[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
http://www.aaoms.org/docs/position_p...onj_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
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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
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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