Dental Care Steps to Prevent and Treat Osteonecrosis of the Jaw

Everyone can benefit from good oral hygiene, but people with cancer need to pay particular attention to their dental health because of side effects associated with certain treatments.

Osteonecrosis of the jaw (ONJ) involves dead bone in the jaw that becomes exposed after a tooth extraction or, in some cases, from a denture rubbing against the skin in the mouth.¹ ONJ may also be caused by radiation of the head and neck, chronic steroid use, herpes infection in very ill patients, uncontrolled infections, and major trauma.²

Scientists do not yet know all the causes of ONJ or how often it occurs.³ The few studies on the risk of developing ONJ suggest the risk is low for patients on bisphosphonate therapy.² Although ONJ has been uncommon in patients receiving treatments for cancer, including bisphosphonates, chemotherapy, and radiotherapy, researchers believe trauma may limit the ability of teeth and gums to heal due to the effects of bisphosphonate therapy.^3,4

“Osteonecrosis can cause severe pain,” says Joel S. Teig, DMD, a board-certified oral and maxillofacial surgeon in practice for more than 20 years. “It can spontaneously develop with or without dental treatments, although dental extractions or other dental surgeries, like periodontal surgery and dental implant surgery, can dramatically increase the chance of its development.”

Dr. Teig suggests that patients be aware of potential symptoms of ONJ, such as pain; loose teeth; numbness of the jaw, lips, and chin; fluid or pus drainage; and exposed bone and gums that don’t heal (frequently with dramatic gum recession). “Initially, just a dull ache or recession of reddened gums may occur,” says Dr. Teig, “but if not recognized and diagnosed for what it is, osteonecrosis and its potentially devastating symptoms can quickly expand.”

Cancer patients should maintain good oral hygiene and have a dental exam with preventive dentistry before treatment with bisphosphonates.⁵ An expert panel, comprised of oncologists, oral surgeons, and other specialists, published its recommendations in the Journal of Oncology Practice. The panel’s first suggestion was that patients complete any dental treatments and procedures that require bone healing beforeinitiating IV bisphosphonate therapy. The panel concluded that for patients currently receiving bisphosphonates who require dental procedures, there is no evidence to suggest that stopping bisphosphonate therapy will prevent or lower the risk of ONJ. Instead they recommended frequent dental visits and conservative dental management for these patients. For treatment of patients who develop ONJ, they strongly recommended a nonsurgical approach.⁶

“The most important thing a metastatic cancer patient who is taking bisphosphonate medications needs to do is to be attentive to his or her oral health. Brushing and flossing of their teeth, along with the use of an antibacterial mouth rinse twice a day can help reduce the chance of developing the need for invasive dental treatments that could potentially stimulate osteonecrosis development,” Dr. Teig stresses. “Metastatic cancer patients must see their dentists regularly for simple cleanings, repair of dental decay, and evaluations to nip potential dental degenerations along with any bony changes seen on x-rays,” Dr. Teig warns.

“The confirmed clinical benefit of bisphosphonates in cancer patients outweighs the potential risk of developing ONJ,” the panel concluded. Trials will be needed to evaluate the true incidence and clearly establish what really causes ONJ in cancer patients.

Increased awareness of this potential problem is the key to prevention and to better treatment for patients with bone metastases.⁶ Cancer patients who are aware of potential side effects from treatment put themselves in a better position to receive the best possible care.

References

1. Osteogenesis Imperfecta Foundation. What is Osteonecrosis of the Jaw? Available at: http://www.oif.org/site/DocServe/Osteonecrosis_of_the_Jaw.pdf?docID=7218. Accessed December 28, 2010.
2. American Dental AssociationReport of the Council on Scientific Affairs. Dental Management of Patients Receiving Oral Bisphosphonate Therapy Expert Panel Recommendations. July, 2008Available at: http://www.ada.org/sections/professionalResources/pdfs/topics_osteonecrosis_bisphosphonate_report.pdf. Accessed December 28, 2010.
3. Blanchaert RH, Jr. Emedicine from WebMD: Bisphosphonate-related osteonecrosis of the jaw. Available at: http://emedicine.medscape.com/article/1447355-overview. Accessed December 29, 2010.
4. Gnant M, Mlineritsch B, Schippinger W, et al. Endocrine therapy plus zoledronic acid in premenopausal breast cancer. N Engl J Med. 2009;360(7):679-691.
5. Zometa® (zoledronic acid) Injection: highlights of prescribing information. Available at:http://www.pharma.us.novartis.com/product/pi/pdf/Zometa.pdf. Accessed December 28, 2010.
6. Ruggiero S, Gralow J, Marx RE, et al. Practical guidelines for the prevention, diagnosis, and treatment of osteonecrosis of the jaw in patients with cancer.J Oncol Pract. 2006;2(1):7-14.Available at: http://www.jopasco.org/content/2/1/7.full#T2. Accessed December 28, 2010.