OSTEOCHEMONECROSIS
OSTEOCHEMONECROSIS
Valid until October 2009
- What is Osteochemonecrosis?
It is a condition where bone death occurs.
Bisphosphonates are being implicated in an increasing number of complications of the jaws. It is a relatively new phenomenon, with the first cases being reported in 2003.
Patient exposure to bisphosphonate drugs for the management of hypercalcemia of malignancy, osteolytic lesions of metastatic cancer and osteoporosis has led to increasing reports of osteochemonecrosis of the jaws. This serious and debilitating condition requires dental practitioners to be alert for signs and symptoms of this syndrome. So far, nitrogen containing bisphosphonates have been implicated as a causative agent. While only a small fraction of patients who have taken these agents will develop osteochemonecrosis, it seems that patients who have received intravenous bisphosphonates are at greater risk than those who have taken oral agents.[1][2]
- What is the Clinical Presentation?
The typical clinical presentation of Osteochemonecrosis includes
•pain
•soft tissue swelling
•infection
•loosening/mobility of teeth
•drainage
•exposed bone.
The symptoms may arise spontaneously in the bone; but more frequently occur at the site of previous dental extractions.
Atypical presentations have been described:
Patients may seek treatment complaining of pain that may mimic a dental problem. Infection may or may not be present.
Osteochemonecrosis may remain asymptomatic for weeks or months, and may be evident when exposed bone in jaw is noted during routine clinical examination
In some case, the symptoms may mimic dental or periodontal disease, and conditions unresponsive to routine treatment in patients with a history of bisphosphonate exposure should always have osteochemonecrosis considered as a possible diagnosis.1, 2, [3]
All Wales Dental Public Health Team Version 1A: March 2009 Page 1 of 4
National Public Health Service for Wales / NPHS Briefing Papers: Dental Public HealthOSTEOCHEMONECROSIS
- What Medications cause Osteochemonecrosis?
Recently reported cases have been found among patients taking nitrogen based bisphosphonate medications. The most widely used nitrogen based bisphosphonate medications are medications for the prevention and treatment of osteoporosis, which include:
•Fosamax (generic name alendronic acid)
•Actonel (generic name risedronate sodium)
•Boniva (generic name ibandronatic acid)
Other nitrogen-based bisphosphonates are intravenously-administered (“IV”) medications for the treatment of cancer, which include:
•Aredia (generic name disodium pamidronate)
•Zometa (generic name zolendronic acid) 2, 3
- Dental management of patients at risk of developing Osteochemonecrosis?
The British Dental Association have now produced a factfile summary of current recommendations on the management or treatment of patients at risk of developing osteochemonecrosis. The advice is summarised below7:
As with all dental patients, routine examinations are recommended, the interval being in accordance with NICE guidelines.
Inform the patient taking bisphosphonates that:
There are ways to minimise the risk but not to eliminate it.
The consensus is that good oral hygiene along with regular dental care is the best way to minimise risk.
Smoking cessation and limiting alcohol intake should also be emphasised.
Patients should be advised to contact their dentist immediately if any problems develop in the mouth.
Dentures should be well-fitting with soft linings as required.
The patient should also be informed of the dental treatment needed, alternative treatments, how any treatment relates to the risk of osteochemonecrosis, other risks associated with various treatment options, and the risk of foregoing treatment even temporarily.
For patients with non-malignant disease who have taken bisphosphonates > 3 years:
There is NO need for a comprehensive oral evaluation to be carried out on all patients about to begin bisphosphonate therapy. The risk is very low and no changes should be made to routine dental care.
Endodontics are preferable to root treatments. If extractions required, perform as atraumatically as possible. Refer if chronic exposed bone.
Periodontal surgery, apical surgery and implants are not contra-indicated currently, but should be avoided if possible, and documented informed consent gained if necessary.
For patients with malignancy who are starting or receiving bisphosphonates:
Avoid extractions wherever possible as increased risk of ONJ. If extraction cannot be avoided, careful follow up is important.
Patients with destructive periodontal diseases who are receiving bisphosphonate therapy should receive appropriate forms of non-surgical therapy which should be combined with a prolonged phase of initial therapy for observation. If the disease does not resolve, surgical treatment should be aimed primarily at obtaining access to root surfaces with modest bone recontouring being considered when necessary.
At this time, there is limited data regarding the effects of implant placement in patients taking bisphosphonates. Prior to implant placement, the dentist and the patient should discuss the risks, benefits and treatment alternatives, which may include but are not limited to periodontal, endodontic or non-implant prosthetic treatments. Maintenance of implants should follow accepted mechanical and pharmaceutical methods to prevent peri-implantitis, with regular monitoring of the patient.
If extractions or bone surgery are necessary, conservative surgical technique with primary tissue closure should be considered, when possible. In addition, immediately prior to and following surgical procedures involving bone, the patients should rinse with a chlorhexidine mouthwash.
Typically, chlorhexidine is used two times per day for two months post surgery.
Prophylactic antibiotics may be utilized during the healing/wound closure phase, for procedures that involve extensive manipulation of bone (eg. Extractions, periodontal contouring, sinus lifts etc) but is not mandatory or even recommended. Use of prophylactic antibiotics depends on the clinician’s level of concern relative to the individual patient.
Odontogenic infections should be treated aggressively with systemic antibiotics. When possible, identification of the responsible micro organism and respective sensitivities is indicated.
Endodontic treatment takes preference over surgical manipulation, if a tooth is salvageable. Routine endodontic technique should be used. Manipulation beyond the apex is not recommended.
All routine restorative procedures can be carried out.
All prosthetic appliances in patients taking bisphosphonates should be adjusted for fit as required.2,3
- Is there any effective treatment?
At the time of writing there are no formal guidelines published in the literature. There are however suggestions for the management of patients at increased likelihood of developing osteochemonecrosis due to therapy with bisphosphonates.2,3, [4]
Prevention is considered to be the best treatment.
Dentists with concernsabout patients with possible osteochemonecrosis are advised to refer the patient toan Oral and Maxillofacial consultant for advice on management of the case.[5]
- Advice to the Profession
Advice in the form of a Drug Alert entitled: ‘Dental Treatment for Patients on or prior to taking Bisphosphonate Medication’ was circulated to all dentists in Wales by the Chief Dental Officer (Wales) in August 2006.[6]
Gareth Williams BDS(Wales), MJDF RCS(Eng), Adv.Dip. Clin. Hyp(Staff)
February 2009
To be reviewed in 18 months
- Key References
All Wales Dental Public Health Team Version 1A: March 2009 Page 1 of 4
[1] Purcell PM, Boyd IW. ADRAC Report – Bisphosphonates and osteonecrosis of the jaw. Medical Journal of Australia 2005; 182 (8): 417-8. Available at:
[2] American Dental Association. Dental Management of patients receiving Oral Bisphosphonate Therapy – Expert Panel Recommendations. June 2006
Available at:
3 Purcell PM, Boyd IW. Op Cit: 417-8
[4] Harrison Z. Treating osteonecrosis [comment] British Dental Journal 2006; 200: 242-3
[5] Landis B, Richter M, Dojcinovic I, Hugentobler M. Osteonecrosis of the jaw after treatment with bisphosphonates. BMJ 2006; 333(7576):982-3
[6] DRUG ALERT: Dental Treatment For patients on or prior to taking Bisphosphonate Medication. CDO Wales 11th August 2006
7 British Dental Association: Bisphosphonates. Fact File. London 2008.