Osteonecrosis of the jaw in a patient under treatment of osteoporosis with oral bisphosphonate

Although uncommon in patients under oral therapy, bisphosphonate-related osteonecrosis of the jaw (BRONJ) can be a very severe issue. Early intervention with surgical resection should be the preferable method of treating any stage of the disease, resulting in better outcomes and decreasing the morbidity of this condition. A 77-year-old female patient attended the Special Care Dentistry Centre of the University of São Paulo Faculty of Dentistry (CAPE FOUSP) complaining mainly of "an exposed bone that appeared after tooth extraction performed six months earlier". The patient was diagnosed with osteonecrosis associated with bisphosphonate (sodium ibandronate) and surgically treated with removal of bone sequestration and antibiotic therapy. The patient was followed up for six years (a total of 6 appointments), presenting good general health and no sign of bone exposure. Imaging findings showed no changes related to BRONJ either.

Prevalence and Risk Factors of Atypical Femoral Fracture Bone Scintigraphic Feature in Patients Experiencing Bisphosphonate-Related Osteonecrosis of the Jaw / 대한핵의학회잡지

PURPOSE: Bisphosphonate (BP) is the first-line therapy for the management of osteoporosis. BP-related osteonecrosis of the jaw (BRONJ) and atypical femoral fracture (AFF) are increasingly common comorbidities in patients with osteoporosis under long-term BP treatment. The aim of this study was to evaluate the incidence and risk factors for AFF features on bone scintigraphy in patients with BRONJ.METHODS: Among total of 373 BRONJ patients treated between September 2005 and July 2014, 237 (220 women, 17 men; median age 73 years) who underwent three-phase bone scintigraphy were enrolled for this retrospective study. AFF features on bone scintigraphy and the related clinical factors were assessed.RESULTS: Among 237 patients with BRONJ, 11 (4.6%) showed AFF features on bone scintigraphy. BP medication duration (p = 0.049) correlated significantly with AFF features on bone scintigraphy in patients with BRONJ. BP intake duration of 34 months was the cutoff value for predicting the presence of AFF features on bone scintigraphy. Among the patients with BRONJ, all those with AFF features on bone scintigraphy were female patients with osteoporosis who were on oral BP medication; however, these factors were not significantly different along with AFF features on bone scintigraphy.CONCLUSIONS: The incidence of AFF features on bone scintigraphy was relatively high in patients with BRONJ. A careful observation of patients presenting with the AFF features on bone scintigraphy may be needed, particularly for female BRONJ patients with osteoporosis who have been on BP medication for over 34 months.

Bisphosphonate-related osteonecrosis of the jaw in metastatic breast cancer patients: a review of 25 cases / 대한악안면성형재건외과학회지

BACKGROUND: Intravenous bisphosphonates have been used in metastatic breast cancer patients to reduce pathologic bone fracture and bone pain. However, necrosis of the jaw has been reported in those who received intravenous bisphosphonates. Bisphosphonate-related osteonecrosis of the jaw (BRONJ) is caused by dental extraction, dental implant surgery, and denture wearing; however, it occurs spontaneously. The purpose of this study was to report BRONJ in metastatic breast cancer patients. METHODS: Consecutive 25 female patients were referred from the Department of Oncology from 2008 to 2014 for jaw bone discomfort. Staging of breast cancer, history of bisphosphonate infusion, etiology of BRONJ, and treatment results were reviewed. Average age of the patients was 55.4 years old (38-74). Twelve maxillae and 16 mandibles were involved. Conservative treatments such as irrigation, antibiotic medication, analgesics, and oral gargle were applied for all patients for the initial treatment. Patients who had sequestrum underwent debridement and primary closure. RESULTS: The etiologies of BRONJ were dental extraction (19 cases), dental implant (2 cases), and endodontic treatment (1 case). However, three patients did not have any risk factors to cause BRONJ. Three patients died of progression of metastasis during follow-up periods. Surgical debridement was performed in 21 patients with success in 18 patients. Three patients showed recurred bone exposure and infection after operation. CONCLUSIONS: Prevention of the BRONJ is critical in metastatic breast cancer patients. Conservative treatment to reduce pain, discomfort, and infection is recommended for the initial therapy. However, if there is a sequestrum, surgical debridement and primary closure is the key to treat the BRONJ.

Bisphosphonate-related osteonecrosis of the jaw in a patient with osteoporosis following treatment of testicular cancer: a case report

Bisphosphonate-related osteonecrosis of the jaw (BRONJ) occurs mainly in female patients. In males the occurrence rate is low, which seems to be related to the low incidence of osteoporosis in men. Unfortunately, BRONJ tends to be ignored in general dental clinics in male patients with a history of osteoporosis treatment. BRONJ occurred in a male patient due to the clinician's lack of interest in the patient's history. In this case, the male patient was on bisphosphonate therapy because of a orchiectomy, and a dental treatment was performed without consideration of his medical history, resulting in BRONJ. We performed careful examinations and treatment with antibiotics and surgical operations. The postoperative healing was successful. In light of this particular case, we concluded that careful listening to the patient's history is very important.

Effect of alendronate on bone remodeling around implant in the rat

PURPOSE: The purpose of this study was to evaluate the effect of alendronates on bone remodeling around titanium implant in the maxilla of rats. MATERIALS AND METHODS: The maxillary first molars were extracted and customized-titanium implants were placed immediately in thirty male Sprague-Dawley rats. The rats were divided into experimental (bisphosphonate) group and control group. At 4 weeks after implantation, the rats in the bisphosphonate group were subcutaneously injected with alendronate three times a week for 6 weeks where as the rats in control group were injected with saline. The rats were sacrificed at 1, 2, 3, 4, or 6 weeks after starting of injection and maxillary bones were collected subsequently. Alveolar bone remodeling around the implants were evaluated by radiographic and histologic analysis. Microarray analysis and immunohistomorphologic analysis were also performed on one rat, sacrificed at 6 weeks after starting of injection, from each group. Statistical analysis was performed using repeated measures analysis of variance and independent t test at a significance level of 5%. RESULTS: There was no statistically significant difference in the bone area (%) around implant between the bisphosphonate group and the control group. However, the amount of empty lacuna was significantly increased in the bisphosphonate group, especially in the rats sacrificed at 4 weeks after starting of injection compared to that of the corresponding control group. The bisphosphonate group showed the same level of TRAP positive cell count, osteocalcin and angiopoietin 1 as the control group. CONCLUSION: Alendronate may not decrease the amount of osteoclast. However, the significantly increased amount of empty lacuna in the bisphosphonate group may explain the suppression of bone remodeling in the bisphosphonate group.

A Case of Intractable Bisphosphonate-Related Osteonecrosis of the Jaw Treated with Teriparatide / 대한골다공증학회지

Bisphosphonates are the most widely used medications for treating high bone turnover osteoporosis, Paget's disease of bone, multiple myeloma and metastatic carcinomas, etc. However, a destructive complication of bisphosphonate-related osteonecrosis of the jaw (BRONJ) can occur. The treatments of BRONJ are challenging and the currently recommended managements for BRONJ are still controversial. Our case demonstrated that teriparatide can be a treatment of choice for intractable BRONJ, which had not been cured for 2 years even with the proper surgical treatment and withdrawal of bisphosphonates.

Clinical Study of Bisphosphonate-Induced Osteonecrosis of Mandibular and Maxillary Bone

Bisphosphonates are compounds widely used in the treatment of various metabolic and malignant bone disease. Recently, an association between bisphosphonate use and a rare dental condition termed 'osteonecrosis of the jaw(ONJ)' has been reported. Bisphosphonate-related osteonecrosis of the jaw(BRONJ) is rare, but serious, side effect of bisphosphonate therapy in affected patients. It is characterized by poor wound healing and spontaneous intra-oral soft tissue break down, which lead to exposure of necrotic maxillary and mandibular bone. We reviewed 11 patients of BRONJ visited Ajou University Hospital Dental clinic from May 2007 to November 2008. The management of the patients included cessation of bisphosphonate therapy and various surgical restorative procedures and conservative care there after. Aggressive debridement is contraindicated. A new complication of bisphosphonate therapy administration, osteonecrosis of jaws, seems to be developing. The improved results after cessation of the medication should make clinicians reconsider the merits of the rampant use of bisphosphonates, while further investigation is needed to completely elucidate this complication.

Maxillary sinusitis as a complication of oral bisphosphonate related osteonecrosis of the jaw: A case report

Maxillary sinusitis is an infectious disease which can arise from odontogenic etiology and a maxillary osteomyelitis can spread into the sinus and consequently develop maxillary sinusitis. In this case report, a mid eighty's lady was diagnosed as BRONJ with maxillary sinusitis as a complication. The patient was managed successfully in collaboration with a endocrinologist. Through serial follow-up of serum CTX, we could decide the timing of surgical intervention.