• Services
  • Surgical Weight Control
  • Joint Replacement
  • Edwards Comprehensive Cancer Center
  • Family Medical Centers
  • Mother & Baby Health
  • Emergency / Trauma Services
  • Complete A-Z list
• News & Events
  • What's New
  • Magazine Highlights
  • Calendar of Events
  • Newsbreaks
  • Newsletters
• Patients & Visitors
  • Patients & Visitors - Main
  • Rights & Responsibilities
  • Advance Directives
  • Shuttle Service & Valet Parking
  • Billing & Financial Information
  • Find a Physician
• For Physicians
  • For Physicians - Main
  • HealthNet Aeromedical
  • Patient Transfer Center
  • Patient Scheduling & Referral
• Employment
  • Employment - Main
  • Current Openings
  • Hospital Ancillary Credentialing
  • Employee Assistance
• Special Features
  • CHH eCards
  • Interactive Health Tools
  • Speakers Bureau
  • 360° Views
  • Photo Gallery
  • Online Nursery
  • Physician Directory
• Facilities & Projects
  • North Patient Tower

Update: Osteonecrosis of the Jaw and Bisphosphonates

While the warning regarding the risk of osteonecrosis of the jaw (ONJ) with bisphosphonate use has been known for some time, recent publicity on the news and radio has raised patients' concerns. Labeling changes occurred as early as August 2004 warning providers of the risk of ONJ with intravenous bisphosphonates. The suspected mechanism by which bisphosphonates may contribute to ONJ is through suppression of bone turnover, which may, in turn, impair bone healing.

Osteonecrosis is bone death resulting from poor blood supply that causes a change in the bone's structural architecture. Common sequelae include bone pain and destruction. Risk factors for ONJ include age greater than 65 years, concomitant use of estrogens or glucocorticoids, periodontitis and prolonged use of bisphosphonates.

While it is true that bisphosphonates do carry a risk, the overall incidence of ONJ is rare. The risk is greatest for patients receiving prolonged intravenous therapy (zoledronic acid [Zometa] and pamidronate [Aredia]). It is thought that the increased risk with intravenous formulations is secondary to the actual amount of drug that is available for incorporation into the bone matrix; much more is available if given intravenously when com-pared to oral administration. As of early this year, there had been 183 cases of ONJ reported for the oral bisphosphonates (alendronate [Fosamax], risedronate [Actonel] and ibandronate [Boniva]) that are commonly used to treat osteoporosis. Alendronate, the most widely used oral bisphosphonate, has an estimated risk of 0.7 cases per 100,000 person-years exposure.

ONJ may occur spontaneously. However, the majority of the cases have occurred around dental procedures that may cause damage to the jaw. Thus, it is recommended that patients do alert their dentist or oral surgeon if they are taking a bisphosphonate. Simply stopping the medication prior to the procedure is not likely to reduce the risk of ONJ as bisphosphonates persist in the bone for years. Thus, the American Dental Association has developed recommendations for dentists on how to approach patients taking bisphosphonates.

Some of the highlights include that patients:

• Starting oral bisphosphonates should have a comprehensive oral exam
• Should practice good oral hygiene
• Call the dentist if any problem arises
• Should be informed of the risk prior to oral manipulation that involves the bone, and nonsurgical options should be utilized when feasible
• Should have appropriate antibiotic or oral disinfectant therapy when necessary

The full panel recommendations are available in J Am Dent Assoc 2006;137:1144-1150.