Updated recommendations for managing the care of patients receiving oral bisphosphonate therapy: An advisory statement from the American Dental Association Council on Scientific Affairs

Background and OverviewIn 2005, the American Dental Association (ADA) Council on Scientific Affairs convened an expert panel to develop clinical recommendations for dentists treating patients who are receiving oral bisphosphonate therapy. The Journal of the American Dental Association published the resulting report in 2006. This 2008 advisory statement is the first of projected periodic updates of the 2006 clinical recommendations.ConclusionThis 2008 advisory statement concludes, on the basis of a review of the current literature, that for patients receiving bisphosphonate therapy, the risk of developing bisphosphonate-associated osteonecrosis (BON) of the jaw apparently remains low. It also newly concludes that current screening and diagnostic tests are unreliable for predicting a patient's risk of developing the condition. This statement updates the 2006 recommendations regarding general dentistry, management of periodontal diseases, implant placement and maintenance, oral and maxillofacial surgery, endodontics, restorative dentistry and prosthodontics, and orthodontics.     

Survey of Korean dentists on the awareness on bisphosphonate‐related osteonecrosis of the jaws

Aim: This survey evaluates the awareness of bisphosphonate‐related osteonecrosis of the jaws among Korean dentists. Methods: We prepared a questionnaire based on bisphosphonate‐related osteonecrosis of the jaw guidelines, suggested by The American Association of Oral Maxillofacial Surgeons. Among 13 405 dentists, we randomly selected 264 (2%) practitioners. Results: A total of 56.5% of respondents had heard of bisphosphonates asmedication related to osteonecrosis, but only 31.4% routinely recorded bisphosphonate medication history. The cross‐sectional analysis demonstrated that most dentists were unaware of The American Association of Oral Maxillofacial Surgeons’ guidelines. Dentists with <5 years’ clinical experience were significantly more aware than those with >5 years’ experience. Experience with treating osteonecrosis of the jaw patients and recording medication histories were significantly greater in dental hospitals with >300 beds or university hospitals. Awareness of the severity of bisphosphonate‐related osteonecrosis of the jaws was greatest among oral surgeons. Conclusion: Dentists should thoroughly check patients’ medical histories, including bisphosphonate intake. With the exception of oral surgeons, most Korean dentists were not adequately aware of bisphosphonate‐related osteonecrosis of the jaws and its seriousness, making it a potential risk in Korean dentistry. Therefore, it is important to educate clinicians regarding the potential risk of bisphosphonate medication in dentistry through education programs.     

Managing the care of patients receiving antiresorptive therapy for prevention and treatment of osteoporosis: executive summary of recommendations from the American Dental Association Council on Scientific Affairs

BackgroundThis narrative review of osteonecrosis of the jaw in patients with low bone mass receiving treatment with antiresorptive agents is based on an appraisal of the literature by an advisory committee of the American Dental Association Council on Scientific Affairs. It updates the committee’s 2008 advisory statement.MethodsThe authors searched MEDLINE for literature published between May 2008 (the end date of the last search) and February 2011.ResultsThis report contains recommendations based on the findings of the literature search and on expert opinion that relate to general dentistry; periodontal disease management; implant placement and maintenance; oral and maxillofacial surgery; endodontics; restorative dentistry and prosthodontics; orthodontics; and C-terminal telopeptide testing and drug holidays.ConclusionsThe highest reliable estimate of antiresorptive agent–induced osteonecrosis of the jaw (ARONJ) prevalence is approximately 0.10 percent. Osteoporosis is responsible for considerable morbidity and mortality. Therefore, the benefit provided by antiresorptive therapy outweighs the low risk of developing osteonecrosis of the jaw.Clinical ImplicationsAn oral health program consisting of sound hygiene practices and regular dental care may be the optimal approach for lowering ARONJ risk. No validated diagnostic technique exists to determine which patients are at increased risk of developing ARONJ. Discontinuing bisphosphonate therapy may not lower the risk but may have a negative effect on low-bone-mass–treatment outcomes.     

How Patients&apos; Lack of Knowledge About Oral Bisphosphonates Can Interfere With Medical and Dental Care

BackgroundOral bisphosphonate use has been associated with a small risk of developing oral osteonecrosis that occurs spontaneously or after the patient has undergone dental surgery. The authors conducted a study to determine whether patients taking bisphosphonates had knowledge about the medical indication for the therapy and the duration of treatment, as well as whether they had been educated by their physicians about possible adverse reactions.MethodsFrom June 2008 through April 2009, people seeking routine care in a dental clinic and who were being treated with bisphosphonates were invited to participate in the study. The participants were asked questions involving knowledge about the medical indications related to their taking bisphosphonates, the duration of their therapy and whether they had been educated about possible adverse reactions.ResultsThe authors interviewed 73 participants; 84 percent stated they knew why they were receiving bisphosphonate therapy. However, 80 percent said they were unsure about the duration of therapy, and 82 percent could not recall if they had been told about the risk of experiencing adverse reactions, including oral osteonecrosis, by their physicians.ConclusionPeople taking bisphosphonates may be unfamiliar with the drug and its possible adverse oral side effects.Clinical ImplicationsDentists should be prepared to educate patients about the risks of developing oral complications resulting from bisphosphonate use and the need for appropriate dental care. Questions regarding discontinuation of bisphosphonate therapy should be answered by the physician.     

Professionally applied topical fluoride: evidence-based clinical recommendations

BackgroundWith the dramatic increase in the amount of scientific information available about oral health, an evidence-based approach to oral health care and the practice of dentistry is necessary. There is a need to summarize, critique and disseminate scientific evidence and to translate the evidence into a practical format that is used easily by dentists The evidence-based clinical recommendations in this report were developed by an expert panel established by the American Dental Association Council on Scientific Affairs that evaluated the collective body of scientific evidence on the effectiveness of professionally applied topical fluoride for caries prevention. The recommendations are intended to assist dentists in clinical decision making.Types of Studies ReviewedMEDLINE and the Cochrane Library were searched for systematic reviews and clinical studies of professionally applied topical fluoride—including gel, foam and varnish—through October 2005.ResultsPanelists were selected on the basis of their expertise in the relevant subject matter. The recommendations are stratified by age groups and caries risk and indicate that periodic fluoride treatments should be considered for both children and adults who are at moderate or high risk of developing caries. Included in the clinical recommendations is a summary table that can be used as a chairside resource.Clinical ImplicationsThe dentist, knowing the patient's health history and vulnerability to oral disease, is in the best position to make treatment decisions in the interest of each patient. These clinical recommendations must be balanced with the practitioner's professional expertise and the individual patient's preferences.     

Dental management of patients at risk of osteochemonecrosis of the jaws: a critical review

Osteonecrosis of the jaw bones is a complication of bisphosphonate (BP) drug usage characterised by trans-mucosal exposure of necrotic bone, often followed by infection and pain. Osteonecrosis is observed in cancer patients on high-potency intravenous BP more frequently than in osteoporotic individuals using low-potency oral BP. The management of osteonecrosis caused by BP is often unsatisfactory and control of risk factors is considered the most effective means of prevention. Surgical manipulation and dental infection of the jawbone are the major risk factors, hence it is suggested that careful management of oral health and relevant dental procedures may decrease the risk of osteonecrosis in individuals on BP. Recommendations for dentists and oral surgeons have been suggested by different groups of clinicians but they are often controversial and there is no clear evidence for their efficacy in reducing the likelihood of osteonecrosis development. This report critically reviews current dental recommendations for individuals using BP with the aim of helping the reader to transfer them into practice as part of pragmatic and non-detrimental clinical decisions making.     

Across-sectional survey on medication-related osteonecrosis of the jaws' knowledge and awareness in a sample of dental society

BackgroundMedication-related osteonecrosis of the jaws (MRONJ) is a prominent complication and growing problem related to the oral and maxillofacial region due to antiresorptive and antiangiogenic agents. Awareness about MRONJ is crucial for all dental practitioners identify ‘at risk’ patients for appropriate advice and management. This cross-sectional survey aimed to appraise MRONJ awareness and knowledge among dentists.Materials and methodsA questionnaire-based survey was carried out through one hundred and seventy eight dentist who recruited in three groups; the first group comprised 113 general dental practitioners (GDP), 33 dental radiologist (DR) included in the second, and 32 oral and maxillofacial surgeon (OMS) in the third group. MRONJ awareness was evaluated by asking all respondents a question of “Did you heard about MRONJ? In addition, the detailed knowledge on the subject in question were addressed through fourteen, nine, and three questions for OMSs, DRs, and GDPs respectively.ResultsA significant difference were existed among groups with a rate of MRONJ's awareness of 33.6%, 48.5%, and 84.4% for GDPs, DRs, and OMSs respectively. Concerning MRONJ knowledge, significantly highest rates seen in OMSs set with 48.55%. In contrast, the average scores of DRs were 30.64%, and the GDPs group recorded the least value with 16.67%.ConclusionsStrengthen the MRONJ awareness and knowledge among general dentists and dental specialists are essential to identify ‘at risk’ patients for appropriate advice and management.     

The observational study of delayed wound healing after tooth extraction in patients receiving oral bisphosphonate therapy

IntroductionIn this study, we investigated whether such a discontinuation of oral bisphosphonate (BP) for 3 months might influence the incidence of BP-related osteonecrosis of the jaw (BRONJ) and wound healing after tooth extraction in patients receiving oral BP therapy.Material and methodsThere were a total of 434 teeth in 201 patients (18 males and 183 females). The patients were divided into two groups depending on whether or not they underwent a 3-month discontinuation of BP therapy (BP? and BP+) before tooth extraction. In this observational study investigated delayed wound healing after tooth extraction in patients receiving oral BP therapy.ResultsIn all cases of the BP? group, there were no BRONJ although there was delayed wound healing in two cases. However, in one case of the BP+ group, oral BP was continued because it was deemed high risk to discontinue treatment by the patient's physician. In this case, an intraoral fistula was still present with bone exposure at 120 weeks after extraction (BRONJ stage 1).ConclusionThis study supports the idea of a drug holiday and encourages further clinical research on this topic of tooth extraction in patients receiving oral BP therapy.     

Oral bisphosphonate use and the prevalence of osteonecrosis of the jaw: An institutional inquiry

BackgroundInitial reports of osteonecrosis of the jaw (ONJ) secondary to bisphosphonate (BP) therapy indicated that patients receiving BPs orally were at a negligible risk of developing ONJ compared with patients receiving BPs intravenously. The authors conducted a study to address a preliminary finding that ONJ secondary to oral BP therapy with alendronate sodium in a patient population at the University of Southern California was more common than previously suggested.MethodsThe authors queried an electronic medical record system to determine the number of patients with a history of alendronate use and all patients receiving alendronate who also were receiving treatment for ONJ.ResultsThe authors identified 208 patients with a history of alendronate use. They found that nine had active ONJ and were being treated in the school's clinics. These patients represented one in 23 of the patients receiving alendronate, or approximately 4 percent of the population.ConclusionsThis is the first large institutional study in the United States with respect to the epidemiology of ONJ and oral bisphosphonate use. Further studies along this line will help delineate more clearly the relationship between oral BP use and ONJ.Clinical ImplicationsThe findings from this study indicated that even short-term oral use of alendronate led to ONJ in a subset of patients after certain dental procedures were performed. These findings have important therapeutic and preventive implications.     

Anatomic site variability in rat skeletal uptake and desorption of fluorescently labeled bisphosphonate

Oral Diseases (2011) 17 , 427–432 Objectives: Bisphosphonates commonly used to treat osteoporosis, Paget’s disease, multiple myeloma, hypercalcemia of malignancy and osteolytic lesions of cancer metastasis have been associated with bisphosphonate‐associated jaw osteonecrosis (BJON). The underlying pathogenesis of BJON is unclear, but disproportionate bisphosphonate concentration in the jaw has been proposed as one potential etiological factor. This study tested the hypothesis that skeletal biodistribution of intravenous bisphosphonate is anatomic site‐dependent in a rat model system. Materials and Methods: Fluorescently labeled pamidronate was injected intravenously in athymic rats of equal weights followed by in vivo whole body fluorimetry, ex vivo optical imaging of oral, axial, and appendicular bones and ethylenediaminetetraacetic acid bone decalcification to assess hydroxyapatite‐bound bisphosphonate. Results: Bisphosphonate uptake and bisphosphonate released per unit calcium were similar in oral and appendicular bones but lower than those in axial bones. Hydroxyapatite‐bound bisphosphonate liberated by sequential acid decalcification was the highest in oral, relative to axial and appendicular bones (P < 0.05). Conclusions: This study demonstrates regional differences in uptake and release of bisphosphonate from oral, axial, and appendicular bones of immune deficient rats.     

Differences in the Knowledge and Experience of Physicians and Dentists About Medication-Related Osteonecrosis of the Jaw in Osteoporotic Patients

Aim: Prevention of medication-related osteonecrosis of the jaw (MRONJ) in patients with osteoporosis requires the cooperation of physicians and dentists. We investigated the knowledge, experience, and behaviour related to medical and dental cooperation for MRONJ prevention in patients with osteoporosis between physicians and dentists practising in the Shiga prefecture. Materials and methods: We conducted a cross-sectional study to investigate the cooperation between practising physicians and dentists for preventing osteonecrosis of the jaw (ONJ) in patients with osteoporosis using 2 separate questionnaires from July 28, 2018, to February 3, 2019. Results: Of 461 dentists who were sent the questionnaires at their dental clinics, 307 (67%) responded via fax. Of 846 physicians who were sent the questionnaire at their clinics, 378 (45%) responded via fax. Of these, 268 (32%) were finally analysed because 110 (13%) physicians had never treated patients with osteoporosis; 50% dentists and 24% physicians were familiar with the MRONJ position paper in Japan, and 39% dentists and 9% physicians had encountered MRONJ in their clinical practice. A total of 30% physicians had requested oral health care by a dentist before administering bone-modifying agents (BMA) therapy. The knowledge and experience of MRONJ differed between physicians and dentists. Conclusion: The behaviour of physicians and dentists was insufficient to enable medical and dental cooperation for the prevention of MRONJ in patients with osteoporosis. The lack of cooperation between physicians and dentists during osteoporosis treatment in the Shiga prefecture in Japan is documented in this study.     

Osteonecrosis of the jaw in patients with cancer who received zoledronic acid and bevacizumab

BackgroundThe authors investigated the incidence of and risk factors for osteonecrosis of the jaw (ONJ) in patients with metastases to the bone who received the bisphosphonate agent zoledronic acid (ZOL) and chemotherapy combined with the antiangiogenic agent bevacizumab (BEV).MethodsThe authors evaluated 59 participants (34 with breast cancer and 25 with nonsmall-cell lung cancer). All of the participants received 4 milligrams of ZOL via intravenous (IV) infusion every four weeks and 15 mg per kilogram of BEV every three weeks. They conducted a dental examination in participants at baseline and every three months until the patients died or were lost to follow-up. If needed, participants received periodontal disease treatment and underwent tooth extraction before they started receiving ZOL and BEV.ResultsThe median time the participants received ZOL therapy was 18.8 months (range, 3.1–28.9 months); 36 participants (61.0 percent) received ZOL therapy for more than one year. The median time participants received BEV therapy was 16.7 months (range, 2.8–29.6 months). None of the participants required dentoalveolar surgery while undergoing cancer treatment. After a median follow-up period of 19.7 months, none of the participants developed bisphosphonate-related ONJ.Conclusions and Clinical ImplicationsZOL combined with BEV did not predispose to ONJ participants with cancer that had metastasized to the bone who underwent a baseline dental examination and preventive dental measures. The study results must be considered in the context of the study’s protocols and the follow-up period.     

Evidence-based clinical recommendations regarding fluoride intake from reconstituted infant formula and enamel fluorosis: a report of the American Dental Association Council on Scientific Affairs

BackgroundThis article presents evidence-based clinical recommendations regarding the intake of fluoride from reconstituted infant formula and its potential association with enamel fluorosis. The recommendations were developed by an expert panel convened by the American Dental Association (ADA) Council on Scientific Affairs (CSA). The panel addressed the following question: Is consumption of infant formula reconstituted with water that contains various concentrations of fluoride by infants from birth to age 12 months associated with an increased risk of developing enamel fluorosis in the permanent dentition?Types of Studies ReviewedA panel of experts convened by the ADA CSA, in collaboration with staff of the ADA Center for Evidence-based Dentistry (CEBD), conducted a MEDLINE search to identify systematic reviews and clinical studies published since the systematic reviews were conducted that addressed the review question.ResultsCEBD staff identified one systematic review and two clinical studies. The panel reviewed this evidence to develop recommendations.Clinical ImplicationsThe panel suggested that when dentists advise parents and caregivers of infants who consume powdered or liquid concentrate infant formula as the main source of nutrition, they can suggest the continued use of powdered or liquid concentrate infant formulas reconstituted with optimally fluoridated drinking water while being cognizant of the potential risks of enamel fluorosis development. These recommendations are presented as a resource to be considered in the clinical decision-making process. As part of the evidence-based approach to care, these clinical recommendations should be integrated with the practitioner's professional judgment and the patient's needs and preferences.     

Concordance between patient satisfaction and the dentist's view: Findings from The National Dental Practice-Based Research Network

ObjectivesIn this study, the authors examined the dentist's view of the patient's experience and concordance with the patient's rating of satisfaction.MethodsPractitioners from 197 practices in The National Dental Practice-Based Research Network recruited consecutively seen patients who had defective restorations that were replaced or repaired. At the end of the dental visit, the treating dentist and 5,315 patients completed and returned a survey that asked about the patient's satisfaction.ResultsMost dentists viewed their patients as having been satisfied with the treatment experience (n = 4,719 [89 percent]) and as having perceived them as friendly (n = 5,136 [97 percent]). Dentists had less strong feelings about whether patients had a preference for the restorative material (n = 2,271 [43 percent]) or an interest in obtaining information about the procedure (n = 1,757 [33 percent]). Overall, patients were satisfied, and most of the time dentists correctly predicted this outcome. Among patients who were less than satisfied, there was a substantial subset of cases in which dentists were not aware of this dissatisfaction.ConclusionFor improved patient-centered care, dentists should assess patients' desires, expectations and perceptions of the dental care experience and then manage or correct the expectations and perceptions as needed.Practical ImplicationsBy taking a patient-centered approach, dentists should seek to understand how patients evaluate and rate the services provided, thereby enabling them to focus on what each patient values most.     

Osteonekrose der Kiefer unter Bisphosphonat-Langzeittherapie

For several decades bisphosphonates have been used to reduce skeletal related events in patients with both osteoporosis or bone metastases. Under long term application, besides the known therapy side effects, a new clinical picture has been described within the last few years. This is osteonecrosis of the jaws, which is characterized by its difficulty in treatment. Besides exposed jaw bone, the start of the disease usually lacks any symptoms. The typical clinical symptoms then are foetor ex ore, swelling, exsudation, loosening of teeth, pain or paresthesia. Later oro-antral/nasal or oro-cutaneous fistula can develop. The X-ray shows persisting tooth sockets after extractions and later cloudy radio-lucency, sequestra or fractures. The patient exposed to bisphosphonate can be grouped according to the risk for osteonecrosis: high risk patients with intravenous bisphosphonate therapy and additional chemo-, radiation or corticoid therapy – predominantly patients with a malignant underlying disease and bone metastases low risk patients with an oral bisphosphonate therapy without additional chemo-, radiation or corticoid therapy – preferably patients with non-corticoid-induced osteoporosis Before starting a bisphosphonate therapy possible causes of infection should be treated and risk of injuries to the mucosa should be reduced according to the individual risk profile. This is supplemented by information of the patient about the risk of necrosis and the possibilities for prevention. Regular dental recall under bisphophonate therapy is emphasised for early recognition of possible problems. Prophylaxis is recommended for the prevention of periodontal infection combined with a follow up of removable denture for possible ulcera. Generally, conservative treatment measures are preferred to surgical ones. Inevitable operations are carried out non- traumatically using broad spectrum antibiotic prophylaxis until the day of suture removal (not before day 10). Long term follow up examinations are recommended. Patients with dental implants inserted before a bisphophonate therapy should be subject to intensive recall examinations. For patients undergoing or following a bisphosphonate therapy the indication for dental implants should be as strict as for patients following head and neck radiation therapy. In the present for patients with osteonecrosis, even after healing, dental implants are regarded as contra-indication. Therapy of the necrosis often requires general anaesthesia, hospitalisation, naso-gastral feeding tube and intravenous, systemic antiinfective treatment. The necrosis is removed completely and a tension free wound closure with vascularised tissue is intended. A literature review shows the metabolic effect of biphosphonates, the known pathogenesis of the bisphosphonate-induced jaw necrosis. It is essential to develop interdisciplinary communication, aiming at a joint care for this group of concerned patients and involving not only those medical disciplines, which order and use bisphosphonates, but especially dentists and maxillofacial surgeons.     

Effect of long-term oral bisphosphonates on implant wound healing: literature review and a case report

BACKGROUND: Bisphosphonates suppress osteoclast activity, and their intravenous use has been reported in hundreds of cases to be associated with osteonecrosis in the jaw. Little is known of the risks associated with long-term use of oral bisphosphonates despite their use for >10 years by an oral mode of delivery for the treatment of osteopenia, osteoporosis, and Paget's disease of bone. The purpose of this report is to review the literature associated with bisphosphonate use that could impact bone healing and to report a case of bone necrosis in a patient on long-term oral bisphosphonates. METHODS: A Medline search was carried out to find relevant articles from both medical and dental literature between 1960 and 2006. A patient, who had been taking an oral bisphosphonate for >10 years, developed unexplained clinical signs of bone necrosis after routine dental implant placement. This case was followed, documented, and the treatment of the osteonecrosis described. RESULTS: A summary of how bisphosphonates may play a role in wound healing is presented. The compromised healing noted in a patient, who was under long-term oral bisphosphonate use, was successfully treated with systemic antibiotics, local microbial mouthrinse, and aggressive defect management (detoxification and mixture of bone graft and tetracycline). CONCLUSIONS: This case suggests that patients under long-term oral bisphosphonate use should be treated with caution. Well-controlled, prospective clinical trials on the effect of oral bisphosphonates on bone are warranted to determine which patients may be at risk for such complications.     

Survival of dental implants in post-menopausal bisphosphonate users

PurposeTo determine whether post-menopausal women with a history of bisphosphonate use are at greater risk for implant failure or osteonecrosis of the jaw (ONJ) than an age- and gender-matched population with no history of bisphosphonate use.MethodsA retrospective chart review and phone interview was conducted of patients seen at the Mayo Clinic who had implants placed after November 2006. Bisphosphonate users were identified by medical chart review. Dental implant survival and ONJ incidence were determined in a total of 82 post-menopausal non-bisphosphonate users and 55 post-menopausal bisphosphonate users using a phone interview. Implant failures were recorded and survival percentages were calculated for comparison.ResultsONJ was not observed consequent to implant placement in any of the bisphosphonate users or non-users. In non-users, 163 out of 166 implants were surviving for a cumulative survival rate of 98.19%. In bisphosphonate users, 120 out of 121 implants were surviving for a cumulative survival rate of 99.17%.ConclusionDental implants placed in post-menopausal women have the same survival potential regardless of whether patients have a history of bisphosphonate use. Bisphosphonate users who undergo dental implant surgery are at low risk for osteonecrosis of the jaw and a bisphosphonate “drug holiday” is not indicated in these patients.