Osteonecrosis of the jaws is a condition whereby there is loss or destruction of the bone underneath the teeth. This loss of bone appears to be caused by a combination of poor blood supply and impaired bone remodeling or healing.

Two recent reports have raised the possibility that osteonecrosis (also referred to as avascular necrosis) of the jaws could be an unexpected complication of bisphosphonate therapy (1, 2). Language addressing this concern has recently been added to the FDA-approved labeling for Aredia^® and Zometa^®.

The implications of these new findings are quite diverse. Further studies are definitely required to clarify many aspects. Nevertheless, a number of basic recommendations can be made:

1. Bisphosphonates remain a critical element of care to reduce bone destruction in myeloma patients. Patients should continue to use bisphosphonates as recommended by their physicians.
   
   
2. Be alert and aware that bisphosphonate use can be associated with jaw or dental problems, including pain, bone loss, and poor healing. Problems are more likely with longer periods of bisphosphonate use (e.g. several years) and possibly more potent bisphosphonates (e.g. Zometa^®).
   
   
3. Be proactive if dental problems exist and/or if any dental or jaw interventions are planned. If feasible, dental evaluation and treatment prior to starting bisphosphonates would seem to be a good idea. Once bisphosphonate therapy has begun, dental extractions, placement of dental implants and/or any other major interventions must be undertaken with due caution. Although there are no conclusive data available at this point, stopping Aredia^® or Zometa^® for 2-4 months prior to a procedure can be considered. This may help even in the absence of any planned surgery.
   
   
4. Conservative measures such as antibiotic treatment and mouth rinses (e.g. Peridex or hydrogen peroxide) would seem to be quite helpful and safe. Intravenous antibiotics may be required for more severe or acute secondary infections. Ongoing use of an antibiotic such as penicillin has also been recommended if problems persist. Major surgical intervention should be avoided if at all possible.
   
   
5. If the osteonecrosis is severe, potential co-factors or co-triggering factors should be stopped or avoided. If at all feasible, steroids such as prednisone or dexamethasone should be discontinued or reduced. There should be no irradiation therapy involving the head/neck.

Further investigations are required to assess more accurately the causes and treatment for the osteonecrosis. For now, awareness is key. Proceed with caution whenever dental or jaw problems emerge. Seek a second opinion if recommendations for management are unclear or uncertain. If you are currently taking bisphosphonates, consider baseline dental evaluation as well as periodic check-ups and review. If you have further questions, you may want to contact the IMF hotline at 800-452-2873 or email TheIMF@myeloma.org.

References

1. Marx RE. Pamidromate (Aredia) and Zoledronate (Zometa) induced avascular necrosis of the jaws: a growing epidemic. J. Oral Maxillofac Surg. 61: 1115-1118; 2003.
2. Ruggiero SL, Mehrotra B, Rosenberg TJ, Engroff SL. Osteonecrosis of the jaws associated with the use of bisphosphonates: a review of 63 cases. J Oral Maxillofac Surg. 62: 527-534; 2004.