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How do you manage patients on intravenous bone-targeted agents who require dental work? For patients who are on IV bisphosphonate therapy and require dento-alveolar procedures there is a suggestion that prophylactic antibiotic use around the procedure may be helpful in reducing ONJ risk [45,49]. A recent study by Lopez-Jornet et al. showed a statistically significant reduction of ONJ with pre and postoperative neuropeptide receptors for extraction procedures in an animal model [50]. If a surgical procedure is unavoidable, conservative surgical intervention is preferred in an attempt to minimize trauma to bone tissue. The procedure should be performed by experienced clinicians familiar with ONJ, ensuring that a minimally invasive, efficient procedure be performed with minimal morbidity.
Should patients on a bone-targeted agent requiring dental work stop their bone-targeted agent? Recommendations on need of discontinuation of bisphosphonates in patients requiring dental work have not been created yet. Given the very long half-life of bisphosphonates in bone, with a 12-year terminal half-life even for oral agents like alendronate, effects of temporary cessation of the agents is questionable [31,46]. On the other hand, temporary discontinuation of bisphosphonates may remove their acute toxic effect on soft tissue and could facilitate the healing process [5]. AAOMS recommends withholding oral bisphosphonates for up to 3 months before a surgical procedure and for up to 3 months thereafter [5]. This strategy also supported by a correlation of the level of the bone turnover marker, C-terminal telopeptide (CTX) with risk of development of ONJ. According to Marx et al. morning fasting serum CTX levels correlated with the duration of oral bisphosphonate use, with increased values for each month of a drug holiday when the oral bisphosphonate was discontinued, suggesting a recovery of bone remodelling during this time. A rising of CTX was associated with reduced risk of ONJ after surgical dental procedures [51]. On the other hand, other trials failed to show a correlation between level of biochemical markers (i.e. CTX, N-terminal telopeptide (NTX), or bone specific alkaline phosphatase) and risk of development of ONJ [52–54]. It however must be recognized that inter individual variability, gender, age, physical activity, and seasonal variation exist that can result in difficulty in interpreting these assays, hence more research is needed.
Management of patients with established osteonecrosis of the jaw This section will deal with the care of patients on bone-targeted agents who then develop ONJ (Fig. 4). Although a number of clinical guidelines for management of patients with ONJ have been released by various oncology, oral surgical organizations and bisphosphonate manufacturers, there is no established gold standard, since most recommendations are based on case-control studies, retrospective analyses and expert opinions. For patients with established ONJ, treatment objectives are elimination of pain, control of infection in the soft and bone tissue, and minimization of the progression or occurrence of bone necrosis. In general, patients with ONJ should be evaluated and managed by a team including an oral and maxillofacial surgeon and an oncologist [5,46]. Several staging systems of ONJ have been developed by different dental and oncology organizations to help facilitate treatment decisions. The most useful system had been proposed by Ruggiero and subsequently revised by the American Association of Oral and Maxillofacial Surgeons (Table 4 and Fig. 1). According to this classification, Stage defines patients presenting with non-specific symptoms such as tooth pain, sinus pain, and unexplained tooth mobility but without significant clinical findings on examination. For these patients conservative management with topical mouth rinses (chlorhexidine gluconate or hydrogen peroxide) and analgesia is recommended. This is to decrease and prevent further progression of infection in the exposed bone [5,11].