What is the appropriate treatment for a patient with osteoporosis who has osteonecrosis of the jaw?

Management of Osteoporosis in Patients with Established Osteonecrosis of the Jaw

For a patient with osteoporosis who has developed osteonecrosis of the jaw, you should immediately discontinue all bisphosphonates and denosumab, treat the ONJ according to its stage with antibacterial rinses, antibiotics, and surgical debridement as needed, and consider transitioning to teriparatide (if no contraindications exist) once the ONJ shows improvement or stabilization. 1, 2

Immediate Management: Stop Antiresorptive Therapy

Bisphosphonates must be absolutely avoided in patients with existing ONJ because they significantly increase the risk of ONJ progression. 1 While the 2019 ASCO/MASCC guidelines state there is insufficient evidence to definitively support or refute discontinuation of bone-modifying agents (BMAs), 3 the critical distinction is that these guidelines address cancer patients where the risk-benefit calculation differs dramatically from osteoporosis management. For osteoporosis patients, the American College of Rheumatology explicitly notes that oral bisphosphonates carry the lowest ONJ risk among antiresorptives, but all antiresorptive agents should be avoided when ONJ is already present. 4, 1

• Denosumab has a shorter half-life than bisphosphonates, and there is low-level evidence that temporary discontinuation may enhance MRONJ resolution, though this must be weighed against skeletal-related event risk in cancer patients. 3 In osteoporosis patients with ONJ, this favors discontinuation.
• Bisphosphonates have extremely long half-lives, so discontinuation at ONJ diagnosis may not immediately affect outcomes, but continued administration will worsen the condition. 3

Stage-Based Treatment of the ONJ Lesion

The treatment approach depends on the stage of ONJ, following the AAOMS staging system: 3, 2

Stage 1 (Exposed bone, asymptomatic, no infection):

• Antibacterial mouth rinse (chlorhexidine gluconate or povidone-iodine) at least twice daily 2
• Meticulous oral hygiene with patient education on modifiable risk factors 2
• Minor conservative surgery to remove mobile dead bone fragments 2
• Clinical follow-up every 8 weeks by dental specialist with communication to treating physician 3, 2

Stage 2 (Exposed bone with pain, infection, erythema):

• Broad-spectrum oral antibiotics combined with antibacterial mouth rinse 2
• Pain control with appropriate analgesics 3, 2
• Conservative surgical debridement to relieve soft tissue irritation and control infection 3, 2
• Continue 8-week follow-up intervals 3

Stage 3 (Extensive bone involvement, pathologic fracture, extraoral fistula):

• Symptomatic treatment with oral antibiotics and topical antibacterial rinse 3, 2
• Aggressive pain control 3
• Surgical debridement or resection for long-term palliation of infection and pain 3, 2
• Regular specialist follow-up 3

Universal Surgical Principles:

• Regardless of stage, remove superficial necrotic bone causing soft tissue irritation and loose bony sequestra without exposing uninvolved bone 3, 2
• Consider extraction of symptomatic teeth within exposed necrotic bone, as this is unlikely to worsen the established necrotic process 3, 2

Alternative Osteoporosis Management Strategy

Once the ONJ is being actively managed, you must address the underlying osteoporosis without using antiresorptives:

Option 1: Teriparatide (Preferred if no contraindications)

• Teriparatide is the optimal choice for osteoporosis treatment in patients with ONJ, as it is an anabolic agent rather than antiresorptive. 5
• Early data suggest enhanced osseous wound healing with teriparatide in patients without contraindications. 5
• Standard dosing: 20 mcg subcutaneous daily for up to 2 years
• Contraindications include: prior radiation therapy to skeleton, Paget's disease, unexplained elevated alkaline phosphatase, open epiphyses, bone metastases, or history of skeletal malignancy

Option 2: Drug Holiday with Supportive Care

• If fracture risk has significantly improved or teriparatide is contraindicated, implement a drug holiday with calcium (1000-1200 mg/day) and vitamin D (800 IU/day) supplementation. 1
• This approach is supported by EULAR/EFORT guidelines for osteoporosis management. 1

Critical Monitoring During Treatment:

• Maintain excellent oral hygiene and ensure regular dental/oral surgery review throughout any bone-targeted therapy 1
• Baseline dental evaluation is essential, and invasive dental surgery should be avoided until complete ONJ healing 1
• Perform DEXA scans to assess bone mineral density response and guide treatment decisions 1
• Monitor serum calcium levels, particularly if considering any future bone-targeted therapy 1
• Ensure adequate vitamin D levels (25-hydroxyvitamin D should be checked and repleted) 6

Common Pitfalls to Avoid

• Do not arbitrarily continue bisphosphonates or denosumab in a patient with established ONJ, as this will worsen outcomes despite the ASCO guidelines' equivocal stance on discontinuation in cancer patients. 1, 2
• Do not use routine antibiotics unless there are clinical signs of infection (Stage 2 or 3). 2
• Antibiotics alone are insufficient for progressive bone necrosis; surgical debridement or resection is necessary for advanced disease. 2
• Never use romosozumab in patients with ONJ history, as it carries increased ONJ risk compared to oral bisphosphonates and should be reserved only for patients intolerant to all other agents. 4
• Do not perform extensive dental surgery to treat ONJ, as this may exacerbate the condition. 6

Long-Term Considerations

• The FDA label for alendronate explicitly states that discontinuation of bisphosphonate therapy should be considered based on individual benefit/risk assessment in patients who develop ONJ. 6
• For patients requiring invasive dental procedures in the future, discontinuation of bisphosphonate treatment may reduce ONJ risk. 6
• The risk of ONJ increases with duration of bisphosphonate exposure, so any future antiresorptive use must be carefully considered. 6
• In osteoporosis patients (as opposed to cancer patients), the incidence of ONJ is extremely low (0.001% to 0.01%), only marginally higher than the general population (<0.001%). 5 However, once ONJ has occurred, the risk-benefit calculation fundamentally changes.