Clinical feature and treatment of bisphosphonate-related osteonecrosis of jaw about oral bisphosphonate administrated patients: case reports

Woo-Sung Choi; Hyun-Joong Yoon; Sang-Hwa Lee

doi:10.5125/jkaoms.2010.36.6.508

Journal List > J Korean Assoc Oral Maxillofac Surg > v.36(6) > 1032437

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Choi, Yoon, and Lee: Clinical feature and treatment of bisphosphonate-related osteonecrosis of jaw about oral bisphosphonate administrated patients: case reports

Original Article

J Korean Assoc Oral Maxillofac Surg 2010;36(6):508-514.

Published online: 7 January 2010

DOI: https://doi.org/10.5125/jkaoms.2010.36.6.508

Clinical feature and treatment of bisphosphonate-related osteonecrosis of jaw about oral bisphosphonate administrated patients: case reports

Woo-Sung Choi, Hyun-Joong Yoon, Sang-Hwa Lee

Department of Oral and Maxillofacial Surgery, Yeouido St. Mary's Hospital, The Catholic University of Korea, Seoul, Korea

Sang-Hwa Lee Department of Oral and Maxillofacial Surgery, Yeouido St. Mary’ s Hospital, The Catholic University of Korea 62 Yeouido-dong, Yeongdeungpo-gu, Seoul, 150-713, Korea TEL: +82-2-3779-2014 FAX: +82-2-769-1689 E-mail: justina@catholic.ac.kr

Received 5 August 201020 November 2010 Accepted 15 December 2010

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Bisphosphonates are used effectively for many medical conditions, such as multiple myeloma, Paget’ s disease, osteoporosis, etc. However, recently, osteonecrosis of the jaw was observed in patients receiving longterm bisphosphonate therapy, including oral administration. This osteonecrosis is refractory, and complete recovery is not guaranteed despite a standard treatment protocol being established by many associations related to oral and maxillofacial surgery. The treatment outcome of oral bisphosphonate-related osteonecrosis of jaw (BRONJ) is reported with a review of the relevant literature.

Keywords: Bisphosphonate, Osteonecrosis, Osteoporosis

REFERENCES

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Fig. 1.

A. Case 1: Initial intraoral view. It was observed gingival swelling, pus discharged.(blue arrow) B. Case 1: Initial CT scan, transverse view. Focal osteolytic lesion at the right upper alveolar process with marked soft tissue swelling. (red arrow) C. Case 1: Thirteen months later intraoral view. Bone exposure was detected.(blue arrow) The other symptom was subside. (CT: computed tomography)

Fig. 2.

A. Case 2: Initial intraoral view. Pus was discharged.(blue arrow) B. Case 2: Initial CT scan, transverse view. Osteolytic lesion at the left maxillary alveolar process.(red arrows) C. Case 2: Intraoperative view. Primary closure and tisseel application was done.(blue arrow) D. Case 2: Postoperation 5 months later CT scan, transverse view. Sequestrae are still observered E. Case 2: Postoperation 5 months later intraoral view. Bone exposure was persisted, but the other symptom was subside.(blue arrow) (CT: computed tomography)

Fig. 3.

A. Case 3: Initial intraoral view. Bone was detected.(blue arrow) Patient had painful sensation. B. Case 3: Bone fragment was extracted during wound irrigation. C. Case 3: Six months later intraoral view. Pain was subside, but bone exposure was remained.(blue arrow)

Table 1.

Staging and treatment strategies of BRONJ by AAOMS position paper⁹

BRONJ staging	Description	Treatment strategies
At risk category	No apparent necrotic bone in patients who have been treated with either oral or IV bisphosphonates	No treatment indicated Patient education
Stage 0	No clinical evidence of necrotic bone, but non-specific clinical findings and symptoms	Systemic management, including use of pain medication and antibiotics
Stage 1	Exposed and necrotic bone in patients who are asymptomatic and have no evidence of infection	Antibacterial mouth rinse. Clinical followup on quarterly basis. Patient education and review of indications for continued bisphosphonate therapy.
Stage 2	Exposed and necrotic bone associated with infection as evidenced by pain and erythema in the region of the exposed bone with or without purulent drainage	Symptomatic treatment with oral antibiotics. Oral antibacterial mouth rinse. Pain control Superficial debridement to relieve soft tissue irritation.
Stage 3	Exposed and necrotic bone in patients with pain, infection, and one or more of the following: exposed and necrotic bone extending beyond the region of alveolar bone, (i.e., inferior border and ramus in the mandible, maxillary sinus and zygoma in the maxilla) resulting in pathologic fracture, extra-oral fistula, oral antral/oral nasal communication, or osteolysis extending to the inferior border of the mandible of sinus floor	Antibacterial mouth rinse. Antibiotic therapy and pain control. Surgical debridement/resection for longer term palliation of infection and pain.

(BRONJ: bisphosphonate-related osteonecrosis of jaw, AAOMS: American Association of Oral and Maxillofacial Surgeons, IV: intravenous)

Table 2.

Etiologic factor, bisphosphonate therapy, treatment and stage changing of each cases: treatment plan was done in accordance with AAOMS position paper. Except in the case 1, conditions of case 2, 3 were improved

Case number	Stage	Etiologic factor	Bisphosphonate therapy	Treatment	Results
1	II (Bone exposure, pus discharge, pain)	Denture irritation	Alendronate (PO)	Antibiotics, dressing	Bone exposure, slightly pain, no pus discharge → Stage II
2	II (Bone exposure, pus discharge, pain)	Tooth extraction	Ibandronate (PO)	Antibiotics, dressing, partial debridement	Bone exposure, no pain, no pus discharge → Stage I
3	II (Bone exposure, pain)	Denture irritation	Risedronate (PO)	Antibiotics, dressing	Bone exposure, no pain, no pus discharge → Stage I

(AAOMS: American Association of Oral and Maxillofacial Surgeons, PO: per oral)

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