Managing the care of patients with bisphosphonate-associated osteonecrosis: an American Academy of Oral Medicine position paper

Abstract

Background: This position paper addresses the prevention of bisphosphonate-associated osteonecrosis (BON) and the management of care of patients with cancer and/or osteoporosis who are receiving bisphosphonates and who have BON or are at risk of developing it.

Methods: The authors reviewed the literature available on this newly described oral complication. Information of interest included bisphosphonates, the medications associated with this oral complication; the patient population at risk of developing BON and the diseases being treated with this class of medications; the clinical presentation of the oral lesions; guidelines for managing the care of patients who develop BON; the prevention of this complication based on current knowledge; and recommendations for routine dental treatment of patients receiving bisphosphonates.

Results: There is strong evidence that bisphosphonate therapy is the common link in patients with BON. The pathobiological mechanism leading to BON may have to do with the inhibition of bone remodeling and decreased intraosseous blood flow caused by bisphosphonates. People at risk include patients with multiple myeloma and patients with cancer metastatic to bone who are receiving intravenous bisphosphonates, as well as patients taking bisphosphonates for osteoporosis. The risk of developing complications appears to increase with time of use of the medication. There are no guidelines based on evidence, and the clinical management of the oral complication is based on expert opinion.

Conclusion: Prevention of BON is the best approach to management of this complication. Existing protocols to manage the care of patients who will receive radiation therapy or chemotherapy may be used until specific guidelines for BON are developed.