Antiresorptive drugs such as bisphosphonates (BP) and denosumab are primarily utilized in the treatment of osteoporosis and certain cancers in bone (e.g. multiple myeloma) or metastatic cancers to the bones (e.g. breast, prostate, colon, lung).
Treating patients with a history of BP or denosumab therapy in the dental setting can have potentially serious complications, particularly bisphosphonate-related osteonecrosis of the jaw (BRONJ) or medication-related osteonecrosis of the jaw (MRONJ). Assessment of high-risk in a patient is established by the following four criteria:
- Previous history of ONJ with exposure of jawbone in BP or denosumab users for more than 8 weeks.
- Patients with conditions that may affect wound healing or blood supply (e.g. diabetes, steroid therapy, radiation).
- Those undergoing dental procedures (tooth extractions, implant placement) or having ill-fitting prostheses that may predispose to ulcerations and microbial colonization and infection.
- Patients receiving intravenous BPs are automatically assumed to be at high risk, or oral BP users after 3-5 years of therapy.
Diagnosis of MRONJ is made by medical history, clinical examination, and radiographic presentation. Lesions appear as non-healing exposed or non-exposed bony lesions usually in the posterior mandible or maxilla. Erythema, pain, and purulence may be present. Morbidity is decreased by the following four protocols:
- Taking a detailed medical history that includes the name of the BP/denosumab, dosage, route, and duration of treatment.
- Any necessary tooth extractions or oral surgical procedures should be completed prior to BP/denosumab treatment. A drug holiday from denosumab may be possible and an MD consult should be made.
- For high-risk patients, perioperative infection reduction with pharmacologic intervention: Chlorhexidine gluconate 0.12%, 15mL PO swish and spit, tid 1 week pre-op/tid post-op until lesions resolve. Amoxicillin 500mg PO tid 2 days pre-op/tid 5 days post-op and Metronidazole 400mg PO tid 2 days pre op/tid 5 days post-op OR Clindamycin 300mg PO bid 3 days pre-op/4 days post-op. If indicated, Nystatin 100,000 USP/mL oral suspensions, 15mL PO swish and swallow, tid 1 week pre-op/tid until complete healing has occurred. Check for any allergies prior to prescribing such medications.
- For patients with active or suspicious ONJ lesions, an Oral Medicine consult is advised.