Bisphosphonates (BPs) are used to treat metabolic bone diseases, such as osteoporosis. In this study the occurrence of bisphosphonates-related osteonecrosis of the jaws (BRONJ) is reported in 25 patients who received BP therapy for osteoporosis with different drug schedules. From June 2005 to May 2009, 25 patients affected by BRONJ were observed. A history of oral surgery was reported for 18 patients (72%). Of the 22 patients treated by the authors, 20 (91%) recorded healing improvement with a mean follow-up of 16.6 months, with particular regard for those treated with oral surgery and laser applications (10/22, 45%) who were all characterised by complete mucosal healing over time. The risk of developing BRONJ in patients treated with BP for osteoporosis is lower than in cancer patients, but is not negligible. It is advisable for the prescribing physician to recommend a dental check-up prior to treatment, at least for patients who have not been to the dentist in the last 12 months. An early surgical and possible laser-assisted approach for patients who develop BRONJ is recommended.
Bisphosphonates (BPs) are non-metabolized analogues of pyrophosphate used to treat metabolic bone diseases, such as osteoporosis, a common condition that affects 10 million individuals aged over 50 . During the past two decades, BP therapy has become the leading clinical intervention for postmenopausal osteoporosis thanks to selective suppression of osteoclast activity and retardation of bone resorption. Oral BP was prescribed at 73% of 6.3 million visits for osteoporosis in 2003 and it is estimated that over 190 million prescriptions for oral BP have been dispensed worldwide .
Osteoporosis is a chronic disease that requires long-term administration of BP: the benefits of prolonged use of these drugs must be evaluated and compared with the possible side effects. Based on literature and clinical evidence, BPs have a safety profile in the treatment of osteoporosis , but an initial report in 2003 , subsequently confirmed by several studies, reported that osteonecrosis of the jaws (ONJ) may occur as an adverse side effect of intravenous BP therapy (BRONJ) . In addition, a low-grade risk of BRONJ is also connected with oral administration of BP . BRONJ is defined as the presence of necrotic bone in the oral cavity for at least 8 weeks in a patient who is taking (or has taken) BP and who has not received radiation to the head and neck . Patients affected by BRONJ may have swelling of oral and perioral tissues, pain, bleeding, persistent purulent discharge and draining fistulas, severe halitosis, lower lip paresthesia, mobility and loosening of teeth.
Owing to the higher risk of developing the disease in onco-haematological patients treated with intravenous (i.v.) BP, the majority of reviews and reports have concentrated on cancer patients. Few studies have investigated the development of BRONJ in patients receiving BP for the treatment of osteoporosis.
In this study, the authors report the occurrence of BRONJ in 25 female patients who received BP therapy for the treatment of osteoporosis with different drug schedules.
Materials and methods
From June 2005 to May 2009, 135 consecutive patients affected by BRONJ were observed. 25 of these patients (females, mean age 70.4 years, range 52–89 years) had been treated with BP therapy for osteoporosis. In particular, 4 of the 25 patients (16%) had received BP therapy for osteoporosis and were also affected by rheumatoid arthritis (RA) ( Table 1 ). The remaining 110 patients, who had been treated for oncological reasons (52 affected by multiple myeloma and 58 by bone cancer metastasis) were not included in this study. Patients were classified as affected by BRONJ according to American Association of Oral and Maxillofacial Surgeons (AAOMS) guidelines .
|Patient||Smoking||Age, years||Disease||Max/Mand||Trigger event||Mobile prosthesis||Stage||BP||Duration BPT months||BPT discontinuation||Co-morbidities||BRONJ therapy||Stage||Follow up (months)|
|BG||–||62||OP||Mand||Extr||No||II||Ale + Clo||84||–||–||G4||0||25|
|CM||+||65||OP||Mand||Extr||No||II||Ale + Iba||72||+||Hypertension–Breast cancer*||G2||I||6|
|FP||–||70||OP||Mand||Extr||Yes||II||Ale + Clo||36||–||Hypertension–Parkinson’s disease||G2||0||24|
|MC||+||74||OP||Max||Extr–Impl||Yes||II||Ale + Iba||42||+||–||G4||0||6|
|PI||–||75||OP||Max||Extr||Yes||II||Ale + Ris||>180||–||–||G3||0||7|
|PC||–||60||OP||Mand||Extr||No||I||Zol + Ale + Clo||30||+||Crohn’s disease||–||–||–|
|TS||–||57||OP||Mand||Extr||Yes||II||Ale + Ris||24||+||Kidney transplant||G3||0||20|
|USE||–||68||OP||Max||Extr||No||II||Ale + Iba||60||–||Breast cancer*||G2||0||12|