by Lynne H. Slim RDH, BSDH, MSDH
I just returned from a family funeral in Northwest England. While there, I visited a library and came across a line from a Victorian musical about phosphorous necrosis, or “phossy jaw,” which was a 19th century consequence of poor working conditions in matchstick factories across Europe. The musical, called “The Matchgirls,” featured a chorus of match factory workers who chanted:
Phosphorous, phosphorous, Our special beauty cream, We look a proper dream, For we are minus a jaw. Uncovering the cause of “phossy jaw” in the late 1800s, and comparing it to today's bisphosphonate-induced osteonecrosis, reveals that they are one and the same. Today's IV and oral bisphosphonate medications represent a second epidemic of “phossy jaw”1 and bisphosphonate-induced osteonecrosis of the jaw (BIONJ), which are linked to phosphate-containing compounds and lead to exposed necrotic bone in the jaws.1
Last month I wrote about IV bisphosphonate-induced osteonecrosis. Initial case reports of osteonecrosis of the jaw in the 21st century indicated that patients receiving oral bisphosphonates were at negligible risk of developing BIONJ compared with patients who received IV bisphosphonates.2 That is now being questioned, and it's possible that BIONJ may be a complication of long-term oral bisphosphonate therapy.2
The most widely prescribed oral bisphosphonate drug is alendronate (Fosamax®). In 2006, it was the 21st most prescribed drug in the U.S.2 Although the estimate of incidence of BIONJ is unsubstantiated because of inadequate research, a recent large institutional study indicated that even short-term use of oral alendronate can lead to BIONJ in a subset of patients following dental procedures such as extractions.2
While waiting for epidemiological evidence to strengthen the association between oral bisphosphonates and BIONJ, the ADA makes regular recommendations for the care of patients who receive oral bisphosphonates. The guidelines can be downloaded from the ADA Web site.3 Here is a brief summary:
Routine dental treatment should not be modified due to oral bisphosphonate use.
Patients taking oral bisphosphonates would benefit from a comprehensive oral exam before using bisphosphonates.
An oral health program consisting of sound oral hygiene practices is advised.
Discontinuing intravenous bisphosphonate therapy may not reduce the risk of developing BIONJ. However, temporarily discontinuing oral bisphosphonate therapy has been shown to reduce the risk of BIONJ.4
If a patient develops a problem in the oral cavity during bisphosphonate therapy, he/she should contact a dentist.
Proceed conservatively to gain insight into how a patient will heal before putting multiple quadrants at risk. On the other hand, severe conditions such as purulent periodontal pockets, active abscesses, or severe periodontitis should be treated immediately,.
It is important to document risks, benefits, and treatment options and obtain written consent for treatment.
Nonsurgical periodontal therapy should be combined with a reevaluation at four to six weeks.
Maintenance of implants, including regular monitoring, should follow accepted mechanical and pharmaceutical methods to prevent peri-implantitis.
Endodontic treatment is preferable to surgical manipulation, and manipulation beyond the apex is not recommended.
Patients undergoing invasive surgical procedures should be informed of the risk of developing BIONJ, and alternative treatment plans should follow removal of the clinical tooth crown. In addition, immediately before and after any surgical procedure involving bone, the patient should rinse gently with chlorhexidine until the site heals.
1. Marx RE. Uncovering the cause of phossy jaw circa 1858 to 1906: oral and maxillofacial surgery closed case files-case closed. J Oral Maxillofac Surg 2008; 2356-2361.
2. Sedghizadeh PP, et al. Oral bisphosphonate use and the prevalence of osteonecrosis of the jaw-an institutional inquiry. J Am Dent Assoc 2009; 140: 61-66.
3. Edwards BJ et al. Updated recommendations for managing the care of patients receiving oral bisphosphonate therapy: an advisory statement from the American Dental Association Council on Scientific Affairs. J Am Dent Assoc 2008; 139: 1674-1677.
4. Marx RE, Cillo JE Jr., Ulloa JJ. Oral bisphosphonate-induced osteonecrosis: risk factors, prediction of risk using serum CTX testing, prevention, and treatment. J Oral Maxillofac Surg. 2007 Dec; 65(12): 2397-2410.
About the Author
Lynne Slim, RDH, BSDH, MSDH, is the CEO of Perio C Dent, a dental practice management company. Lynne is also the moderator of the www.yahoogroups.com/group/periotherapist. Lynne speaks on the topic of conservative periodontal therapy.