Cases of osteonecrosis of the jaw ( ONJ ) have been detected in cancer patients taking bisphosphonates as part of their treatment.
The publications and cases notified to date mention that the majority of the patients were on antineoplastic treatment ( chemotherapy, steroids treatment, or radiotherapy for head and neck tumors ), and they were administered bisphosphonates concomitantly for the treatment of cancer and its related symptoms, indicating, most of such reports, the appearance of ONJ following dental procedures.

A panel of Spanish experts representing the specialties of Medical Oncology, Hematology, Urology, and Stomatology, has held a meeting to debate on and identify the risk factors associated with the osteonecrosis of the jaw, as well as to develop some clinical guidelines on the prevention, early diagnosis, management, and interdisciplinary treatment of such pathology, in patients with advanced malignancies with bone affectation, related with bisphosphonates.

1) Preventive measures to be taken for patients treated with bisphosphonates without osteonecrosis of the jaw

1.A – Before initiating bisphosphonates treatment: All patients with concomitant risk factors ( e.g..cancer, chemotherapy, corticosteroids ), who are going to begin a treatment with bisphosphonates, should consider being examined by their odontologist / stomatologist, before initiating the treatment; the physician should take into account the following recommendations:

- It is very important to detect possible infection sources in the patient, both already existing, as well as potential ones and, if any, to eliminate them before initiating bisphosphonates treatment.

- Those teeth that, due to periodontal pathologies, is not quite clear that could be subsequently maintained, should be extracted before the commencement of the bisphosphonates treatment.

1.B – During bisphosphonates treatment: During bisphosphonates treatment,it is recommended that the patient visits an odontologist / stomatologist, at least once a year, to detect and, if any, to treat caries and periodontal diseases at an early stage.

1.C – In case of extraction during bisphosphonates treatment: In case of a patient treated with bisphosphonates, dental extractions should be avoided, although if it is absolutely necessary to perform an extraction the following recommendations should e taken into account:

- Perform the extraction in the less traumatic way possible. Residues of large alveolar bone defects should be avoided, and, of course, the possibility of conducting an alveolus suture to facilitate subsequent cicatrisation should be evaluated.

- Administrating oral Amoxicillin / Clavulanic acid ( 875 mg / 125 mg three times a day ) or Clindamycin ( 300 mg 3-4 times a day ) two days prior to the extraction, and during ten days after the extraction.

- Following the extraction, the patient should rinse with 0.12% Chlorhexidine, twice day for 5 days.

- The possibility to temporarily suspend the bisphosphonates treatment ( 2-3 months prior to the procedure, and until the lesion cicatrisation has been confirmed ), is up to the physician, since there is no evidence of the benefit of such interruption and lesions without osteonecrosis.

2 ) Action plan in case of a cancer patient with a suspicion of osteonecrosis of the jaw

The above-mentioned recommendations should be followed for areas without osteonecrosis, with regards to dental plaque, caries and periodontal pathology.

2.A - Treatment of patients with osteonecrosis of the jaw: For the treatment of the osteonecrosis area(s), a distinction shall be made between two situations in terms of the expansion of the lesion:

B.1 – Patients with small osteonecrosis of the jaw areas

A conservative treatment shall be initiated. Based on the microbiological analysis, establish a treatment for 10-15 days with the appropriate antibiotic, in parallel with Chlorhexidine rinses ( once every 12 hours for a month ).
In case of a normal flora, it is recommended to use 875 /125 mg of Amoxicillin / Clavulanic acid, or Clindamycin.

- The healthcare professional should carry out irrigation of the exposed necrotic bed, with 0.12% Chlorhexidine, once every 72 hours for four weeks. After one month, the patient should be reevaluated; two possibilities exist:

a. If an improvement is confirmed the patient should continue with the 0.12% Chlorhexidine rinses for another month of follow-up, both for the patient’s daily applications and the professional ’s application very 72 ours.

b. In case there is not a good response to the conservative treatment, the said treatment shall be maintained for another month. If, this period has elapsed but there is still no improvement, then the regimen stipulated in section B.2 should be followed.

B.2 - Patients with large osteonecrosis of the jaw areas and patients who have not evolved satisfactorily following conservative treatment

- Plan a surgical procedure to remove the area of the necrotic bone ( the expansion and magnitude of the surgical procedure will depend on the size of he osteonecrosis ).

- In case of osteonecosis of the jaw presence, bisphosphonates treatment shall be suspended, being up to the physician to reintroduce it in case of an active bone disease, evaluating the risk-benefit ratio. Corticoids withdrawal should also be evaluated, in case they had been administered as a maintenance therapy.

- Source: Medicina Oral Patologia Oral Y Cirugia Bucal, 2007

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