TREATMENT
Patients should undergo a comprehensive oral examination; and any treatment needed, including extraction of any unsalvageable teeth, should be performed before initiation of bisphosphonate therapy.6 In patients already on bisphosphonate therapy, invasive dental procedures should not be delayed until optimal periodontal health is achieved but should proceed conservatively with concurrent antibiotic coverage.3,6 The American Academy of Oral and Maxillofacial Surgeons (AAOMS) Task Force suggests discontinuing oral bisphosphonates from 3 months before an invasive procedure until 3 months after the last invasive dental surgery, if possible. This may lower the risk of BRONJ, although this theory is purely speculative at this point.
There is no treatment protocol for BRONJ. However, the following stages for directing treatment are proposed by the AAOMS:
• At risk No apparent exposed/necrotic bone in patients who have been treated with IV or oral bisphosphonates
• Stage I Exposed/necrotic bone found in patients who are asymptomatic and have no evidence of infection
• Stage II Exposed/necrotic bone found in patients with pain and clinical evidence of infection
• Stage III Exposed/necrotic bone found in patients with pain, infection, and one or more of the following: pathologic fracture, extraoral fistula, or osteolysis extending to the inferior border.3
Using this staging system, the recommended treatment strategy for patients with stage I disease is use of an oral antimicrobial rinse, such as chlorhexidine 0.12%. Surgical treatment is not indicated and prognosis for a full recovery is very good. Patients with stage II disease should use oral antimicrobial rinses in combination with antibiotic therapy. Antibiotics used are penicillin, metronidazole, clindamycin, doxycycline, erythromycin, or a quinolone. Surgical debridement or resection in combination with antibiotic therapy may offer long-term palliation with resolution of acute infection and pain for patients with stage III disease. Once BRONJ has been diagnosed, appropriate referral to an oral and maxillofacial surgeon for evaluation and treatment should be scheduled promptly.
Patient education is important for oral health, especially for patients who are being treated with bisphosphonates. All patients taking oral bisphosphonates should be educated about the risk for developing BRONJ, even though that risk is minimal. Patients should also be informed that an oral health program, consisting of good oral hygiene practices and regular dental care, may lower their risk of developing BRONJ.6 Furthermore, patients should be told that discontinuing bisphosphonate therapy may not eliminate or reduce this risk. If they experience any problems in the oral cavity at any time during therapy or after discontinuing therapy, they should contact their health care provider immediately.6
CONCLUSION
The benefits of bisphosphonate drugs are indisputable. Without these medications, many people would suffer from the devastating effects of bone loss and even succumb to some cancers. However, bisphosphonates have potential side effects as well. PAs should be aware of the signs and symptoms of BRONJ. They should educate their patients about the risks of BRONJ with bisphosphonate therapy. When receiving these medications, patients should be monitored closely, especially if they use the IV form. Bisphosphonate therapy should be discontinued if its risks appear to potentially outweigh its benefits. JAAPA
Denise Rizzolo works at the Care Station, Springfield, New Jersey, and is also faculty assistant professor in the PA program at Seton Hall University, South Orange, New Jersey. Mona Sedrak is an associate professor in the PA program at Seton Hall University. They have indicated no relationships to disclose relating to the content of this article.
Acknowledgement: The authors would like to thank Thomas A. Chiodo, DMD, for his assistance with this paper.
DRUGS MENTIONED
DRUGS MENTIONEDDRUGS MENTIONED
Alendronate sodium (Fosamax, generics)
Chlorhexidine (Peridex, Periogard, generics)
Clindamycin (Cleocin, generics)
Doxycycline
Erythromycin
Metronidazole (Flagyl, Helidac Therapy, generics)
Penicillin
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