Endodontic implications of bisphosphonate-associated osteonecrosis of the jaws

AAE recommendations regarding patients taking these medications

A number of recently published studies have focused on the adverse effects of drugs classified as bisphosphonates and a resulting condition known as osteonecrosis of the jaw (ONJ). More than 30 million Americans take bisphosphonates, which are used to treat cancer and debilitating bone diseases such as osteoporosis and Paget’s disease.

handful of medicationsBecause there currently are no available randomized controlled trials or higher levels of clinical evidence, the American Association of Endodontists (AAE) convened a special committee to retrospectively analyze case reports and expert opinions.

On the basis of the committee’s work, the AAE released a position statement for endodontists and other dental professionals, which shares diagnosis and treatment considerations for patients presenting with bisphosphonate-associated ONJ. Commonly used bisphosphonates include:

  • Zometa, Aredia, Fosamax, Actonel, Boniva, Skelid, Bonefos, Ostac, Didronel

The following are recommendations of the AAE when considering the endodontic implications of treating patients taking bisphosphonates.

  • Recognize the risk factors of bisphosphonate-associated ONJ.
  • Patients at higher risk for bisphosphonate-associated ONJ include those patients taking I.V. bisphosphonates.

    Preventive procedures for high risk patients are important to reduce the risk of developing ONJ because treatment of ONJ is not predictable at this time. Preventive care might include caries control, conservative periodontal and restorative treatments. Similar to the management of the patient with osteoradionecrosis, this might include non-surgical endodontic treatment of teeth that otherwise would be extracted.

    Teeth with extensive carious lesions might be treated by non-surgical endodontic therapy possibly followed by crown resection and restoration similar to preparing an overdenture abutment.

    For patients at higher risk of developing bisphosphonate-associated ONJ, surgical procedures such as tooth extractions, endodontic surgical procedures or placement of dental implants should be avoided if possible.
  • Patients at low risk for bisphosphonate-associated ONJ include those patients taking oral bisphosphonates.

    Appropriate clinical procedures might include caries control, appropriate periodontal and restorative treatments and patient education about the symptoms of bisphosphonate-associated ONJ and their low risk for developing ONJ from surgical or soft tissue procedures.
  • As usual, informed consent for procedures should involve a discussion of risks, benefits and alternative treatments with the patient.
  • Consider bisphosphonate-associated ONJ when developing a differential diagnosis of nonodontogenic pain.
  • Utilize the entire health care team, including the patient’s oncologist and oral surgeon, when developing treatment plans for these patients.
  • Cases of bisphosphonate-associated ONJ should be reported 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.
  • Be aware that the knowledge base for bisphosphonate-associated ONJ is rapidly increasing, and it is likely that these recommendations may change over time. Thus, the practitioner is encouraged to monitor developments in this area.

To review the AAE’s Position Statement in its entirety and/or review references, please visit www.aae.org and search for “Endodontic Implications of Bisphosphonate-Associated Osteonecrosis of the Jaws.”

You may also contact our office at (916) 485-6900 and we will be happy to provide you with a copy of the article.