Clinical article
Osteonecrosis of the jaws associated with the use of bisphosphonates: a review of 63 cases

https://doi.org/10.1016/j.joms.2004.02.004Get rights and content

Abstract

Purpose

Bisphosphonates are widely used in the management of metastatic disease to the bone and in the treatment of osteoporosis. We were struck in the past 3 years with a cluster of patients with necrotic lesions in the jaw who shared 1 common clinical feature, that they had all received chronic bisphosphonate therapy. The necrosis that was detected was otherwise typical of osteoradionecrosis, an entity that we rarely encountered at our center, with less than 2 patients presenting with a similar manifestation per year.

Patients and methods

We performed a retrospective chart review of patients who presented to our Oral Surgery service between February 2001 and November 2003 with the diagnosis of refractory osteomyelitis and a history of chronic bisphosphonate therapy.

Results

Sixty-three patients have been identified with such a diagnosis. Fifty-six patients had received intravenous bisphosphonates for at least 1 year and 7 patients were on chronic oral bisphosphonate therapy. The typical presenting lesions were either a nonhealing extraction socket or an exposed jawbone; both were refractory to conservative debridement and antibiotic therapy. Biopsy of these lesions showed no evidence of metastatic disease. The majority of these patients required surgical procedures to remove the involved bone.

Conclusions

In view of the current trend of increasing and widespread use of chronic bisphosphonate therapy, our observation of an associated risk of osteonecrosis of the jaw should alert practitioners to monitor for this previously unrecognized potential complication. An early diagnosis might prevent or reduce the morbidity resulting from advanced destructive lesions of the jaw bone.

Section snippets

Patients and methods

In accordance with the office of the Institutional Review Board, a chart review was performed on all oncology patients who presented with a diagnosis of osteonecrosis or osteomyelitis of the jaw. Patients who had a prior history of radiation therapy to the jaw region or neoplastic disease that directly involved the jaws were excluded from the review.

Results

From February 2001 through June 2003, a total of 63 patient charts from Long Island Jewish Medical Center and The University of Maryland were identified and reviewed (Table 1). There were 45 female patients and 18 male patients ranging in age from 43 to 89 years (mean age, 62 years). The most common oncologic diagnoses at presentation were multiple myeloma (28 patients) and breast cancer (20 patients), followed by prostate cancer (3 patients), lung cancer (1 patient), uterine leiomyosarcoma (1

Discussion

Based on these patients’ respective histories, clinical presentations, and responses to surgical and antibiotic treatments, it appears that the pathogenesis of this osteonecrotic process is most consistent with localized vascular insufficiency. The lesion’s clinical similarity to osteoradionecrosis, with compromised bone that sequestrates either spontaneously or after a minor procedure, followed by secondary infection, is striking. The incidence of osteonecrosis in our patient population who

Acknowledgements

The authors would like to thank Dr Kanti Rai, Dr John Fantasia, Dr Ronald Burakoff, and Dale Janson, RPAC, for their assistance and support in preparation of the manuscript.

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