Bisphosphonate associated osteomyelitis of the jaw in patients with bony exposure: prevention, a new way of thinking

Objective There is strong evidence of a link between the use of systemic bisphosphonates (BPs) and osteonecrosis of the jaw, especially in cancer patients. Among risk factors for BRONJ, tooth extraction and immune suppressive drugs seem to have significant role on bone healing. Therefore, the importance of these parameters in development of BRONJ was reviewed in this retrospective study in two maxillofacial surgery units. Material and Methods From 2007 to 2012, 46 patients on bisphosphonate who had developed oral bony lesions participated in this study. The pharmacological exposure, comorbidities, maxillofacial findings, types of treatment and outcome data were collected from clinical and radiological records. Results The most frequently used BP was alendronate (67%). Tooth extraction was reported in 61% of patients with BRONJ. Systemic corticosteroids were prescribed in 35 cases (76%) as an adjuvant for BP. Patients on corticosteroids had a lower probability of bony lesion healing (p<0.05) than patients without corticosteroids. Of the 46 patients who underwent conservative treatments, only ten were completely healed (21%). Conclusions Beside tooth extraction, corticosteroids were shown to be an implant risk factor for low rate of bone healing and hence the development of BRONJ. The outcome of conservative treatment was uncertain and this emphasizes the importance of prevention. .

The use of bisphosphonates does not contraindicate orthodontic and other types of treatment!

Bisphosphonates have been increasingly used not only to treat bone diseases as well as conditions such as osteopenia and osteoporosis, but also in oncotherapy. The use of bisphosphonates induces clinicians to fear and care. These reactions are associated with controversy resulting from lack of in-depth knowledge on the mechanisms of action as well as lack of a more accurate assessment of side effects. Scientific and clinical knowledge disclosure greatly contributes to professionals' discernment and inner balance, especially orthodontists. Fear does not lead to awareness. For these reasons, we present an article that focuses on that matter. This article was adapted from different journals of different dental specialties, as mentioned on footnote. There is no scientific evidence demonstrating that bisphosphonates are directly involved with etiopathogenic mechanisms of osteonecrosis and jaw osteomyelitis. Their use is contraindicated and limited in cases of dental treatment involving bone tissue. Nevertheless, such fact is based on professional opinion, case reports, and personal experience or experiment trials with failing methods. Additional studies will always be necessary; however, in-depth knowledge on bone biology is of paramount importance to offer an opinion about the clinical use of bisphosphonates and their further implications. Based on bone biopathology, this article aims at contributing to lay the groundwork for this matter.

Cada vez mais se usa os bisfosfonatos nos tratamentos de doenças e de estados ósseos, como a osteopenia e osteoporose, assim como nos protocolos oncoterápicos. O uso dos bisfosfonatos induz muitas reações de medo e cuidado, associadas a polêmicas e controvérsias quase sempre resultantes de uma falta de conhecimento mais profundo dos mecanismos de ação e da falta de uma avaliação mais criteriosa de seus efeitos colaterais. A divulgação e o conhecimento dos aspectos científicos e clínicos contribuem, em muito, para o discernimento e tranquilidade dos profissionais, especialmente dos ortodontistas. O medo não resulta em conscientização. Por essas razões, apresentamos alguns artigos sobre o mesmo assunto, semelhantes e adaptados, em revistas voltadas para as diferentes especialidades odontológicas, entre os quais o citado na nota de rodapé. Nos mecanismos etiopatogênicos da osteonecrose e nas osteomielites, nos maxilares, os bisfosfonatos não se encaixam como um dos fatores diretamente envolvidos e com base em evidências científicas. Suas contraindicações e limitações na prática odontológica como fator limitante de alguns tratamentos envolvendo o tecido ósseo estão baseadas, principalmente, em opiniões, casos clínicos e na experiência pessoal ou trabalhos experimentais com algumas falhas nos métodos experimentais. Sempre serão necessários mais estudos, mas um cuidado importante é se aprofundar no conhecimento da biologia óssea para, quando necessário, emitir-se opiniões sobre protocolos de conduta na clínica odontológica quanto ao uso bisfosfonatos e suas implicações. Esse artigo objetiva contribuir na fundamentação de abordagens sobre esse assunto a partir da biopatologia óssea.

Osteomyelitis due to BCG vaccination.

A six month-old immunocompetent boy who received BCG at birth presented with multiple abscesses in left subaxillary region, and swelling and wound infection on the left arm. Radiographs revealed osteolytic lesion in the left humerus. A biopsy from the site revealed chronic granulomatous lesion, positive for M. bovis on tissue culture. The lesion responded to antituberculous therapy and surgical treatment. There are no sequelae after 2 years of follow-up.