Guidelines for the diagnosis of bisphosphonate-related osteonecrosis of the jaw (BRONJ)

Abstract

Bisphosphonates are a class of agents used to treat osteoporosis and malignant bone metastases. Despite these benefits, osteonecrosis of the jaws has recently emerged as a significant complication in a subset of patients receiving these drugs. Based on a growing number of case reports and institutional reviews, bisphosphonate therapy may cause exposed and necrotic bone that is isolated to the jaw. This complication usually presents following simple dentoalveolar surgery and can cause a significant adverse effect on the quality of life for most patients. The pathogenesis for this complication appears to be related to the profound inhibition of osteoclast function and bone remodeling. This report will review the clinical signs and symptoms and risks associated with this new complication and provide a guideline for establishing a stage-specific diagnosis of BRONJ.

Figure 1

A non-healing extraction site in a patient with a history of intravenous bisphosphonate exposure.

Figure 2

An area of exposed, necrotic bone that appeared spontaneously (i.e. no history of trauma) on the medial aspect of the mandible.

Figure 3

Extra-oral draining fistula at the submental region of the jaw in a patient with stage 3 BRONJ.

Figure 4

Coronal CT of the right maxillary sinus demonstrating necro-sis of the maxillary alveolar ridge and sinusitis.

Figure 5

Resected right hemi-mandible in a patient with stage 3 BRONJ. Note the extensive amount of necrosis throughout the ramus and body region of the mandible.

Figure 6

Panoramic radiograph demonstrating a region of osteolysis at the right mandibular angle region.

Figure 7

Panoramic radiograph demonstrating a pathologic fracture of the right parasymphysis region of the mandible in a patient with metastatic breast and stage 3 BRONJ.