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Bisphosphonates and Oral Health

Bisphosphonates and Oral Health
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  74 WHAT ARE THEY? Bisphosphonates are drugs used forthe prevention and treatment of bone diseases such as osteoporosis,Paget’s disease, metastasis of can-cers, and hypercalcemia. They workin a relatively complex way byinterfering with cells that form andbreak down bone. Bisphosphonatesremain attached to the bone for along time after they are taken, anddecrease significantly the bone’sability to remodel and heal afterinjuries. 1 There are many types of bisphosphonates available, includ-ing nitrogenous, nonnitrogenous,intravenous, and oral presentations.Examples of bisphosphonates onthe market include Actonel (rise-dronate), Procter & Gamble Phar-maceuticals, Cincinnati, OH, USA;Aredia (pamidronate), NovartisNovartis Pharmaceuticals Corp.,East Hanover, NJ, USA; Boniva(ibandronate), Roche Therapeutics,Inc., Nutley, NJ, USA; Didronel(etidronate), Procter & GamblePharmaceuticals; Fosamax (alen-dronate), Merck & Co., Inc.,Whitehouse Station, NJ, USA; Skelid (tiludronate); Sanofi Pharmaceuticals, New York, NY,USA; and Zometa (zoledronate),Novartis Novartis PharmaceuticalsCorp. 2 HOW DO THEY AFFECT YOUR ORAL HEALTH? It has been recently reported thatthe long-term use of bisphospho-nates is associated with an oral con-dition called osteonecrosis of thejaws. In patients affected with bis-phosphonates-related osteonecrosisof the jaws, or BRONJ, the jawbone’s ability to respond to oth-erwise routine procedures, such astooth extractions and oral surgery,is impaired. In extreme cases, a partof the jawbone dies and can beexposed in the mouth. Somepatients experience severe pain,drainage of pus, bone fractures, andeven systemic signs and symptomsof infection, such as fever and lym-phadenopathy. BRONJ is morelikely to develop in the presence of bacteria, when high doses of bis-phosphonates are used for a longtime, and when nitrogenous andintravenous forms of the drug are used. 3 PREVENTION AND TREATMENT For patients who are taking or havetaken bisphosphonates, limiting thearea of bone exposure during toothextractions and oral surgeries iscritical to prevent BRONJ. Patients Bisphosphonates and Oral Health André V. Ritter, DDS, MSRicardo Padilla, DDS* Talking with Patients who will start taking bisphospho-nates should undergo a thoroughdental examination to prepare themouth to be in optimal healthbefore bisphosphonates exposure. If the condition develops, availabletreatments include topical antimi-crobial rinses, systemic antibiotics,pain control, and, sometimes,surgery to remove fragments of dead bone with active infection that do not respond to antibiotics. 4 Discontinuing bisphosphonate usein patients with established BRONJ is of controversial benefitbecause of the documented long-lasting effects of the drug on thebone. A blood test that measuresbone turnover, called C-terminaltelopeptide, is currently being studied as a potential test to determine the patient’s risk todevelop BRONJ. SUMMARY AND CONCLUSIONS Bisphosphonates are drugs used totreat bone disorders but are associ-ated with a potentially serious sideeffect called BRONJ. Although theprevalence of the condition is lowoverall, the risk increases substan-tially for patients who use or haveused intravenous bisphosphonateson a long-term basis. It is of utmost © 2008, COPYRIGHT THE AUTHORS JOURNAL COMPILATION © 2008, BLACKWELL PUBLISHING DOI 10.1111/j.1708-8240.2008.00152.x *Clinical assistant professor, graduate program director, Department of Diagnostic Sciences and General Dentistry, University of North Carolina at Chapel Hill School of Dentistry, Chapel Hill, NC  TALKING WITH PATIENTSVOLUME 20, NUMBER 1, 2008 75 importance to inform your dentistif you are taking or have taken bis-phosphonates. The dental teamshould work closely with thepatient’s physician to develop astrategy to prevent BRONJ whileunder bisphosphonate therapy. If you suspect you may have thiscondition, contact your dentist as soon as possible for a complete evaluation. Figure 1 illus-trates an example of bisphospho-nate-related osteonecrosis of thejaw over a palatal torus. DISCLOSURE The authors do not have any finan-cial interest in the manufacturerswhose materials are discussed inthis article. REFERENCES 1.Woo SB, Hellstein JW, Kalmar JR. System-atic review: bisphosphonates andosteonecrosis of the jaws. Ann Intern Med2006;144:753–61.2.American Dental Association. Report of the Council of Scientific Affairs. ExpertPanel Recommendations: Dental Manage-ment of Patients in Oral BisphosphonateTherapy. Available at:http://www.ada.org/prof/resources/top-ics/osteonecrosi/asp (accessed December3, 2007).3.Ruggiero SL, Fantasia J, Carlson E. Bis-phosphonate related osteonecrosis of thejaw: background and guidelines for diag-nosis, management, and staging. OralSurg Oral Med Oral Pathol Oral RadiolEndod 2006;102:433–41.4.Hewitt C, Farah CS. Bisphosphonate-related osteonecrosis of the jaws: a com-prehensive review. J Oral Pathol Med2007;36(6):319–28. Figure 1.Example of bisphosphonate-related osteonecrosisof the jaw over a palatal torus.
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