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Practical considerations for treatment of patients taking bisphosphonate medications: an update Gareth Brock Kate Barker Christopher J Butterworth Simon Rogers Dental Update 2024 38:5, 707-709.
Authors
GarethBrock
Specialist Registrar in Restorative Dentistry, Liverpool Dental Hospital, The University of Queensland, Australia
Osteonecrosis of the jaw – bisphosphonate-related (ONJ-BR) is an established clinical entity associated with both oral and intravenous (IV) bisphosphonate therapy. An update for the general practitioner on the indications for bisphosphonate therapy and both risk assessment and prevalence of ONJ-BR is provided. Management philosophy within a local unit is illustrated through four brief case studies. It is not uncommon to encounter patients on bisphosphonate therapy in the dental practice environment; the vast majority of these will be on oral bisphosphonates as part of their management for osteoporosis. The risk of developing ONJ-BR is rare in these patients compared with those receiving treatment for skeletal complications associated with cancer, many of whom will be managed with IV bisphosphonates. Although rare, it is important to recognize the potential risk of ONJ-BR. Whilst most patients on oral bisphosphonates can be managed no differently from other patients, it should be appreciated that the relative risk of long-term cumulative exposure, comorbidity and other factors are still to be determined. Surgical intervention and extractions can place the patient at risk of ONJ-BR and vigilance is necessary to ensure that healing progresses satisfactorily. Early referral to the local hospital should be sought if there is cause for concern.
Clinical Relevance: Although the risk of ONJ-BR is low in non-oncological indications, it is important to be aware that it exists and to know how the risk may be minimized.
Article
Osteonecrosis of the jaw – bisphosphonate-related (ONJ-BR) is now a well recognized side-effect of bisphosphonate treatment.1–7 Bisphosphonates are a commonly prescribed medication; delivery via oral preparations (generally for long-term management of osteoporosis) is associated with a low incidence of ONJ-BR (typically reported as between 1 in 10,000 to 1 in 100,000 patients). Intravenous bisphosphonates, although much more likely to cause ONJ-BR (1 in 10 to 1 in 100 patients), are much less commonly used and tend to be prescribed in an oncology setting. ONJ-BR adversely affects the quality of life and produces significant morbidity in affected patients.8 There is an incomplete understanding of associated risk factors for developing ONJ-BR; furthermore, the cumulative effect of long-term oral bisphosphonate therapy, that is now prescribed for a large number of patients, is a concern. In a previous paper,9 we discussed the pharmacology of bisphosphonate medications, their role in the aetiology of ONJ-BR and its clinical presentation, as well as introducing methods of prevention and treatment. Since that paper was published, there have been numerous articles and the most salient of these will serve as an update in this article. This paper will present the most recent data on the indications, incidence, risk factors, prevention of ONJ-BR and the role of the general dental practitioner. The article should serve to help put the risk of ONJ-BR in perspective and help to reassure the clinician that it is an infrequent complication in those patients taking oral bisphosphonates. Four case scenarios have been included to illustrate some of the management issues. The paper focuses on the GDP's role in the prevention of ONJ-BR and does not address the management of established ONJ-BR as this has been already briefly discussed in the earlier article and is the subject of a further update.10
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