From the Guidelines
Osteonecrosis of the jaw (ONJ) prevention and management should prioritize completing necessary dental work before starting antiresorptive medications, maintaining excellent oral hygiene, and regular dental check-ups, as recommended by the most recent guideline 1.
Prevention Strategies
To minimize the risk of ONJ, several preventive measures can be taken:
- Completing necessary dental work before starting antiresorptive medications 1
- Maintaining excellent oral hygiene 1
- Regular dental check-ups 1
- Informing dentists about ongoing antiresorptive medication treatment 1
Treatment Approaches
For patients already diagnosed with ONJ, treatment typically involves:
- Conservative management with antimicrobial mouth rinses (0.12% chlorhexidine) 1
- Pain control 1
- Antibiotics for secondary infections (amoxicillin 500mg three times daily, or clindamycin 300mg four times daily for penicillin-allergic patients) 1
- Surgical intervention is generally reserved for advanced cases with extensive bone involvement or pathological fractures 1
Risk Factors
Risk factors for ONJ include:
- Invasive dental procedures (especially extractions) 1
- Poor oral hygiene 1
- Concurrent chemotherapy 1
- Corticosteroid use 1
- Pre-existing dental disease 1
Guideline Recommendations
The most recent guideline 1 emphasizes the importance of preventive dental care and regular monitoring for patients on antiresorptive medications. Additionally, the guideline recommends individualized treatment decisions based on the risk-benefit ratio and severity of bone disease 1.
From the Research
Definition and Causes of Osteonecrosis of the Jaw
- Osteonecrosis of the jaw (ONJ) is defined as exposed bone in the maxillofacial area, not associated with radiation or any other known cause and not healing for 8 weeks 2.
- ONJ is commonly precipitated by a tooth extraction in patients treated with zoledronate, pamidronate or a combination of these agents, for the management of myeloma, breast cancer or prostate cancer 3.
- The condition is associated with oncology-dose parenteral antiresorptive therapy of bisphosphonates (BP) and denosumab (Dmab) 4.
Risk Factors and Incidence
- Risk factors for ONJ include glucocorticoid use, maxillary or mandibular bone surgery, poor oral hygiene, chronic inflammation, diabetes mellitus, ill-fitting dentures, as well as other drugs, including antiangiogenic agents 4.
- The incidence of ONJ is greatest in the oncology patient population (1% to 15%), where high doses of these medications are used at frequent intervals 4.
- In the osteoporosis patient population, the incidence of ONJ is estimated at 0.001% to 0.01%, marginally higher than the incidence in the general population (<0.001%) 4.
- In patients receiving high-dose i.v. bisphosphonates for malignant diseases, ONJ may occur in 5 to 10% over 3 years 2.
Prevention and Management
- Prevention strategies for ONJ include elimination or stabilization of oral disease prior to initiation of antiresorptive agents, as well as maintenance of good oral hygiene 4, 5.
- Management of ONJ is based on the stage of the disease, size of the lesions, and the presence of contributing drug therapy and comorbidity 4.
- Conservative therapy includes topical antibiotic oral rinses and systemic antibiotic therapy, while localized surgical debridement is indicated in advanced nonresponsive disease 4.
- Practical approaches in the prevention of ONJ include thorough pre-treatment evaluation and performing any preventative procedures, initiating amino-bisphosphonates only after any gum tissue damage has healed, and establishing a regimented check-up schedule and hygiene precautions 5.