Bisphosphonate therapy and osteonecrosis of the jaw

Many prostate cancer patients are advised to use bisphosphonate therapy to prevent bone loss and other bone-related adverse events associated with long-term hormonal therapy. A disorder now known as bisphosphonate-related osteonecrosis of the jaw (BRONJ) was initially associated with bisphosphonate therapy in 2003-04 and there has been extensive research on this relationship since that date.

In September 2006 a series of strategies for management of patients with or at risk for BRONJ were set forth by the American Association of Oral and Maxillofacial Surgeons (AAOMS) in an initial position paper. This position paper was recently updated and the revised edition was released in January this year; the full, revised position paper is available on line.

This guidance document is detailed and complicated. It is perhaps a pity that AAOMS has not seen fit to issue a “patient-friendly” version of the document to support the actual position paper. However, as far as we are able to tell, the core recommendations (from a patient perspective) are now as follows:

  • The risk of BRONJ is significantly higher among patients treated with intravenous bisphosphonates (e.g., zoledronate and pamidronate) than among patients treated with oral bisphosphonates (e.g., risedronate and alendronate).
  • Cancer patients receiving intravenous bisphosphonate therapy appear to be at 2.7 to 4.2 times greater risk for BRONJ than cancer patients not exposed to such therapy.
  • Risk appears to increase with duration of bisphosphonate therapy
  • Local dental risk factors include (but are not limited to) tooth extractions, dental implant surgery, and other forms of dental surgery
  • Cancer patients treated with intravenous bisphosphonates who also have a history of inflammatory dental disorders are at 7 times greater risk for BRONJ than other cancer patients.
  • Patients who are prescribed intravenous bisphosphonate therapy should, if possible, undergo an appropriate dental examination and relevant treatment prior to the initiation of intravenous bisphosphonate therapy.
  • For patients being treated with intravenous bisphosphonate therapy, good oral hygiene and dental care is of paramount importance in maintenance of dental health and prevention of dental surgery.

2 Responses

  1. The “new ” recommendations for a thorough dental examination and completion of necessary dental work prior to initiating bisphosphonate therapy are actually not new to what physicians specializing in the treatment of prostate cancer have been directing. However, another consideration that was advanced by Medical Oncologist Stephen Strum some time back is important: “I believe it is possible that I have not seen this problem because I advise my patients to use a comprehensive bone supplement such as Bone Up by Jarrow or Bone Assure or Bone Restore by Life Extension. In the past, issues of bone brittleness relating to therapies using fluoride or bisphosphonates have come up. In both situations, I have found that such a problem relates to NOT supplying the patient with the needed raw materials to make healthy bone. And, one other point. This process is called avascular necrosis & drugs which inhibit angiogenesis might be working with bisphosphonates to create SYNERGISTIC TOXICITY. It is known that part of the mechanism of action of bisphosphonates is that of anti-angiogenesis. Therefore, think carefully when adding additional anti-angiogenesis agents to bisphosphonate therapy. This includes drugs like thalidomide, tetracyclines, and COX II inhibitors like Celebrex. These may be found to be risk factors”

  2. It’s becoming clear what the ONJ risks are, but what are really the BENEFITS of IV bisphosphonates for metastatic prostate cancer and others? My past study suggests that the risks and benefits are coming close to overlapping.

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