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Bisphosphonate-related osteonecrosis of the jaw (BRONJ) is found in patients who have received intravenous and oral forms of bisphosphonate therapy for various bone-related conditions including bone cancer, osteoporosis, osteopenia, Paget’s disease of bone, and osteogenesis imperfecta of childhood.  Bisphosphonate is marketed under the brand names Boniva (Ibandronate), Fosamax (Alendronate), and Actonel (Risendronate), Zometa (Zolendronic acid) and Aredia (Pamidronate).

BRONJ is a condition in which the maxillofacial bones, in particular the tooth areas, become exposed and necrotic.  Bisphosphonate slows the body’s ability to remove and replace bone, specifically in the jawbone area.  BRONJ can appear spontaneously or can be a result of trauma to the dentoalveolar structures from periodontal (gum) disease, dental surgery, implants, root canals, abscessed teeth, or tooth extraction.

BRONJ patients normally present with pain, swelling, halitosis, cellulitis, and trismus.  Physical findings include clinical infection, mandibular and or maxillary bone exposure, oral-cutaneous fistula, or pathologic fracture.  Upon examination, a varied amount of exposed and painful alveolar, maxillary, and/or mandibular  bone is revealed.  Clinical detection involves sloughing of pieces of bone, spicules of bone protruding through the gums, and drainage.  A patient with this condition should be referred to an oral and maxillofacial surgeon who is then responsible for counseling, managing and treating the patient.

BRONJ Diagnosis

The American Association of Oral and Maxillofacial Surgeons outlines the following parameters to distinguish BRONJ from other delayed healing conditions. Patients may be considered to have BRONJ if all of the following three characteristics are present:

1. Current or previous treatment with a bisphosphonate;
2. Exposed, necrotic bone in the maxillofacial region that has persisted for more than eight weeks; and
3. No history of radiation therapy to the jaws.

To make a definitive diagnosis, laboratory studies should be conducted to rule out a primary malignancy.  Additionally, a CT scan, MRI, panoramic or plain-film imaging, and/or area biopsy may be conducted (if warranted.)

It is important to understand that patients at risk for BRONJ or with established BRONJ can also present with other common clinical conditions not to be confused with BRONJ. Commonly misdiagnosed conditions may include, but are not limited to, alveolar osteitis, sinusitis, gingivitis / periodontitis, caries, periapical pathology and TMJ disorders.

Treatment of BRONJ

The treatment objectives for patients with an established diagnosis of BRONJ are to eliminate pain, control infection of the soft and hard tissue and minimize the progression or occurrence of bone necrosis. There are two ways to manage and treat patients with BRONJ – non-surgical and surgical.

Non-surgical management includes antibiotics, systemic or topical antifungals, antimicrobial rinses, ceasing bisphosphonate therapy, and stopping dental therapy or changing strategy to minimally invasive dental therapy.

Surgical solutions for BRONJ are limited due to the patient’s impaired healing ability.  Again deferring to the American Association of Oral and Maxillofacial Surgeons’ guidelines, the suggested treatment of BRONJ patients is determined by which stage the patient presents in:

• Stage I
  • Antimicrobial rinses
  • No surgical intervention

• Stage II
  • Antimicrobial rinses
  • Systemic antibiotics or antifungals
  • Analgesics
• Stage III
  • Antimicrobial rinses
  • Systemic antibiotics or antifungals
  • Analgesics
  • Surgical debridement or resection

Management and Prevention of BRONJ

Although a small percentage of patients receiving bisphosphonates develop osteonecrosis of the jaw spontaneously, the majority of affected patients experience this complication following dental surgery.   The use of oral bisphosphonates and their role in BRONJ have yet to be completely determined. Long-term studies identifying the patients who are at risk for this disease process are still pending.  Currently, the best solution to the problem is prevention.

Prior to treatment with an IV bisphosphonate, the patient should have a thorough oral examination, any unsalvageable teeth should be removed, all invasive dental procedures should be completed and optimal periodontal health should be achieved. Patients with full or partial dentures should be examined for areas of mucosal trauma, especially along the lingual flange region. It is critical that patients are educated as to the importance of dental hygiene and regular dental evaluations, and specifically instructed to report any pain, swelling, or exposed bone.

For individuals who have taken an oral bisphosphonate for less than three years and have no clinical risk factors, no alteration or delay in dental surgery is necessary. The risk of developing BRONJ associated with oral bisphosphonates, while exceedingly small, appears to increase when the duration of therapy exceeds three years.  For patients who have taken an oral bisphosphonate for less than three years with or without corticosteroids concomitantly, the prescribing provider should be contacted to consider discontinuation of the oral bisphosphonate for at least three months prior to oral surgery, if systemic conditions permit. The bisphosphonate should not be restarted until healing has occurred.

If you have a patient who is presenting with BRONJ symptoms, or at risk of contracting BRONJ, we would be happy to evaluate them and work together with you on a treatment plan.  If you have any questions for us or would like to discuss a patient situation with us, please contact us at 713-439-7575 or 281-277-6622.  We look forward to partnering in your patient’s care.

Resources:
American Association of Oral and Maxillofacial Surgeons Position Paper
Wikipedia – BRONJ
Journal of Oral and Maxillofacial Surgery Abstract