J Korean Assoc Oral Maxillofac Surg.  2011 Feb;37(1):54-61. 10.5125/jkaoms.2011.37.1.54.

Clinical study of diagnosis and treatment of bisphosphonate-related osteonecrosis of the jaws

• Kim KW
• Kim BJ
• Lee CH

• KMID: 2189807
• DOI: http://doi.org/10.5125/jkaoms.2011.37.1.54

Abstract

INTRODUCTION
Bisphosphonates is used widely for the treatment of the Paget's disease, multiple myeloma, bone metastases of malignant tumors with the prevention of pain and their pathological fracture. However, it was recently suggested that bisphosphonates related osteonecrosis of the jaw (BRONJ) is a side effect of bisphosphonate use.
MATERIALS AND METHODS
Twenty-four individuals, who were referred to the Department of Oral and Maxillofacial surgery, Dankook University Dental Hospital, were selected from those who had exposed bone associated with bisphosphonates from January, 2005 to December, 2009 according to the criteria of American Association of Oral and Maxillofacial Surgeons (AAOMS) for BRONJ. The patients group consisted of 7 males and 17 females between the age of 46 to 78 years (average 61.8 years). Each patient had panoramic imaging, computed tomography (CT), whole body bone scanning performed for a diagnosis and biopsy sampling from the necrotizing tissue. C-terminal cross-linking telopeptide of type I collagen (CTX) level of patients who had undergone surgical intervention was measured 7 days before surgery.
RESULTS
The main cause of bone exposure was post-extraction (15), chronic periodontitis (4), persistent irritation of the denture (3). Twenty people had undergone BRONJ treatment for two to eight months except for 4 people who had to maintain the bisphosphonates treatment to prevent a metastasis and bone trabecular pain with medical treatment. When the bisphosphonate treatment was suspended at least for 3 months and followed up according to the AAOMS protocols, the exposed necrotizing bones were found to be covered by soft tissue.
CONCLUSION
Prevention therapy, interruption of bisphophonates for at least 3 months and cooperation with the physician for conservative treatment are the essential for treating BRONJ patient with high risk factors. The CTX level of BRONJ patients should be checked before undergoing surgical intervention. Surgical treatments should be delayed in the case of a CTX level <150 pg/mL.

Keyword

Bisphosphonates; Osteonecrosis; Jaw Diseases; Therapeutics

MeSH Terms

Biopsy
Bisphosphonate-Associated Osteonecrosis of the Jaw
Chronic Periodontitis
Collagen Type I
Dentures
Diphosphonates
Female
Fractures, Spontaneous
Humans
Jaw
Jaw Diseases
Male
Multiple Myeloma
Neoplasm Metastasis
Osteonecrosis
Risk Factors
Surgery, Oral
Collagen Type I
Diphosphonates

Figure

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  Fig. 1. Necrotic bone.

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  Fig. 2. Purulent exudate and necrotic bone.

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  Fig. 3. After extraction, the extraction socket remains.

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  Fig. 4. With disappearing of lamina dura and widening of periodontal space, signs of osteolysis are shown on a panoramic view.

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  Fig. 5. The bony trabecula deformation of the alveolar bone in the left anterior maxilla and the large sequestrum with poor cor-ticomedullary differntiation are shown on CT scan image.(CT: computed tomography)

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  Fig. 6. Periosteal reaction is shown with bone sequestration.

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  Fig. 7. Many plasma cells, neutrophils and capillaries in granulation tissue are seen.(H&E staining, original magnification×200).

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  Fig. 8. Empty osteocytic lacuna.(H&E staining, original magnification ×100)

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  Fig. 9. The temporal muscle flap reconstruction was performed after segmental resection of the right posterior maxilla. A complete wound healing was achieved.

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  Fig. 10. The R-plate reconstruction was performed after segmental resection of the right posterior mandible. A complete wound healing was achieved.

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  Fig. 11. Chemical fomula of basic bisphosphonates structure.

Reference

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