Jaw Complications Associated with Bisphosphonate Use in Patients with Plasma Cell Dyscrasias

Abstract

Osteonecrosis of the jaw has been linked with bisphosphonate use in breast cancer and multiple myeloma patients. We report 17 cases of patients with plasma cell dyscrasia being treated with bisphosphonate who developed osteonecrosis/osteomyelitis of the jaw. Seventeen patients evaluated at our institution between 1998 and 2005 are reported. All were being treated with bisphosphonates for a median of 5 mo prior to the onset of jaw symptoms. Sixteen of the 17 patients are 51 yr or older. None of the patients had been irradiated in the jaw nor had obvious osseous manifestation of multiple myeloma in the jaw. Thirteen patients were receiving zoledronic acid and four patients were receiving pamidronate at the onset of jaw symptoms. Six of the 17 did receive both agents at some time and all of these individuals were receiving zoledronic acid at diagnosis. Microorganisms were isolated in 7/17 patients with the most common organism being actinomycosis. We have initiated the following guidelines in an effort to ameliorate the incidence of this complication. Patients should have a full dental examination at the time of diagnosis of the plasma cell dyscrasia especially if bisphosphonates are to be considered as part of the therapy. In addition, bisphosphonates are held for a period of 3 mo prior to invasive dental procedures to allow for the osteoclastic recovery, therefore enhanced debris removal and lessening the chance of creating a fertile bacterial medium. Following the dental procedure we would re-introduce bisphosphonates only after the healing process is complete. Finally, multiple myeloma patients diagnosed with jaw osteonecrosis probably have a concurrent infection and should be aggressively treated with antibiotics.

Bisphosphonates in Oncology: Rising Stars or Fallen Heroes

“…Some authors suggest the withdrawal of bisphosphonate therapy for 1-3 months before performing invasive dental procedures [86,93]. Considering the long half-life of bisphosphonates in bone, however, it remains doubtful if adequate osteoclast recovery is realistic [94].…”

Bisphosphonate-related Osteonecrosis of the Jaws: An Update on Clinical, Pathological and Management Aspects

“…Non-restorable teeth should be treated by removal of the crown and endodontic treatment of the root remnants. One report [57] suggests the withdrawal of bisphosphonate treatment for 4-12 weeks before invasive dental surgery in order to allow restoration of osteclast function; however, considering the long half-life of bisphosphonates recovery of osteoclasts remains quite unrealistic. No scientific evidence is available so far to support this recommendation.…”

Bisphosphonate Complications Including Osteonecrosis of the Jaw

“…The expert panel also recommended avoiding tooth extractions and instead recommended endodontic (root canal) therapy where appropriate. When invasive dental procedures are to be performed electively, some investigators have recommended withholding intravenous bisphosphonates for 1 to 3 months before the procedure 18,19 and resuming treatments after oral healing is complete. Although this short period of interrupting the exposure to bisphosphonates is unlikely to change bone osteoclastic and remodeling environment, it may abrogate the anti-angiogenic properties of bisphosphonates and allow for soft tissue healing.…”