Bisphosphate-induced osteonecrosis of the jaws (BIONJ)

Content
Despite the denials from the major drug companies involved and their effort to corrupt several professional organizations and individuals by distributing large money grants, Bisphosphonate Induced Osteonecrosis of the Jaws (BIONJ) is a very real world wide epidemic with over 10,000 reported cases and over 776 published scientific articles in just the past five years alone. Although both intravenous bisphosphonates and oral bisphosphonates cause BIONJ, the IV drugs cause a more severe form, sooner, and one that is more resistant to prevention and treatment. Many cases of intravenous BIONJ can be prevented by preventative dental care aimed at arresting periodontal inflammation and stabilizing dental health to avoid extractions which are the two most common dental risk factors.1 Intravenous BIONJ is usually treated with 0.12% chlorhexidine oral rinses and courses of antibiotics to control infections and therefore pain, but leaving residual exposed bone.2, 3 However, some cases refractory to this regimen require jaw resection to cure the BIONJ.3 Oral BIONJ is mostly caused by Alendronate (Fosamax Merck Co.) because this formulation is twice the dose of its equal potent competitors, Residronate (Actonel Procter and Gamble) and Ibandronate (Boniva Roche Laboratories). In addition to prevention schemes to arrest periodontal inflammation and avoid extractions, dentist and oral surgeons can use the serum C-terminal telopeptide test (CTX ) to monitor the bone suppression affect of bisphosphonates. A stratification of risk for BIONJ when an oral surgery procedure into the alveolar bone is planned has been advanced as a CTX 100 pg/ml relates a high risk, 100 to 149 pg/ml relates a moderate risk and > 150 pg/ml relates little or no risk.4 The CTX test has been widely used and is the most accurate and least variable of all bone suppression markers.5 Its utility is extended into treating oral BIONJ by using a bisphosphonate drug holiday until the CTX value rises to over 150 pg/ml.4 At this value, elective oral surgery procedures such as extractions and dental implants can be accomplished with the least risk of BIONJ and in cases of exposed bone, the necrotic bone can be debrided with the expectation of healing.

References:

1. Marx RE ed. Oral and Intravenous Bisphosphonate- Induced Osteonecrosis of the Jaws. History, Etiology, Prevention, and Treatment. Quintessence Publ Hanover Park, ILL 2006, pp 77-95
2. Ruggerio SL, Mekrota B, Rosenberg TJ, Engroff S. Osteonecrosis of the jaws associated with the use of bisphosphonates: A review of 63 cases. J Oral Maxillofac Surg 2004, 62:527-534
3. Marx RE, Sawatari Y, Fortin M, Broumand V. Bisphosphonate induced exposed bone (osteonecrosis/ osteopetrosis) of the jaws: Risk factors, recognition, prevention and treatment. J Oral Maxillofac Surg 2005; 63:1567-75
4. Marx RE, Cillo JE, Ulloa JJ. Oral Bisphosphonate Induced Osteonecrosis: Risk Factors, Prediction of Risk Using Serum CTX Testing, Prevention, and Treatment. J Oral Maxillofac Surg 2007; 65:2397-2410
5. Rosen HN, Moses AC, Garber J, Ross DS, Lee SL, Greenspan SL. Utility of biochemical markers of bone turnover in the follow up of patients treated with bisphosphonates. Calcif Tissue Int 1998, 63:363-368