We followed the accepted criteria 20 to establish the diagnosis of onj. Osteonecrosis of the jaw is very painful and can lead to serious complications, including ulcerations within the lining of the mouth, infection, and breakdown of the jawbone with disfigurement. Mar 29, 2008 osteonecrosis of the jaws associated with bisphosphonate therapy was first identified in 2003 as a condition typified by exposed bone that does not heal after 8 weeks. Imaging findings in bisphosphonate induced osteonecrosis of the jaws katarina surlan popovic1, miha kocar2 1 department of neuroradiology, institute of radiology, university medical centre ljubljana, ljubljana, slovenia 2 department of maxillofacial and oral surgery, university medical centre ljubljana, ljubljana, slovenia received 26 may 2010. Medicationrelated osteonecrosis of the jaw is an oral complication in cancer patients. Bisphosphonateinduced osteonecrosis of the jaw onj. Orn is the result of hypocellularity, hypovascularity, and tissue hypoxia following ionizing radiation. The duration of therapy is important, as longer duration appears to be associated with increased risk of bon development. Bisphosphonate related osteonecrosis of the jaws rev bras reumatol 2011. Request pdf on nov 1, 2009, noam yarom and others published osteonecrosis of the jaws induced by drugs other than bisphosphonates a call to update terminology in light of new data find, read.
Pdf bisphosphonaterelated osteonecrosis of jaw bronj. Bisphosphonate related osteonecrosis of the jaws bronj is a poorly understood pathologic entity from the standpoints of its nomenclature, frequency, pathogenesis, and best method of treatment. Pdf bisphosphonateinduced osteonecrosis of the jaws bionj. Bisphosphonates bps are a widely used class of drugs indicated for the prevention and treatment of postmenopausal and steroidinduced osteoporosis. Osteonecrosis of the jaw and the role of bisphosphonates.
It can cause persistent pain and infection to the jawbones, and is currently considered incurable. The disease is characterized by the exposure for over 8 weeks of necrotic bone in the maxillofacial region. Bisphosphonates are drugs that decrease bone turnover by inhibiting osteoclast activity. Normal serum bone markers in bisphosphonateinduced osteonecrosis of the jaws steven lehrer, md,a andre montazem, md, dmd,b lakshmi ramanathan, phd,c melissa pessinminsley, md, phd,d john pfail, dds,e richard g.
Patients treated with bps may subsequently develop osteonecrosis of the jaw or. Sep 17, 2015 osteonecrosis of the jaws definition onj sawatari and marx 2007 exposed bone in the mandible or maxilla that fails to heal within 8 weeks in a patient receiving, or who has received, a systemic bisphosphonate, and who has not received local radiation therapy to the jaws. Osteonecrosis of the jaws is a recently described adverse side effect of bisphosphonate therapy. Osteonecrosis of the jaw onj occurs specifically in the cells of the maxilla and mandible jaw bones. Since intravenous administration leads to a higher drug exposure than the oral route, osteonecrosis related to oral bisphosphonate therapy is less common than that of related to intravenous forms such as zolendronate which is also more potent than oral bisphosphonates. Bisphosphonates and osteonecrosis of the jaws journal of. Osteonecrosis of the jaw associated with bisphosphonate. Osteonecrosis of the jaws induced by drugs other than. Patients with multiple myeloma and metastatic carcinoma to the skeleton who are receiving. Cdho factsheet bisphosphonaterelated osteonecrosis of the jaw.
Medicationrelated osteonecrosis of the jaw mronj is a rare but severe side. Bisphosphonateassociated osteonecrosis of the jaws baonj is a side effect of treatment with bisphosphonate bp. May 16, 20 advisory task force on bisphosphonaterelated ostenonecrosis of the jaws and american association of oral and maxillofacial surgeons, american association of oral and maxillofacial surgeons position paper on bisphosphonaterelated osteonecrosis of the jaws, journal of oral and maxillofacial surgery, vol. Osteonecrosis of the jaw and bisphosphonates in cancer. Nbisphosphonates cause gastric epithelial injury independent of effect on. Six cases 4056 patients had previously been identified in all controlled clinical trials and the first postmarketing report was made in december 2002.
Bisphosphonaterelated osteonecrosis of the jaw workup. Several recent reports have described osteonecrosis of the jaws onj associated with the use of bisphosphonates. Rarely found in the jaws is a steroidinduced form of osteonecrosis that is much more common in long bones, and, unlike the bisphosphonateinduced necrotic bone, it almost never produces exposed bone. Group 2 was a sample of 20 patients with osteoradionecrosis of the jaws orn, the diagnosis being established following the criteria described by thorn et al. Osteonecrosis of the jaw international osteoporosis foundation. The special committee favors the term medication related osteonecrosis of the jaw mronj.
Osteonecrosis of the jaw and osteoporosis management. Bisphosphonate related osteonecrosis of the jaws bronj was initially recognised and reported in the literature in 2002. Oral bisphosphonates and the risk for osteonecrosis of the. Medicationrelated osteonecrosis of the jaw in patients. The present study describes a model of maxillary osteonecrosis in spraguedawley rats, applying bisphosphonates and examines the changes occurring after tooth extraction. Osteonecrosis of the jaws by intravenous bisphosphonates. Medicationrelated osteonecrosis of the jaw2014 update. Page 1 medicationrelated osteonecrosis of the jaw 2014 update. The change is justified to accommodate the growing number of osteonecrosis cases involving the maxilla and mandible associated with other antiresorptive denosumab. Endodontic implications of bisphosphonateassociated osteonecrosis of the jaws the guidance in this statement is not intended to substitute for a clinicians independent judgment in light of the conditions and needs of a specific patient. Nature and frequency of bisphosphonate associated osteonecrosis of the jaws in australia. Oral bisphosphonate related osteonecrosis of the jaw. Pathophysiology of bisphosphonatesassociated osteonecrosis of the jaw r01 pa072.
Oral and intravenous bisphosphonate induced osteonecrosis of. Harper and fung 1, i wish to comment and raise questions on the recent editorial by kahn 2 and article by etminan, et al 3. Hyperbaric oxygen treatment and bisphosphonates induced osteonecrosis of the jaw. Prevention of osteonecrosis of the jaw onj in patients on bisphosphonate therapies purpose the nsw centre for oral health strategy recognises that there has been growing concern regarding the number of patients who take bisphosphonate agents, thereby placing them at potential risk for developing osteonecrosis of the jaws, especially. Article bisphosphonate associated osteonecrosis of the jaw. Bisphosphonateinduced avascular osteonecrosis of the jaws. Oral and intravenous bisphosphonate induced osteonecrosis of the jaws. Bisphosphonateinduced osteonecrosis of the jaw bionj studies have shown that the use of bisphosphonate in patients with cancer is associated with osteonecrosis of the jaw.
Prevention of osteonecrosis of the jaw onj in patients on. Osteonecrosis of the jaw in patients treated with bisphosphonates is a relatively rare but well known complication at maxillofacial units around the world. Osteonecrosis of the jaws is an increasingly recognised complication of bisphosphonate therapy. Bisphosphonate associated osteonecrosis of the jaw is an important condition seen most commonly in oncology patients receiving highdose intravenous bisphosphonates. It has since come under increasing scrutiny especially as it affects not only patients receiving intravenous bisphosphonates for cancer related conditions unrelated to radiotherapy but also those on oral preparations for osteoporosis. Pdf osteonecrosis of the jaws in patients treated with. Medical comorbidities included the malignancy itself 97. Treatment and prevention of bisphonate induced osteonecrosis of the jaws bisphosphonates are therapeutic agents utilized in the treatment of osteoclastmediated bone loss due to osteoporosis, hypercalcemia of malignancy, pagets disease of the bone, multiple myeloma, and metastatic malignancies. Lowdose bisphosphonates given either orally or intravenously in osteoporosis patients have not been causally linked to the development of osteonecrosis of the jaw. Medicationrelated osteonecrosis of the jaw wikipedia. Drug related risk factors a bisphosphonate potency.
We compared the extent of bonj on contrastenhanced mr imaging, 18f fluoride petct, and panoramic views derived from standard conebeam ct with clinical pre and intraoperative examinations. This series included patients diagnosed with bisphosphonate induced osteonecrosis of the jaws treated by block resection. Since it was first identified in 2003, bisphosphonateinduced osteonecrosis has come under growing scrutiny by medical and dental specialists alike because it affects cancer patients receiving intravenous bisphosphonate therapy and osteoporosis patients receiving oral bisphosphonate therapy and yet its presentation of exposed bone is limited to the jaws. It is important to recognize osteonecrosis of the jaws in patients treated with bisphosphonates because an early diagnosis can make a significant difference to the outcome of the disease. Osteonecrosis of the jaw, commonly called onj, occurs when the jaw bone is exposed and begins to starve from a lack of blood. Cases of osteonecrosis of the jaw in connection with the use of bisphosphonates were reported in 2003. The histopathologic features described herein may explain the physiopathology of this disease, which is different from other necrotizing and inflammatory conditions such as osteoradionecrosis and suppurative osteomyelitis. Bisphosphonates have become the standard of care in the treatment of patients with osteoporosis 1,2 and in the prevention and treatment of skeletal.
Bisphosphonate related osteonecrosis of the jaws the. Oral bisphosphonate induced osteonecrosis of the jaws is less common, less severe, and more likely to undergo spontaneous resolution or resolution with local debridements after a drug holiday and return of bone remodeling documented by the morning fasting ctx test than its counterpart caused by intravenous bisphosphonates. Most cases of osteonecrosis of the jaw happen after a dental extraction. Aug 09, 20 bisphosphonates related osteonecrosis of the jaw bronj is related to the development of avascular osteonecrosis or osteochemonecrosis 1, 2.
Imaging findings of bisphosphonate associated osteonecrosis of the jaws. In study 1, no cases of onj were observ ed in either treatment group. Bisphosphonaterelated osteonecrosis of the jaws bronj is a severe complication that has recently emerged in patients treated with intravenous bisphosphonates for malignant diseases. In this article, bisphosphonate associated osteonecrosis or bon will be the terms used to describe an osteonecrosis of the jaws secondary to bisphosphonate therapy. However, a causeandeffect relationship has not been established, and most of the reported cases have been in patients with cancer who were receiving much higher doses than those used to treat osteoporosis or paget disease of bone. Findings in contrastenhanced imaging of the jaws of 11 patients with bisphosphonateinduced osteonecrosis of the jaws findings in contrast. Bisphosphonateassociated osteonecrosis than the oral bisphosphonates. Furthermore, a trend to ward lo wer incidences of infection and tooth loss was observed in the alendronate group. The aim of this study is to describe the radiological features of bisphosphonate osteonecrosis bon in order to aid its prompt recognition. Harper and fung1, i wish to comment and raise questions on the recent editorial by kahn2 and article by etminan, et al 3. History, etiology, prevention, and treatment, second edition robert e. T1 imaging findings in bisphosphonate related osteonecrosis of jaws. An association between the use of bisphosphonates and osteonecrosis of the maxilla and mandible has recently been described. Bisphosphonaterelated osteonecrosis of the jaws bronj is mainly observed in patients with multiple myeloma and bone metastasis from solid tumors receiving iv bisphosphonate therapy.
Bisphosphonates and bisphosphonateinduced osteonecrosis of. Yusuf farouk suleman, shabnum meer and russel lurie, bisphosphonateinduced osteonecrosis of the jaws. Concept, diagnosis and classification of bisphosphonateassociated osteonecrosis of the jaws. Imaging findings in bisphosphonaterelated osteonecrosis of jaws.
Patients undergoing treatment with bisphosphonates may develop jaw lesions consisting mainly of bone necrosis. Even though patients benefit of bp therapy is huge, various side effects may develop. In the presence of bp accumulation capable of decreasing bone metabolism, tissue repair following an induced or a physiological trauma does not occur properly. Bisphosphonates and bisphosphonate induced osteonecrosis of the jaws. Bisphosphonate related osteonecrosis of the jaw bronj is defined as exposed necrotic bone in the maxillofacial area that persists for more than 8 weeks in patients with a history of nitrogencontaining bisphosphonate use without a history of radiation exposure. Despite the benefits of these drugs, bisphosphonate related osteonecrosis of the jaw bronj which was first published in the literature in 2003 is a severe side effect of bisphosphonate therapy 47. Osteonecrosis of the jaws in patients treated with. Bisphosphonateassociated osteonecrosis is a new disease that is becoming increasingly more common. Pdf recently, bisphosphonates bps have been widely used in medical practice as antiresorptive agents owing to their antiosteoclatic action. The etiology of orn is, however, completely different from the mechanism behind bisphosphonate induced osteonecrosis.
Imaging findings in bisphosphonateinduced osteonecrosis of. Scintigraphy tc99scan is the most sensitive diagnostic strategy to identify edema and vascular changes. Bisphosphonaterelated osteonecrosis of the jaw scielo. Bisphosphonateinduced osteonecrosis of the jaw request pdf. Concept, diagnosis and classification of bisphosphonate. The aim of this study was to describe the incidence and risk factors of onj in patients with breast cancer or gynecological malignancies receiving bisphosphonates bp. Endodontic implications of bisphosphonateassociated. Evidence also suggests bisphosphonates induce apoptosis of osteoclasts.
In 2002, the food and drug administration fda received first reports related to several patients with cancer, treated with the iv bisphosphonates bp, who developed osteonecrosis of the jaw. Medicationrelated osteonecrosis of the jaws oxford academic. What is bisphosphonateinduced osteonecrosis of the jaw. Osteonecrosis of the jaw onj is a potentially severe adverse effect of bisphosphonates. Nbisphosphonates cause gastric epithelial injury independent of effects on the. Tosi p, zamagni e, cangini d, tacchetti p, offidani m, ronconi s, et al. Osteonecrosis of jaws onj might be old, dating back a century in the form of phossy jaw. Osteonecrosis of the jaw in patients treated with bisphosphonates is a. Imaging findings of bisphosphonateassociated osteonecrosis. Medicationrelated osteonecrosis of the jaw mon, mronj is progressive death of the. In early 2005 the fda in the united states released a statement saying that osteonecrosis is a risk with all forms of. Clinically it is diagnosed by an area of exposed bone in the mandible, maxilla, or palate that typically heals poorly or does not heal over a period of 6 to 8 weeks. Osteonecrosis of the jaw onj, a condition characterized by necrotic.
Bisphosphonatesrelated osteonecrosis of the jaw in cancer patients and hyperbaric oxygen therapy. Orally administered bps may induce recurrent ulcers with. Medicationrelated osteonecrosis of the jaw mronj, which was first described in 2002, is a relatively uncommon but potentially serious side effect of treatment with osteoclast inhibitors, such as intravenous highpotency bisphosphonates and denosumab, which decrease the risk of skeletalrelated events in patients with cancer and metastatic bone disease. Bisphosphonate induced osteonecrosis is a chemical toxicity resulting in the death of osteoclasts. Since this initial identification, many cases have been reported 811. Introduction bisphosphonate induced osteonecrosis of the jaws onj was first described by marx in the year 2003 1. Axial and coronal computed tomography ct images of the maxillofacial bones figures 2 and 3 demonstrate extensive cortical destruction, osteosclerosis, cortical thickening, and fragmentation of the right maxilla, which extends into the frontal process of the zygomatic bone and pterygoid plates.
Before we begin to examine the issues as we currently understand them, it is important to discuss what bisphosphonates are, what they are used for, and how they work. Radiographic findings in bisphosphonateassociated osteonecrosis of the jaws. Since it was first identified in 2003, bisphosphonate induced osteonecrosis has come under growing scrutiny by medical and dental specialists alike because it affects cancer patients receiving intravenous bisphosphonate therapy and osteoporosis patients receiving oral bisphosphonate therapy and yet its presentation of exposed bone is limited to the jaws. Bisphosphonateinduced avascular osteonecrosis of the jaws article in international journal of oral and maxillofacial surgery 357.
Pdf bisphosphonateinduced osteonecrosis of the jaw. Potential pathophysiological mechanisms in osteonecrosis of the jaw. Bisphosphonate is used to treat osteoporosis, bone metastases, hypercalcemia of malignancies and multiple myeloma. Review, clinical implications and case report, head and neck pathology, 10. Oral and intravenous bisphosphonateinduced osteonecrosis of. As a rheumatologist who has seen and managed bisphosphonate related osteonecrosis of the jaws fung e, medwatch case reports. Bisphosphonate osteonecrosis was first identified in 2001. Nih funding opportunities and notices in the nih guide for grants and contracts. It has been speculated that the medication, especially longterm i. Since 2003, multiple cases of bisphosphonateinduced osteonecrosis of the jaw onj were reported. This complication usually presents after simple dentoalveolar surgery.
Imaging of bisphosphonateinduced osteonecrosis of the jaw is essential for surgical planning. Mar 11, 2019 bisphosphonate related osteonecrosis of the jaw bronj is a condition found in patients who have received intravenous and oral forms of bisphosphonate therapy for various bonerelated conditions. Severe osteonecrosis of the jaws in a compromised patient. The reported incidence of bronj is significantly higher with the iv preparations zoledronic acid and pamidronate while the risk appears to be minimal for. This complication usually presents after a minor local trauma during a dental treatment. However, these imaging resources are not able to show the difference between bronj and other causes of bone exposure in the jaw, such as osteoradionecrosis, osteomyelitisrelated osteonecrosis of the jaw, or steroid induced osteonecrosis. Several etiopathogenic mechanisms of this pathological condi. Reconstruction of defects caused by bisphosphonateinduced. Development of medicationrelated osteonecrosis of the jaw after. Bisphosphonaterelated osteonecrosis of the jaws rev bras reumatol 2011. Normal serum bone markers in bisphosphonateinduced. Reports of this complication have increased recently. While osteonecrosis can be caused by a number of other factors, this particular form of the condition is called bisphosphonateinduced osteonecrosis of the jaw bionj.
Case report a 77yearold male caucasian patient was referred to the stomatology department. Bisphosphonates and osteonecrosis of the jaws australian. Periapical disease and bisphosphonates induce osteonecrosis. This is a rare condition associated with dental extractions and bone therapies often used in cancer treatments, and occurs when jaw bones become. Sclerostin antibody do not induce osteonecrosis of the jaw onj in rats with. Bisphosphonateassociated osteonecrosis of the jaws. Osteonecrosis of the jaws onj is a complication of antiresorptive medications, such as denosumab or bisphosphonates, prescribed to patients with bone malignancy or osteoporosis. To evaluate the level of knowledge of dentists from plovdiv, bulgaria, about possible complications of bisphosphonate therapy of patients in dental practice.
Bisphosphonate related osteonecrosis of the jaws bronj is a welldescribed clinical condition with consistent radiographic findings. The text below is from the executive summary of a european society on clinical and economic aspects of osteoporosis and foundation for research on osteoporosis and other bone diseases working group meeting december 2006. Osteonecrosis of the jaws and bisphosphonates springerlink. Bisphosphonate related osteonecrosis of the jaw bronj manifests as exposed, nonvital bone involving the maxillofacial structures. Bisphosphonateinduced osteonecrosis of the jaws, bone. Bisphosphonaterelated osteonecrosis of the jaws bronj is among the most serious ones. Imaging findings in bisphosphonateinduced osteonecrosis. Rheumatologists treating bone diseases with bisphosphonate need, therefore, to be aware of this potential risk and plan the prophylaxis, early diagnosis and prevention of potential consequences. Osteonecrosis of the jaws onj is characterized by the death of bone as a natural consequence of a wide variety of systemic and local factors compromising the blood flow of the bone. Although this has generated a large amount of literature in the last few years, it is difficult to. Bisphosphonate associated osteonecrosis of the jaw.