Αικατερίνη Νικοπούλου-Καραγιάννη Καθηγήτρια, Κλινικής Διαγνωστικής και Ακτινολογίας Στόματος,Κωνσταντίνος Τσιχλάκης Καθηγητής και Διευθυντής, Κλινικής Διαγνωστικής και Ακτινολογίας Στόματος,Αικατερίνη Δοντά Αναπληρώτρια Καθηγήτρια, Κλινικής Διαγνωστικής και Ακτινολογίας Στόματος
Douka E.: Effects of bisphosphonate use at the jaws: review
Bisphosphonates are the first-line drugs for osteoporosis, as well as for many
types of cancer. They can be administered orally or intravenously, and one of
their side-effects is osteonecrosis of the jaw, which has mainly been
associated with their intravenous administration.
Bisphosphonate-associated osteonecrosis of the jaws (ONJ) presents both
radiological and clinical findings such as avascular bone in the maxilla or the
mandible and, according to clinical stage, pain, inflammation, fractures and/or
extensive osteolysis. In the vast majority of cases, the patients had been on
intravenous drug therapy and had undergone dentoalveolar surgery.
Bisphosphonates inhibit bone resorption by inhibiting osteoclast activity,
although other actions such as inhibition of angiogenesis have also been
Common risk factors associated with the development of
bisphosphonate-associated ONJ include:
• History of taking bisphosphonates, especially I.V. formulations. The
concurrent use of steroids appears to contribute to this risk.
• Previous history of cancer (e.g., multiple myeloma or metastatic disease to
bone), osteoporosis, Paget’s disease or other indications for bisphosphonate
• A history of a traumatic dental procedure. Most case reports occur after a
tooth extraction, although other traumatic dental procedures (placement of
dental implants) may also be associated with the occurrence of ONJ.
• Several reports indicate the spontaneous development of
bisphosphonate-associated ONJ without a prior traumatic dental procedure.
Patients presenting with bisphosphonate-associated ONJ typically present with
at least some of the following signs and symptoms:
• An irregular mucosal ulceration with exposed bone in the mandible or maxilla
• Pain or swelling in the affected jaw
• Infection, possibly with purulence
• Altered sensation (e.g., numbness or heavy sensation).
Some important issues related to bisphosphonate-associated ONJ are:
• The site of occurrence of the osteonecrosis is the jaws, and
presentation occurs more frequently in the mandible than in the maxilla. The
reasons for the presentation of osteonecrosis in the jaws versus other parts
of the skeleton are unknown at this time.
• The mechanism for bisphosphonate-associated ONJ is unknown.
• The treatment for bisphosphonate-associated ONJ is problematic. Case
reports document no response or a limited response to local surgical wound
debridement, marginal or segmental resection, antibiotics and hyperbaric
oxygen. Therefore, recognition of risk factors and application of preventive
dental treatment procedures are important for patients taking I.V. or oral
According the update information from the literature about
bisphosphonate-associated ONJ the following issues are relevant to the
management of patients under bisphosphonate treatment:
• Routine dental treatment generally should not be modified solely
because of the patient’s use of oral bisphosphonates.
• The low risk of developing ONJ in patients using oral bisphosphonates
may be minimized but not eliminated.
• Although routine endodontic technique should be used, manipulation
beyond the apex is not recommended.
• At the management of periodontal diseases appropriate forms of
nonsurgical therapy should be combined with the commonly recommended
reevaluation at four to six weeks.
Bisphosphonates, Osteonecrosis, Jaws, ONJ