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Dr. Nader Elbokle, DDS, MSc, PhD( Emory University and Medical college of Georgia, USA)

A. Professor Maxillofacial Surgery, Cairo University,

Head of Department, Maxillofacial surgery, MSA University

Chairman & CEO Esthetica Hospital

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Definition: A condition characterized by exposure of bone inthe mandible or the maxilla for more than 8 weeks in a patient

who has taken or currently taking a bisphosphonate and whohas no history of radiation therapy of the jaws.

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Dearden in 1899 described phosphateminers and match-factory workers in the

US and Britain as developing non healingbone exposures in the mouth only,particularly those exposed to the heatedphosphate vapors. (Phossy jaw).

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100 years later, described by Marx and Stern in 2002 as acurious finding.

Later Marx in 2003 described 36 cases associated with IVbisphospohonates (Zometa).

Novartis company in their original clinical trial on 3600patient had flaws in that they failed to inspect or look atexposed bone in the mouth before and afterbisphosphonates therapy.

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A study conducted at Miami University showed 180

cases of BRONJ as a result of Fosamax, 127 IV and

53 oral form.

Over 1100 additional reports and 14 position

papers have been written on BRONJ or BIONJ

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1 in 3 women over 50 will suffer a fracture due toosteoporosis; this increases to 1 in 2 over 60.

There are more than 14 million women in the US

alone treated annually for osteoporosis with oralbisphosphonates.

Bisphosphonates act by inhibiting bone resorptionand hence bone turnover

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Repeated doses of bisphosphonates accumulate in thebone matrix and are taken up by the osteoclast leadingto cell apoptosis.

The osteoclast lose its ruffled borders at howships

lacunae and retract from the bone surface and die.

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Without bone resorption, old bone is not removedand survives far beyond the programmed lifespan.

Osteocyte is not an immortal cell, it eventually dies

leaving dead bone behind.

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Clinically presents as spontaneous exposure ofalveolar bone or following dental surgical proceduresuch as tooth extraction or implant placement.

This disease manifests itself in the jaws and has notbeen reported in other skeletal areas.

Recent reports have identified femur fractures ascaused by long term use of alendronate (Fosamax).

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Usually it starts in the alveolar bone, then extends tothe basilar bone or ramus.

Early subclinical radiographic signs include: sclerosis ofthe lamina dura, loss of the lamina dura, and wideningof periodontal ligament space especially in molars.

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Why Alveolar bone?

Dixon et al in 1997 documented the rate of boneturnover at various sites: Alveolar bone remodels 10times the rate of the tibia, and 5 times the rate of themandible at the inferior border.

Thus a greater uptake of bisphosphonates and readilyaccumulates at higher concentrations than any otherbone

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Alveolar bone can no longer respond to new boneformation from osteoclastic bone resorption followed

by new bone formation and becomes necrotic.

Overlying mucosa becomes deprived of its blood

supply, breaks down leading to exposed bone.

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Stage 1:

Characterized by

exposed bone that isasymptomatic, with noevidence of significantsoft-tissue

inflammation

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Stage 2:

Exposed bone

associated with pain,soft-tissue and/or boneinflammation orinfection

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Stage 3:

pathologic fracture;exposed bone

associated with softtissueinflammation/infectionor pain that is notresponsive toantibiotics; extraoralfistula.

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Treatment Objectives in the Management of

BRONJ

Eliminate pain

Manage or eliminate infection

Prevent additional exposure/necrosis

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Treatment Recommendations-All patients (all stages)

with established BRONJ

Consultation between OMSs, general dentists and thetreating physician is strongly recommended

Superficialbony debridement to reduce sharp surfaces andprevent further trauma to adjacent soft tissues

Protect exposed bone or adjacent tissues; a removableappliance or protective stent may be used

Avoidinvasive dental procedures where possible

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Concern over dental implants beingcontraindicated in patients with osteoporosis

This is based on the assumption that osteoporosisaffects the jaws in the same way as it affects other

parts of the skeleton, such as the lumbar spine,femur, neck and forearm.

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Earlier animal studies have

described the deleterious

effect of osteoporosis on theosseointegration process,mainly with regard totrabecular bone volume.

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Osteoporosis acts on peri-implant bone is basedon the decrease in both cancellous bone

volume and bone-to implant contact,consequently reducing the bone tissue availableto support dental implants

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Recent papers / clinical trials andhistomorphometric studies

suggest that osteoporosis maynot present a contraindicationfor implant placement, at least

once osseointegration has beenestablished.

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