Authors: Dr. Rajbir Singh, Dr. R.S. Bhatia

In osteoporosis, prophylactic and therapeutic use of Bisphosphonate (BIPN) has, been quite Common in practice. It is being used to treat bone loss occurring in patients with non malignant disorders such as genetic conditions, post menopause (hormonal effect), lack of mobility (geriatric patients) or iatrogenic (oral glucocorticoids therapy induced). BIPN are synthetic analogues of naturally occurring pyrophosphates, having higher affinity for calcium which allows them to bind by hydroxyapatite of bone and inhibit osteoclast- mediated bone resorption. Common adverse effects (ADRS) of BIPN are listed in the table.

ADRS with Bisphosphonate therapy

Common

Occasional

Nausea

Atrial fibrillation

Oesophagitis

Oesophageal Cancer

Dyspnoea

Acute renal failure

Fever

Osteonecrosis of jaw

Bone pain

 

Anemia

 


Osteonecrosis of Jaw occurs in 1/10,000 to 1/100,000 patients being treated with BIPN for osteoporosis patients receiving bisphosphonate treatment for oncologic conditions, (94%) are getting BIPN through intravenous route. However, no osteonecrosis of the jaw was reported in a large study of 60,000 patients of osteonecrosis who received BIPN treatment for two years. Clinical symptoms of osteonecrosis of the jaw in non- neoplastic were similar1 i.e. pain, bone exposures and purulent secretions; nevertheless, more severe manifest actions such as sinus involvement, paresthesia or discontinuation of inferior mandible border are also reported. Cutaneous fistulae are common in patients with neoplastic disorders in contrary to non-neoplastic cases where osteonecrosis of jaw follows indolent clinical course. In the ederly osteonecrosis of the jaw occurs possibly because of alteration in the local vascularity and reduced immunity bisphosphonate has toxic effect on oral epithelium overlying the bone areas, and also reduced ability to heal following trauma during tooth extraction2.

Occurrence of contact stomatitis in a patient sucking bisphosphonate tablets, supports their view. Dental risks of osteonecrosis of the jaw have been listed in the table,

Table
  1. Periodontitics with chronic infection and inflammation of supportive alveolar bone.
  2. Osteonecrosis of jaw occurs in almost 2/3rd of patients, following tooth extraction.
  3. Concomitnant oral infections predispose
  4. Failure of RCT with retained periapical infection.
  5. (Removable) denture induced trauma, often precipitates Osteonecrosis.
  6. Placement of implants with simultaneous intravenous bisphosphonate.


Appearance of a number of reports demands at least a registry of bisphosphonate induced osteonecrosis of jaw, along with record of accompanying systemic disorders or co-therapies3. A joint group from physicians rheumatologist, dentists and orthopaedicians should create a task force to collect data so as to formulate guidelines regarding prevention & management of osteonecrosis of jaw occurring due to bisphosphonate treatment, which should be purely on evidence based prospective data4 and not simply on opinion or anecdotal experience. We humbly suggest a registry of all these cases should be done along with formulating guidelines for prevention & treatment of this serious complication of bisphosphonate therapy in neoplastic and non-neoplastic disorders.

References:-
  1. Favia G; Osteonecrosis of jaw correlated to bisphosphonate therapy in nononcologic patients, clinic pathological features of 24 patients: J. Rheumatol; 2009; 36; 2780-87
  2. Reid IR; etal; Is bisphosphonate associated osteonecrosis of jaw called by soft tissue toxicity? Bone; 2007; 41: 318-20.
  3. Sharma V; etal; Bisphosphonate induced osteonecrosis of jaw; JAPI; 2011; 59; 516-17.
  4. Khan AA; etal; Bisphosphonate associated osteonecrosis of the jaw; J. Rheumatol; 2009; 36; 478- 90.