G E T T I N G T O T H E ROOT O F T H E M A T T E R !

Maheeb Jaouni, BDS, DDS, MS

THEAPEX

IntroductionIn 2006, total U.S. prescriptions for oral bisphos-phonates exceeded 30 million. America’s agingbaby boomer population will likely produce anamplification of those numbers over the next twodecades. The increased use is to address bone frac-tures, which is one of the biggest problems facingolder individuals with bone disease, especially

those with osteoporosis. Bisphosphonates are gen-erally prescribed in the prevention and treatmentof resorptive bone diseases such as osteoporosisand bone metastasis associated with breast andprostate cancers. Their use will only spread in thenext few years.

Mode of actionTheir mode of action is still unclear, but they areknown to inhibit osteoclastic function, induceapoptosis of osteoclasts, and inhibit osteoclast dif-ferentiation from precursors. Their mechanism ofaction for altering angiogenesis is also unclear andmay be variable. However, a study found that they

are potent inhibitor of angiogenesis by reducingvessel sprouting. They can also cause a significantand lasting decrease in vascular endothelial growthfactor (VEGF) levels in patients, and thus maynegatively affect angiogenesis. This may lead toprolonged interference with the normal homeosta-tic mechanisms of bone.

Dental implicationsThere is growing recognition that bisphosphonatesare associated with osteonecrosis of the jaws(ONJ). Several case reports, reviews and positionstatements from the FDA and interested pharma-ceutical companies have been published on bis-phosphonate-associated ONJ .

Patients presenting with bisphosphonate-associ-ated ONJ typically present with at least some ofthe following signs and symptoms:

n An irregular mucosal ulceration with exposedbone in the mandible or maxilla.

n Pain or swelling in the affected jaw

n Infection, possibly with purulence

n Altered sensation (numbness or heaviness)

The treatment for bisphosphonate-associated ONJ

The Dental Implications ofBisphosphonatesby Tariq Alsmadi, BDS, DMD

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F I R E W H E E L C E N T E R F O R D E N T A L S P E C I A L T I E S T E X A S E N D O D O N T I C S

is problematic. Case reports document no re-sponse or a limited response to local surgicalwound debridement, marginal or segmental resection, antibiotics or hyperbaric oxygen.Therefore, recognition of risk factors and applica-tion of preventive dental treatment procedures are important for patients taking I.V. or oral bisphosphonates.

Common risk factors associated with the development of bisphosphonate-associatedONJ include:

n History of taking bisphosphonates, especiallyI.V. formulations. The concurrent use of steroidsappears to contribute to this risk.

n Previous history of cancer (e.g., multiplemyeloma or metastatic disease to bone), osteo-porosis, Paget’s disease or other indications forbisphosphonate treatment.

n A history of a traumatic dental procedure.Most case reports occur after a tooth extraction,although other traumatic dental procedures mayalso be associated with the occurrence of ONJ(e.g., implant placement) and ill-fitting

dentures have also been associated with the occurrence of ONJ.

n Indications in several reports that there isspontaneous development of bisphosphonate-associated ONJ without a prior traumatic dentalprocedure.

RecommendationsConsensus guidelines promote careful and com-plete oral care for all patients receiving bisphos-phonates as the cornerstone of osteonecrosisprevention and treatment. The following is recom-mended when considering the endodontic impli-cations of treating patients takingbisphosphonates:

n Know the risk factors of bisphosphonate-associated ONJ.

n Recognize that patients taking I.V. bisphospho-nates are at higher risk for developing bisphos-

phonate associated ONJ. Recognize that patients taking oral bisphosphonates are at lowrisk for developing bisphosphonate-associatedONJ.

n Preventive procedures for high risk patients areimportant to reduce the risk of developing ONJbecause treatment of ONJ is not predictable atthis time. Preventive care might include cariescontrol, conservative periodontal and restorativetreatments, and, if necessary, appropriate endo-dontic treatment. Teeth with extensive carious lesions might be treated by nonsurgical endodon-tic therapy possibly followed by crown resectionand restoration similar to preparing an overden-ture abutment. Surgical procedures such as toothextractions, endodontic surgical procedures orplacement of dental implants should be avoided ifpossible.

n Obtain, as usual, informed consent for endodontic procedures that should involve a discussion of risks, benefits and alternative treatments with the patient.

n Consider bisphosphonate-associated ONJwhen developing a differential diagnosis of non-odontogenic pain.

n Utilize the entire healthcare team, includingthe patient’s general dentist, oncologist and oralsurgeon, when developing treatment plans forthese patients.

n Report cases of bisphosphonate-associated osteonecrosis of the jaws to the U.S. FDA MedWatch online at:https://www.accessdata.fda.gov/scripts/medwatch/

Additional background information on how to report adverse effects of drugs can be found at:www.fda.gov/opacom/backgrounders/problem.html.

n Be aware that the knowledge base for bisphos-phonate-associated ONJ is rapidly increasing, andit is likely that these recommendations maychange over time. Thus, the practitioner is encour-aged to monitor developments in this area.

F I R E W H E E L C E N T E R F O R D E N T A L S P E C I A L T I E S T E X A S E N D O D O N T I C SFirewheel Center for Dental Specialties n 4170 Lavon Dr. #164 Garland, TX 75040 n 972.496.0164Texas Endodontics n 2840 Keller Springs Rd. #703 Carrollton, TX 75006 n 214.483.3660

www.firewheeldentalspecialties.com nwww.texasendodontics.net

Rajiv Patel, BDS, DDSTariq Alsmadi, BDS, DMDMaheeb Jaouni, BDS, DDS, MSDaniel M. Stewart, DDS

Staff Attended Endodontics Conference in San Diego In September 2013, our staff attended an endodontic conference in beautiful San Diego.This seminar provided us a great opportunity to attend in-depth training sessions and learnabout the latest technology in the field that allows us to better serve our patients.

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