non vital bone in a site which receives

radiation. its related to radiotherapy, radio therapy has an

effect on the bone which makes it hypocellular, hypovascular

and hypoxic (3 H) , those are the three histological features

which make the healing capacity of the bone is less and that's

why it cause osteonecrosis.

- Risk factors of ORN, radiation therapy dose is more tha 60 gray

(1 gray = 100 Centigray)

Osteoradionecrosis is not caused by a dose of 48 or less

-The R-therapy has to be to max. or Mand. in order to get

necrosis in the jaws not like OCN, for example if the

patient have a cancer and he took bisphosohonate

chemotherapy, he might have necrosis in the jaws this is

important difference.

- ORN might happen due to injuries which is the most Common, due to extraction or it can happen spontaneously.

Osteoradionecrosis ( ORN )



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Extract teeth 2 weeks before R-therapy (ideal method).

Regular preventive dental care to avoid extraction during

R-therapy.

Extraction the teeth that needs to be extracted during R- therapy, I

would wait until muocositis "side effect of R- therapy'' is subsided

and then extract the teeth, usually 4 to 6 months after the starting of

R-therapy.

Usually ORN is greater beyond 18 months after finishing the therapy so

Mucositis resolves within 4 months (1st safest period) and then after the

mucositis is gone up to 18 months (2nd safest period).

Even if the patient comes in the safe period you don’t do an extraction as

a GP (general physician) to protect yourself and the patient, So the

treatment is done by a OMF surgeon

-It is commoner in Mand. than max. same as OCN



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-Although it is not an infectious process but to prevent infection: we give

systemic antibiotics not like OCN that we give antibiotics only if there is

an infection.

-There is a difference between someone who presented with osteoradionecrosis and

someone who wants to do a procedure.

-Our problem here with the hypoxic stage , oxygen doesn’t reach to the

sac.

-So there is a treatment modality called hyperbaric oxygen … (hyperbaric

oxygen: a pressurized oxygen where you are placing a patient in a

chamber that has 100% & 2.3 atoms. pressure of oxygen so they make

multiple dives into this chamber) 20-30 dives before the procedure and 10

after to maximize the oxygenation of the tissues

so it is a suggested treatment modality ,so we ask the patient to do it

before the extraction and after and follow up is needed.

-Its problematic as in OCN

We give AB if there is a pain or infection

remember

Hyperbaric Oxygen Therapy:

Remember:

In OCN management we give AB if there is a pain or infection only.

In ORN Management same as OCN we give AB if there is a pain or

infection.

In ORN prevention we give AB.



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Remove sequestra: which is the pieces of dead bone.

A difference between ORN and OCN if I have bone less than 1 cm by

irrigation and removal of the sequestrum it tends to heal in ORN but not

in OCN

Hyperbaric oxygen therapy ( HBO Therapy ) improve the oxygenation to

the site.

Surgical intervention in cases that there is no response, I have to remove

to reach a healthy bone which is unlikely to be found , unless a specific

site is radiated for example the angle and the anterior mandible is

healthy.

The End

Dedicated to the kind friends :

Anas Abu Ghazalah , Yusif Sadik , Ibrahim Amer , Mutasem Dom & Wael Al Harbi

Last but not least our amazing group (Group 1 ).

Documents

Bisphosphonate Associated Osteonecrosis of the Jaws