To Anne, our dentist: Biosulphonates and osteonecrosis

[TriciaK]

Dear Anne, I was given the biosulphonate zometa for about 5 times just before I finished herceptin two years ago. Now I understand that most bone meds like this, including boniva and others like it, can cause a serious condition known as osteonecrosis or "jaw bone death" in case of dental work such as extractions. I have a tooth needing to be extracted and don't know what to do. Could only 5 injections of zometa be dangerous and possibly cause osteonecrosis ? What would you as a dentist suggest I do? I don't want to put you on the spot, but decided to post this rather than send it privately because there may be others searching for answers, too. If you would rather, you can reply privately to pairadox1@beyondbb.com. I appreciate any information you may be able to give on this subject as it really has me worried. Thank you! Hugs, Tricia

[Soccermom]

Dear Tricia,
I was at the dentist just today and was discussing this with the hygenist. I am on Boniva, but didn;t see it on the list of culprits for osteonecrosis of the jaw...Aredia,Zometa and Fosomax were included.
Thanks for posting this Tricia. I hope you get the answers you need!
Marcia

[anne2]

Hi Tricia,
How are you??
Your question is something that is on a lot of patients minds. Although I can't give you personal advice, the recent recommenations from ADA is that all patients who have had previous tx with biophosphonates seriously consider not having any oral surgery. You need to see an oral surgeon to determine your risk of necrosis of your jaw bone after extraction.
You can email me your specifics if you want me to look at your tooth. Is there any alternative treatments to extracting the tooth. There is also something called hyperbaric therapy to prevent and manage the osteonecrosis of the jaw. My suggestion would be to get multiple opinions and go to someone who is very knowledgeable about this.
You can send me an email at saxenachetana@yahoo.com if you need any more info.
Good luck,
Anne

[dchips1]

I had a root canal in March and they nicked the tori in the bottom of my mouth, it left a sore that would not heal and wound up a big mess. Nothing seemed to help and then I did 30 hyperbaric dives and vitamins coq10 c e and I only have 1 tiny area of healthy exposed bone. I thought I would lose all my lower left teeth one additional "gentle " root canal my jaw is stable. Marx protocal for hyperbaric dives has shoen to reduce the risk. 20-30 dives prior to extraction then 10 post extraction. My damage was from steroids/18 months zometa/ whole brain radiation. But you need to try to save the tooth if at all possible and that they are atraumatic as possible. I have a mouth full of braces/bite plate but the are attached to my own teeth!!!!! Goodluck Darita

[Mary Anne in TX]

Darita, you bee'z amazing girl!!!

[suzan w]

Thank you Tricia for asking this, and Anne for your answer. I have just asked my dentist the same thing, and my doctor, and oncologist...it is an issue that needs explaining!!! I got vague answers from everyone that I asked.

[Cathya]

Tricia;

Thank you so much for posting. I also need to have a tooth removed at the back of my mouth and am very concerned. I have been on actonel for 2 years and worry about the impact of this surgery. I have been referred to the same oral surgeon who removed my kids wisdom teeth but still.......

Happy Holidays,

Cathy

[KristinSchwick]

So I have not had any problems with my teeth during my treatments (Xgeva/denosumab) for almost 2 years. No cavities, no extractions. But for the past 3 days, I've had some tooth pain- and I'm worried that it could be ONJ.

I just had a brain MRI, that showed a perfectly healthy brain- but I'm wondering if they looked carefully at my jaw too. I know if it was super obvious they'd probably see ONJ, but would they see a really small area of ONJ? Also do the routine X-Rays done during dental exams pick up ONJ? Thanks,
Kristin

[Lien]

I didn't take biphosphonates as I have lots of jaw issues already. 6 months ago my Dad was prescribed bisphosphonates, so we looked into the ONJ problems. We found that a small percentage of bisphosphonate users developed problems. Here in the Netherlands there's a specific protocol for dentists to use when they treat patients who have been taking bp's.

According to this article ([PDF]
AAOMS Position Paper on Bisphosphonate-Related Osteonecrosis of
www.aaoms.org/docs/position_papers/bronj_update.pdf)

the incidence of ONJ problems is up to 12% in IV bisphosphonate users and less than 1% in oral bisphosphonate users.

Quote:

Based on available data, the risk of BRONJ for patients receiving IV bisphosphonates is significantly greater than the risk for patients receiving oral bisphosphonates. Regardless, given the large number of patients receiving oral bisphosphonates for the treatment of osteoporosis/osteopenia it is likely that most practitioners may encounter some patients with BRONJ. It is important to determine accurately the incidence of BRONJ in this population and to assess the risk associated with long-term use, i.e., greater than 3 years, of oral bisphosphonates. The low prevalence of BRONJ in osteoporosis patients poses a significant challenge for future clinical trials aimed at establishing accurate incidence data.
Risk factors
In the original Position Paper BRONJ risks were categorized as drug-related, local, and demographic or systemic factors. 1 Other medications, such as steroids, thalidomide, and other chemotherapeutic agents were thought to be risk factors, but no measurable associations were identified. Subsequently, two new sets of factors, genetic and preventative, are available to report.
I. Drug-related risk factors include: ®
A. Bisphosphonate potency: zoledronate (Zometa ) is more potent than pamidronate
(Aredia®) and pamidronate (Aredia®) is more potent than the oral bisphosphonates; the IV route of administration results in a greater drug exposure than the oral route. 37-38, 45, 52 Using a number of different risk measures, the BRONJ risk among cancer patients given IV bisphosphonate exposure ranged from 2.7 to 4.2, suggesting that cancer patients receiving IV bisphosphonates have a 2.7 to 4.2-fold increased risk for BRONJ than cancer patients not exposed to IV bisphosphonates. 37, 53
B. Duration of therapy: longer duration appears to be associated with increased risk. 38, 45
II. Local risk factors include: 37, 45, 52 A. Dentoalveolar surgery, including, but not limited to
1. Extractions
2. Dental implant placement
3. Periapical surgery
4. Periodontal surgery involving osseous injury
In the original Position Paper, local factors such as dentoalveolar procedures, local anatomic structures, e.g., tori, and concomitant dental disease were hypothesized to increase the risk for BRONJ in the setting of IV bisphosphonate exposure. 1 Patients receiving IV bisphosphonates and undergoing dentoalveolar surgery are at least seven
4
times more likely to develop BRONJ than patients who are not having dentoalveolar surgery. 45, 52 In the setting of IV bisphosphonate exposure, four studies reported that dentoalveolar procedures or concomitant dental disease increased the risk for BRONJ between 5.3 (odds ratio) to 21 (relative risk). 37, 52, 54-55 In other words, cancer patients treated with IV bisphosphonates who undergo dentoalveolar procedures have a 5 to 21- fold increased risk for BRONJ than cancer patients treated with IV bisphosphonates who do not undergo dentoalveolar procedures.
B. Localanatomy
1.
a.
b.
2.
a.
Mandible Lingual tori Mylohyoid ridge Maxilla
Palatal tori
It has been observed that lesions are found more commonly in the mandible than the maxilla (2:1 ratio) and more commonly in areas with thin mucosa overlying bony prominences such as tori, bony exostoses and the mylohyoid ridge. 24, 26, 56 No data are available to provide risk estimates for anatomic structures and BRONJ.
C. Concomitantoraldisease
Cancer patients exposed to IV bisphosphonates with a history of inflammatory dental disease, e.g., periodontal and dental abscesses, are at a seven-fold increased risk for developing BRONJ. 45

Treatment plans:

The risk of developing BRONJ associated with oral bisphosphonates, while exceedingly small, appears to increase when the duration of therapy exceeds three years. This time frame may be shortened in the presence of certain comorbidities, such as chronic corticosteroid use. If systemic conditions permit, the clinician may consider discontinuation of oral bisphosphonates for a period of three months prior to and three months following elective invasive dental surgery in order to lower the risk of BRONJ. The rationale for this approach is based on extrapolated data that demonstrate fluctuations of osteoclast function, which is related to bisphosphonate therapy, and recent outcomes studies that show improved outcome of BRONJ treatment with drug cessation. 61-64 Long-term, prospective studies are required to establish the efficacy of drug holidays in reducing the risk of BRONJ for patients receiving oral bisphosphonates. The risk
6
reduction may vary depending on the duration of bisphosphonate exposure. Modification or cessation of oral bisphosphonate therapy should be done in consultation with the treating physician and the patient.
Treatment Goals
The major goals of treatment for patients at risk of developing or who have BRONJ are:  Prioritization and support of continued oncologic treatment in patients receiving IV
bisphosphonates.
o Oncology patients can benefit greatly from the therapeutic effect of bisphosphonates by
controlling bone pain and reducing the incidence of other skeletal complications.
 Preservation of quality of life through: o Patient education and reassurance o Control of pain
o Control of secondary infection
o Prevention of extension of lesion and development of new areas of necrosis

And some more:

D. Patients with BRONJ
The treatment objectives for patients with an established diagnosis of BRONJ are to eliminate pain, control infection of the soft and hard tissue, and minimize the progression or occurrence of bone necrosis.
These patients respond less predictably to the established surgical treatment algorithms for osteomyelitis or osteoradionecrosis. Surgical debridement has been variably effective in eradicating the necrotic bone. 22-24, 29 It may be difficult to obtain a surgical margin
9
with viable bleeding bone as the entire jawbone has been exposed to the pharmacologic influence of the bisphosphonate. Therefore, surgical treatment should be delayed if possible and reserved for those patients with stage 3 disease or in those cases with well- defined sequestrum. Areas of necrotic bone that are a constant source of soft tissue irritation should be removed or recontoured without exposure of additional bone. Loose segments of bony sequestrum should be removed without exposing uninvolved bone. 70 The extraction of symptomatic teeth within exposed, necrotic bone should be considered, since it appears unlikely that the extraction will exacerbate the established necrotic process.
Patients with established BRONJ should avoid elective dentoalveolar surgical procedures, since these surgical sites may result in additional areas of exposed necrotic bone. Symptomatic patients with stage 3 disease may require resection and immediate reconstruction with a reconstruction plate or an obturator. Recent case series have described acceptable outcomes following surgical therapy for patients with stage 2 and stage 3 disease. 69 The potential for failure of the reconstruction plate because of the generalized effects of the bisphosphonate exposure needs to be recognized by the clinician and patient. Immediate reconstruction with non-vascularized or vascularized bone is still considered potentially problematic as necrotic bone may be present at the resection margins or develop at the recipient site.
The effectiveness of hyperbaric oxygen therapy as an adjunct to non-surgical and surgical treatment is under investigation at two institutions where a randomized controlled trial is underway.71 Preliminary results have shown some improvement in wound healing and long-term pain scores, but its use as the sole treatment modality for BRONJ cannot be supported at this time.
Case reports with small sample sizes have documented the use of other non-surgical treatment strategies, such as, platelet rich plasma, parathyroid hormone, and bone morphogenic protein. 72 The efficacy of these treatment modalities needs to be established through additional research and controlled studies.


Hope this helps a bit.

Jacqueline

[CoolBreeze]

I've been mets 3 years now, on Zometa for 2, had c.diff 3 times, and no dentist wants to treat me. I have had some tooth pain but I'm good with the oral hygeine and salt down that tooth every night and use a braun electric toothbrush and keep my mouth from getting sores. I don't know what else I can do.

Take as good a care of your teeth as you can. Before I started my chemo, when I was only Stage 2, I did the most complete dental cleaning possible and took care of everything. That has to last, I guess.

[jaykay]

I had been on Actonel, Fosamax, injection of Reclast for quite a long time due to early menopause and osteopenia due to Femera and just bad genes.

That being said, I had full mouth gum surgery 20+ years ago and am anal about my teeth. I've had 2 implants with bone grafts over the past 4 years and have had no problems. Plus lots of "regular" crowns. My dentist is a periodontist/implant specialist and is very well versed in all the issues and ramifications around biophasphates. I trust him implicitly. Plus I'd rather have "teeth" than holes in my mouth which can cause other issues.

Just make sure you have someone at the top of his/her field. My biggest fear with starting chemo was that I was going to lose a cycle of teeth-cleaning - I go every 3 months. But so far so good.

The biggest concern with any kind of extensive dental surgery is smoking. My dentist wouldn't do anything with implants until I had stopped smoking for at least a year.