Makindo Medical Notes

Related Subjects: |Bisphosphonates |Osteoporosis |Osteonecrosis of the jaw

Osteonecrosis of the Jaw (ONJ) is a serious condition in which the jawbone starts to die due to lack of blood flow. This condition is often associated with the use of certain medications, particularly bisphosphonates and denosumab, which are used to treat osteoporosis and prevent bone complications in cancer patients.

About

• Only recently described in 2002

Aetiology

• Trauma to dentoalveolar structures
• Limited capacity for bone healing due to the effects of bisphosphonate/other therapies.
• Cancer patients appear to be at greater risk
• Histopathologic findings implicate bone necrosis and infection,

Causes

• Drugs - Denosumab (RANKL inhibitors), Bisphosphonates, Steroids, Cancer chemotherapy
• Most cases occurring in people with cancer, but some occurred in people with osteoporosis

Clinical

• Exposed Bone: The most characteristic sign of ONJ is exposed bone in the mouth that does not heal within 8 weeks.
• Pain or Swelling: Persistent pain, swelling, or infection of the gums or jaw.
• Loose Teeth: Teeth may become loose or feel as if they are shifting.
• Numbness or Heaviness: Some patients experience numbness, tingling, or a feeling of heaviness in the jaw.
• Pus or Discharge: There may be pus or discharge from the affected area.

Investigations

• Clinical Examination: oral cavity shows areas of exposed bone.
• Imaging: X-rays, CT scans, or MRI may be used to assess the extent of the bone damage.
• Medical History: medical history, including current medications and recent dental procedures.

Prevention

• All patients being treated with these drugs should have a dental exam and preventive dentistry before treatment and know to alert clinicians to any dental pain or swelling. Generally, Optimise oral care. Smoking cessation.
• Ideally dental check-up before starting bisphosphonates or denosumab, and any necessary dental work should be completed before treatment begins. Maintaining excellent oral hygiene and regular dental check-ups can help reduce the risk of ONJ.
• Avoid Invasive dental procedures if possible, and consider alternative treatments.
• Inform dentists and healthcare providers about the use of these medications before any dental procedures are performed.

Management

• Conservative Management: Initial treatment may include rinses with antimicrobial mouthwash, antibiotics, and pain management. Avoiding further dental procedures is also recommended.
• Surgical Intervention: In more severe cases, surgical debridement (removal of dead bone) or resection of the affected bone may be necessary.
• Discontinuation of Medications: Temporarily stopping the use of bisphosphonates or denosumab may be considered, though this should be done in consultation with a healthcare provider.