Oral bisphosphonate-related osteonecrosis of the jaws in rheumatoid arthritis patients: a critical discussion and two case reports

Abstract

BackgroundBisphosphonate-related osteonecrosis of the jaw (BRONJ) is a clinical condition characterized by the presence of exposed bone in the maxillofacial region. Its pathogenesis is still undetermined, but may be associated with risk factors such as rheumatoid arthritis (RA). The aim of this paper is to report two unpublished cases of BRONJ in patients with RA and to conduct a literature review of similar clinical cases with a view to describe the main issues concerning these patients, including demographic characteristics and therapeutic approaches applied.MethodsTwo case reports of BRONJ involving RA patients were discussedResultsBoth patients were aging female taking alendronate for more than 3 years. Lesions were detected in stage II in posterior mandible with no clear trigger agent. The treatment applied consisted of antibiotics, oral rinses with chlorhexidine, drug discontinuation and surgical procedures. Complete healing of the lesions was achieved.ConclusionsThis paper brings to light the necessity for rheumatologists to be aware of the potential risk to their patients of developing BRONJ and to work together with dentists for the prevention and early detection of the lesions. Although some features seem to link RA with oral BRONJ and act as synergistic effects, more studies should be developed to support the scientific bases for this hypothesis.

Epidemiological aspects of rheumatoid arthritis patients affected by oral bisphosphonate-related osteonecrosis of the jaws

“…This assumption corroborates with the higher incidence of BRONJ in patients using alendronate, as seen in the studies revised here [4,6-9,11,12,15,16,18-21], since it is the most potent drug among the BPs [9]. …”

“…The mean duration of BP therapy was 48 months, ranging from 6 months to 10 years, and most of the patients (73%) were using BPs for 3 or more years [4,6,9,12,15-17,19-21] (Table 1). …”

“…Of note, a large proportion of BRONJ lesions appeared spontaneously (41.38%) [9,10,12,13,15,19-21] (Table 2). …”

Treatment strategies and outcomes of bisphosphonate-related osteonecrosis of the jaw (BRONJ) with characterization of patients: a systematic review

“…Some studies have found no statistically significant correlation between gender and BRONJ. 159,182 The large proportion of female patients reported in some studies 1,43,48,80,127,137,[190][191][192][193][194][195] could represent a coincidence, since women take oral BPs more frequently than males, especially because rheumatoid arthritis and osteoporosis are more common in women. 196 In accordance with other series reported in the literature, 172 the present review found a high prevalence of BRONJ among women (67.2%).…”

“…1,2 They are commonly prescribed for bone diseases such as osteoporosis, Paget's disease of bone, hypercalcaemia of malignancy, osteolytic bone metastases, and osteolytic lesions of multiple myeloma. 1,3,4 Their use has resulted in a statistically significant reduction in skeletal complications, including pathological fractures, spinal cord compression, and hypercalcaemia of malignant disease, and has reduced the need for subsequent radiotherapy or surgery to bone. [5][6][7] BPs are synthetic analogues of the naturally occurring pyrophosphate molecule.…”