Relevance of a prolonged preoperative antibiotic regime in the treatment of bisphosphonate-related osteonecrosis of the jaw

Abstract

Purpose: Bisphosphonate-related osteonecrosis of the jaw (BRONJ) is a severe and therapy-resistant disease. The present study was performed to evaluate the role of the duration of preoperative antibiotic therapy within an otherwise standardized treatment protocol of patients with BRONJ stages I and II. One group of patients received a short-term preoperative antibiotic regime (A-ST) and the other a long-term preoperative antibiotic regime (B-LT).

Patients and methods: A retrospective chart review was used to analyze 46 patients with BRONJ from 2004 to 2009 who were treated with the same surgical technique and the same postoperative antibiotic treatment. Ten patients were classified as stage I, and 37 as stage II. All patients had intravenous bisphosphonate therapy in their case histories. Surgical treatment included an extended surgical procedure with sequestrectomy, bone smoothing, tension-free tissue covering, and drainage, with attention to neighboring teeth. After surgery, antibiotics were given (median) for 7 days intravenously and orally for another 10 to 12 days. Only patients who fulfilled these criteria were included in the retrospective chart review. In group A-ST 16 patients with 17 operations received antibiotics for 1 to 8 days before operation, whereas in group B-LT 30 patients had preoperative therapy of 23 to 54 days. Postoperative clinical examination followed a standardized protocol. Complete healing with intact soft tissue coverage was regarded as a success.

Results: The mean follow-up in both groups was 17.4 months (median, 11.5 months). Within the overall observation period, only 35% of patients in group A-ST and 70% in group B-LT showed complete healing, but at the time of the last clinical examination, 53% in group A-ST and 87% in group B-LT were free of soft tissue dehiscence. A certain number of soft tissue dehiscences within the observation period could clearly be related to later tooth extractions or pressure sores of dentures; excluding these interfering problems, 47% in group A-ST and 87% in group B-LT were treated successfully. Differences between these groups were significant.

Conclusions: This study indicates that surgical treatment in patients with stage I BRONJ and especially in those with stage II BRONJ in combination with a long-term preoperative antibiotic treatment can lead to a complete healing in 70% to 87% of cases in contrast to 35% to 53% with a short-term regime. The higher success rate after prolonged preoperative antibiotic therapy may be linked to an infectious role in BRONJ etiology requiring adequate treatment. Antibiotics may effectively treat neighboring lightly infected bone, whereas surgery removes the irreversibly infected and necrotic bone. To achieve complete healing, an extended surgical procedure in combination with local mouth rinses and prolonged antibiotic therapy can be recommended for treatment of BRONJ.