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Osteonecrosis of the jaw: Research still needed

Increased dentist-physician communication would help further understanding of the condition.

Issue: November 2006

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Osteonecrosis of the jaw has been diagnosed more frequently during the last few years, but the true incidence of the condition is unknown.

At the 28th Annual Meeting of the American Society for Bone and Mineral Research, Catherine Van Poznak, MD, spoke about improving the diagnosis of and knowledge about osteonecrosis of the jaw.

Currently, little is known about osteonecrosis of the jaw and there is no consensus definition of the condition, she said. A definition would help physicians uniformly diagnose the condition and ultimately develop optimal management for it.

“Risk of osteonecrosis of the jaw to date is greatest in patients with advanced cancer receiving intravenous bisphosphonates,” said Van Poznak, an associate professor in the department of internal medicine, University of Michigan.

“The incidence in that population appears to be 1% to 10% for metastatic bone disease,” she said, adding that approximately 90% of the current identified cases of osteonecrosis of the jaw are in this patient population.

“In patients receiving oral bisphosphonates for benign conditions, the risk appears to be 0.7 cases per 100,000 person years of exposure,” she said. “The risk is small in the population receiving oral bisphosphonates.”

Research

Currently, components of dental evaluations are present within many clinical trials exploring bisphosphonates in patients with cancer, Van Poznak said. “Right now, studies might not be specifically directed at osteonecrosis of the jaw, they are directed more toward patients with cancer receiving bisphosphonates, but aspects of some studies include the evaluation of osteonecrosis of the jaw,” she said.

Van Poznak said that prospective registries to document osteonecrosis of the jaw are in development. For example, the Southwest Oncology Group (SWOG), a cancer group that carries out clinical trials within a network of academic and clinical practices, is planning a registry. “In the SWOG study, they will prospectively examine the oral health of individuals with cancer as they begin IV bisphosphonate therapy. They will look at zoledronic acid and follow patients over time to monitor oral health and try to identify specific risk factors,” Van Poznak said.

There has also been a recent call for research proposals to try to generate basic and clinical research in this field, she said.

Communications

Opening communications between dentists and physicians to gain knowledge about osteonecrosis of the jaw is critical to future understanding of the disease.

“Awareness needs to be raised. Should dentists see something that is suspicious for osteonecrosis of the jaw, or diagnosed [as] osteonecrosis of the jaw, the communication between the medical and dental team needs to be fluid,” she said. “The case, suspected or confirmed, should be reported to the FDA through MedWatch.

“I would advocate good communications between medical and dental teams and optimize oral health,” Van Poznak said. “There are a number of basic guidelines within the health care system specifically addressing osteonecrosis of the jaw, including those published in the Journal of Oncology Practice and the Journal of the American Dental Association.”

Maximizing oral hygiene is particularly important in patients prescribed bisphosphonates to decrease the likelihood of developing the disease. Most guidelines recommend that patients should receive an oral evaluation prior to initiation of bisphosphonates, Van Poznak said.

They should be informed that the risk of osteonecrosis of the jaw associated with oral bisphosphonates is generally low and risk-benefit ratio should be reviewed. Routine dental care generally need not be modified. However, if any bone invasive procedures are needed, the risks of osteonecrosis of the jaw should be reviewed, she said.

For more information:

• Van Poznak CH. Medical oncology meets dentistry: osteonecrosis of the jaw. Presented at: 28th Annual Meeting of the American Society for Bone and Mineral Research; Sept. 15-17, 2006; Philadelphia.
• American Dental Association Council of Scientific Affairs. Dental management of patients receiving oral bisphosphonate therapy: expert panel recommendations. J Am Dent Assoc. 2006;137:1144-1150.
• Ruggiero S, Gralow J, Marx R, et al. Practical guidelines for the prevention, diagnosis, and treatment of osteonecrosis of the jaw in patients with cancer. J Oncol Pract. 2006;2:7-14.