Bisphosphonates (BP) are nonhormonal medications used in the treatment of various bone malignancies and metabolic conditions. Since 2003, there have appeared a significant and growing number of articles in the worldwide medical and dental literature describing the complication of an osteonecrosis of the jaws associated with the intravenous and, most recently, the oral form of BP medication that has been refractory to any definitive form of treatment. The authors have successfully managed 2 patients taking the oral form of BP with adjunctive treatment using platelet-rich plasma (PRP), and in one case with hyperbaric oxygen (HBO). We were able to obtain complete remission in each case, which is defined as resolution of pain and complete closure of exposed bone in the jaws. The purpose of this report is to describe a treatment protocol and the rationale for using PRP and HBO to obtain complete remission of this new pathologic condition.

Biochemical markers of bone metabolism have been used in medicine to evaluate and provide treatment to patients with metabolic bone diseases, such as osteoporosis. Serum cross-linked C-telopeptide of type I collagen (CTX) is a marker of osteoclast activity and is used to assess the level of bone resorption. Recently, in oral and maxillofacial surgery, it was proposed that the levels of serum CTX may predict the subsequent risk of developing osteonecrosis of the jaws (ONJ) after oral surgery procedures for patients taking oral bisphosphonates (BPs). The goal of this study was to determine whether this specific serum marker of bone resorption could preoperatively predict the risk of developing ONJ from oral BPs.We hypothesized that there is no clinical correlation between the observed preoperative serum CTX values and the risk of developing ONJ. The authors examine the scientific basis (validity) of the morning fasting serum CTX test in 163 consecutive patients who underwent various oral surgery procedures in the office. The authors also review the laboratory test results and the recommended protocol based on the test values. One hundred sixty-three patients (mean age, 75.9 years) were divided into 2 groups. Group I was the control group that consisted of 109 patients taking oral BPs who did not take the CTX test preoperatively. Group 2 consisted of 54 patients taking BPs and who elected to have the CTX test performed to assess their level of risk of developing ONJ, preoperatively. Both groups of patients were observed for a period of 8 weeks for signs and symptoms of BP-associated ONJ after surgery. The clinical data at 8 weeks and beyond revealed that there was no evidence of BP-associated ONJ in all participants. We conclude that the serum CTX is not a valid preoperative test to accurately assess the level of risk of developing ONJ and is not indicated in the oral surgery patient.

The outcome of this overview suggested that the following will increase the success of sinus augmentation and survival of implants placed in the grafted sinus: (1) the use of barrier membranes over the lateral window when using a lateral approach to graft the sinus, (2) the use of particulate autogenous bone with or without other substitute graft materials, (3) sinus augmentation without the use of grafting materials may be considered provided that the space between the sinus membrane and floor can be maintained, (4) the use of rough-surfaced implants, (5) simultaneous implant placement with residual bone height greater than 4 mm, and (6) the cessation of smoking.

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Biochemical markers of bone metabolism have been used in medicine to evaluate and provide treatment to patients with metabolic bone diseases, such as osteoporosis. Serum cross-linked C-telopeptide of type I collagen is a marker of osteoclast activity and is used to assess the level of bone resorption. Recently, in oral and maxillofacial surgery, it was proposed that the levels of serum cross-linked C-telopeptide of type I collagen may predict the subsequent risk of developing osteonecrosis of the jaws after oral surgery procedures for patients taking oral bisphosphonates. The astute clinician must critically review the scientific literature and must decide if biochemical markers of bone resorption are of benefit in managing the oral surgery patient on bisphosphonates.

The preliminary results of this clinical study indicate that immediate nonfunctional loading using PRP and 50% autogenous bone combined with different substitute graft materials is a predictable protocol in the grafted maxillary sinus as early as 4 months of postgrafting. The high implant survival rate is due to the early formation of large percentages of new vital bone as confirmed by using histologic and histomorphometric analysis.

Osteonecrosis of the jaws (ONJ) is a condition characterized by necrotic exposed bone in the jaws of patients receiving intravenous or oral bisphosphonate therapy. A review of the medical and dental literature reveals that the pathoetiology of ONJ remains unknown and there is no established link that bisphosphonates are the primary cause of this bone pathology. However, there is clinical evidence that Actinomyces may play a critical role in the pathogenesis of bisphosphonate-associated ONJ. Identification and a prolonged course of oral antimicrobial therapy may lead to complete resolution of this actinomycotic osteonecrosis.

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