II. Pathophysiology
- Mandibular alveolar process undergoes constant bone remodeling
- Osteoclast-mediated bone resorption
- Osteoblast-mediated bone deposition
- Medications may disrupt bone remodeling
- Osteoclast apoptosis or inhibition
- Decreased localized Blood Flow
- Mandible is at increased risk of osteonecrosis due to increased bone turnover rate
III. Risk Factors
- High dose or long duration of triggering medication
- Corticosteroid use (in combination with other causative agents below)
-
Tooth Extraction (or dental implant)
- Precedes drug-induced Jaw Osteonecrosis in 45-61% of cases
- Dentures and gum inflammation may also increase risk
- Head and Neck Radiation Therapy
- Increased risk at sites exposed to >60 Gy radiation
- Nabil (2011) Int J Oral Maxillofac Surg 40(3): 229-43 [PubMed]
IV. Causes: Osteoporosis Agents
- Intravenous Bisphosphonates (occurs in 3-18% of patients)
- Zoledronic acid (Reclast)
- Ibandronate (Bonival)
- Oral Bisphosphonates (occurs in 0.1 to 0.2% of patients)
-
Denosumab (Prolia)
- RANK Ligand Inhibitor used in Osteoporosis, bone matastases, giant cell Bone Tumors
- Occurs in 0.7 to 1.9% of patients
- Romosozumab (Eventity)
- Sclerostin inhibitor used in Osteoporosis
V. Causes: Chemotherapeutic Agents
- Antiangiogenic Medications (monoclonal antibodies or Nucleic Acids)
- Chemotherapeutic agents that block solid tumor Angiogenesis (Vascular Endothelial Growth Factor)
- Bevacizumab (Avastin)
- Ramucirumab
- Ranibizumab
- Pegaptanib
- Tyrosine Kinase Inhibitors
- References
VI. Signs
- Exposed, necrotic bone
- Tooth socket remains after Tooth Extraction
- Suppurative discharge from osteonecrosis site
- Mucosal sloughing
- Persistent jaw pain
- Fistula formation
- Gingival Hypertrophy or bone hypertrophy
VII. Imaging
- Mandible XRay demonstrates radiolucency of bone in necrotic areas
VIII. Prevention
- Alert dentist to Radiation Therapy to head and neck
- Perioperative hyperbaric oxygen may be indicated prior to procedure
- Avoid dental surgery if patient is on intravenous Bisphosphonates, Antiangiogenic Medications, Denosumab
-
Exercise caution in performing dental surgery on those on oral Bisphosphonates for >4 years
- Dentists typically will ask for medical clearance for dental surgery in these cases
- Oral bisphosphonate holiday
- Not evidence based (however standard of care in dental practice as of 2020)
- Stopping bisphosponates has NOT been shown to modify risk
- Protocol
- Stop oral Bisphosphonates for 2 months before dental procedure
- Wait at least 3 months after dental procedure to restart oral Bisphosphonates
- Not evidence based (however standard of care in dental practice as of 2020)
IX. References
- (2023) Presc Lett 30(6): 33
- Glick (2020) Am Fam Physician 102(10):613-21 [PubMed]
Images: Related links to external sites (from Bing)
Related Studies
| Definition (NCI) | An area of necrotic bone in the mandible or maxilla. |
| Definition (NCI_CTCAE) | A disorder characterized by a necrotic process occurring in the bone of the mandible. |
| Concepts | Disease or Syndrome (T047) |
| SnomedCT | 441809006 |
| English | Jaw Osteonecrosis, ONJ, Osteonecrosis of Jaw, Aseptic necrosis of bone of jaw (disorder), Aseptic necrosis of bone of jaw, Osteonecrosis of jaw, jaw; osteonecrosis, osteonecrosis; jaw |
| Spanish | necrosis aséptica de hueso de la mandíbula (trastorno), necrosis aséptica de hueso de la mandíbula, Osteonecrosis mandibular |
| Portuguese | Osteonecrose da mandíbula |
| German | Osteonekrose des Kiefers |
| Dutch | osteonecrose van kaak, kaak; osteonecrose, osteonecrose; kaak |
| French | Osteonécrose de la mâchoire |
| Czech | Osteonekróza čelisti |
| Japanese | 顎骨壊死, ｶﾞｸｺﾂｴｼ |
| Italian | Osteonecrosi della mascella |
| Hungarian | Állkapocs osteonecrosisa |
Ontology: Bisphosphonate-Associated Osteonecrosis of the Jaw (C3178777)
| Definition (MSH) | Necrotic jaws or other maxillofacial skeleton necrosis associated with bisphosphonate use (see BISPHOSPHONATES). Injury, dental procedures, and trauma can trigger the necrotic process. |
| Concepts | Pathologic Function (T046) |
| MSH | D059266 |
| SnomedCT | 699687003 |
| English | Bisphosphonate-Related Osteonecrosis of the Jaw, Bisphosphonate Related Osteonecrosis of the Jaw, Osteonecrosis of the Jaws, Bisphosphonate Associated, Osteonecrosis of the Jaw, Bisphosphonate Related, Osteonecrosis of the Jaws, Bisphosphonate Related, Osteonecrosis of the Jaw, Bisphosphonate Induced, Osteonecrosis of the Jaws, Bisphosphonate-Associated, Bisphosphonate Induced Osteonecrosis of the Jaws, Osteonecrosis of the Jaw, Bisphosphonate-Related, Osteonecrosis of the Jaws, Bisphosphonate-Related, Bisphosphonate-Associated Osteonecrosis of the Jaw, Bisphosphonate-Induced Osteonecrosis of the Jaw, Bisphosphonate Induced Osteonecrosis of the Jaw, Osteonecrosis of the Jaws, Bisphosphonate-Induced, Bisphosphonate-Associated Osteonecrosis of the Jaws, Bisphosphonate Associated Osteonecrosis of the Jaws, Bisphosphonate Associated Osteonecrosis of the Jaw, Osteonecrosis of the Jaw, Bisphosphonate-Associated, Osteonecrosis of the Jaw, Bisphosphonate Associated, Osteonecrosis of the Jaw, Bisphosphonate-Induced, Bisphosphonate-Induced Osteonecrosis of the Jaws, Osteonecrosis of the Jaws, Bisphosphonate Induced, Bisphosphonate-Associated Osteonecrosis of the Jaw [Disease/Finding], Osteonecrosis of jaw due to bisphosphonate (disorder), Bisphosphonate related osteonecrosis of jaw, Osteonecrosis of jaw due to bisphosphonate |
| French | Ostéonécrose de la mâchoire liée aux biphosphonates, Ostéonécrose de la mâchoire associée aux biphosphonates, Ostéonécrose de la mâchoire induite par les biphosphonates |
| Russian | BISFOSFONAT-ASSOTSIIROVANNYI OSTEONEKROZ CHELIUSTI, BISFOSFONATNYI OSTEONEKROZ, БИСФОСФОНАТ-АССОЦИИРОВАННЫЙ ОСТЕОНЕКРОЗ ЧЕЛЮСТИ, БИСФОСФОНАТНЫЙ ОСТЕОНЕКРОЗ, BISFOSFONAT-SVIAZANNYI OSTEONEKROZ, БИСФОСФОНАТ-СВЯЗАННЫЙ ОСТЕОНЕКРОЗ |
| Spanish | Osteonecrosis de los Maxilares Asociada a Bifosfonato, Osteonecrosis de los Maxilares Asociada a Bisfosfonato, osteonecrosis de mandíbula debida a bisfosfonato (trastorno), osteonecrosis de mandíbula debida a bisfosfonato |
| Czech | osteonekróza čelistí indukovaná bisfosfonáty, osteonekróza čelisti způsobená bisfosfonáty |
| Polish | Bifosfonianowa nekroza szczęk, Bifosfonianowa martwica kości szczęki i żuchwy, Martwica kości szczęk bifosfonianowa |
| Italian | Osteonecrosi della mascella da bifosfonati, Osteonecrosi della mascella indotta da bifosfonati, Osteonecrosi della mascella da terapia con bifosfonati, Osteonecrosi dei mascellari da bifosfonati |
| German | Bisphosphonat-assoziierte Osteonekrose, Kiefer, Bisphosphonat-assoziierte Kieferosteonekrose, Bisphosphonat-induzierte Osteonekrose, Kiefer, Kieferosteonekrose, Bisphosphonat-induzierte, Kieferosteonekrose, Bisphosphonat-assoziierte |
| Norwegian | Bisfosfonatassosiert osteonekrose i kjeven, Bisfosfonatrelatert osteonekrose i kjeven, Kjeveosteonekrose grunnet bisfosfonat, Bisfosfonatassosiert kjeveosteonekrose, Bisfosfonatindusert osteonekrose i kjeven |
| Portuguese | Osteonecrose da Arcada Osseodentária Associada a Bisfosfonatos, Osteonecrose Associada a Bisfosfonatos, Osteonecrose da Arcada Osseodentária Associada aos Bisfosfonatos, Osteonecrose da Arcada Osseodentária por Bisfosfonatos, Osteonecrose Associada aos Bifosfonatos, Osteonecrose da Arcada Osseodentária Associada a Bifosfonatos, Osteonecrose da Arcada Osseodentária Associada aos Bifosfonatos, Osteonecrose Associada aos Bisfosfonatos |
