Abstract
Objective
Following publication of the first reports of osteonecrosis of the jaw (ONJ) in patients receiving bisphosphonates in 2003, a call for national multidisciplinary guidelines based upon a systematic review of the current evidence was made by the Canadian Association of Oral and Maxillofacial Surgeons (CAOMS) in association with national and international societies concerned with ONJ. The purpose of the guidelines is to provide recommendations regarding diagnosis, identification of at-risk patients, and prevention and management strategies, based on current evidence and consensus. These guidelines were developed for medical and dental practitioners as well as for oral pathologists and related specialists.
Methods
The multidisciplinary task force established by the CAOMS reviewed all relevant areas of research relating to ONJ associated with bisphosphonate use and completed a systematic review of current literature. These evidence-based guidelines were developed utilizing a structured development methodology. A modified Delphi consensus process enabled consensus among the multidisci-plinary task force members. These guidelines have since been reviewed by external experts and endorsed by national and international medical, dental, oral surgery, and oral pathology societies.
Results
Recommendations regarding diagnosis, prevention, and management of ONJ were made following analysis of all current data pertaining to this condition. ONJ has many etiologic factors including head and neck irradiation, trauma, periodontal disease, local malignancy, chemotherapy, and glucocorticoid therapy. High-dose intravenous bisphosphonates have been identified as a risk factor for ONJ in the oncology patient population. Low-dose bisphosphonate use in patients with osteoporosis or other metabolic bone disease has not been causally linked to the development of ONJ. Prevention, staging, and treatment recommendations are based upon collective expert opinion and current data, which has been limited to case reports, case series, surveys, retrospective studies, and 2 prospective observational studies. Recommendations: In all oncology patients, a thorough dental examination including radiographs should be completed prior to the initiation of intravenous bis-phosphonate therapy. In this population, any invasive dental procedure is ideally completed prior to the initiation of high-dose bisphosphonate therapy. Non-urgent procedures are preferably delayed for 3 to 6 months following interruption of bisphosphonate therapy. Osteoporosis patients receiving oral or intravenous bisphosphonates do not require a dental examination prior to initiating therapy in the presence of appropriate dental care and good oral hygiene. Stopping smoking, limiting alcohol intake, and maintaining good oral hygiene should be emphasized for all patients receiving bisphos-phonate therapy. Individuals with established ONJ are most appropriately managed with supportive care including pain control, treatment of secondary infection, removal of necrotic debris, and mobile sequestrate. Aggressive debridement is contraindicated.
Conclusion
Our multidisciplinary guidelines, which provide a rational evidence-based approach to the diagnosis, prevention, and management of bisphosphonate-associated ONJ in Canada, are based on the best available published data and the opinion of national and international experts involved in the prevention and management of ONJ.
Key Indexing Terms:Footnotes
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Supported by the Oral and Maxillofacial Surgery Foundation of Canada and the Calcium Disorders Clinic at Joseph’s Healthcare, McMaster University.
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A.A. Khan, MD, FRCPC, FACP, FACE, Professor of Clinical Medicine, Divisions of Endocrinology and Geriatrics, McMaster University; G.K.B. Sándor, MD, DDS, PhD, FRCDC, FRCSC, FACS, Professor and Head of Oral and Maxillofacial Surgery, Director, Graduate Training Programme in Oral and Maxillofacial Surgery and Anesthesia, University of Toronto, Coordinator of Pediatric Oral and Maxillofacial Surgery, The Hospital for Sick Children and Bloorview Kids Rehabilitation, Professor, Regea Institute for Regenerative Medicine, University of Tampere, and Dosent in Oral and Maxillofacial Surgery, University of Oulu; E. Dore, DDS, Oral and Maxillofacial Surgery, Assistant Clinical Professor, Faculty of Health Sciences, McMaster University; A.D. Morrison, DDS, MSc, FRCD(C), Department of Oral and Maxillofacial Sciences, Faculty of Dentistry, Dalhousie University; M. Alsahli, MD, Fellow in Endocrinology, Department of Medicine, Division of Endocrinology and Metabolism, University of Rochester School of Medicine; F. Amin, BHSc; E. Peters, DDS, MSc, FRCD(C), Professor, Oral Pathology and Oral Medicine, Department of Dentistry, Faculty of Medicine and Dentistry, University of Alberta; D.A. Hanley, MD, FRCPC, Professor, Departments of Medicine, Community Health Sciences, and Oncology, Division of Endocrinology and Metabolism, University of Calgary Health Sciences Centre; S.R. Chaudhry, BHSc; D.W. Dempster, PhD, Professor of Clinical Pathology, Columbia University, Director, Regional Bone Center, Helen Hayes Hospital; F.H. Glorieux, OC, MD, PhD, Professor of Surgery, Pediatrics, and Human Genetics, McGill University, Director of Research, Genetics Unit, Shriners Hospital for Children; A.J. Neville, MD, MBChB, MEd, Professor, Departments of Oncology and Medicine, Assistant Dean, Undergraduate MD Program, Michael G. DeGroote School of Medicine, McMaster University; R.M. Talwar, DDS, PhD, Division of Oral and Maxillofacial Surgery, University of Toronto; C.M. Clokie, DDS, PhD, CRCDC, Professor, Division of Oral and Maxillofacial Surgery and Anesthesia, Mount Sinai Hospital, University of Toronto; M. Al Mardini, DDS, University of Rochester Eastman Dental Center; T. Paul, MSc, MD, FRCPC, Assistant Professor, Divisions of Encocrinology and Metabolism, Department of Medicine, Schulich School of Medicine and Dentistry, The University of Western Ontario; S. Khosla, MD, Professor of Medicine, College of Medicine, Mayo Clinic; R.G. Josse, BSc, MB, BS, FRCP, FRCPC, FACP, FACE, Medical Director, Osteoporosis Centre, Division of Endocrinology and Metabolism, St. Michael’s Hospital, Professor of Medicine, University of Toronto; S. Sutherland, DDS, MSc, FRCDC; D.K. Lam, DDS, Division of Oral and Maxillofacial Surgery and Anesthesia, Mount Sinai Hospital, University of Toronto; R.P. Carmichael, DMD, MSc, FRCDC, Chief of Dentistry, Bloorview Kids Rehabilitation, Hospital for Sick Children; N. Blanas, DDS, FRCDC, Women’s College Health Sciences Centre and Faculty of Dentistry; D. Kendler, MD, FRCPC, Associate Professor of Medicine, University of British Columbia, Past President, International Society for Clinical Densitometry; S. Petak, MD, JD, Texas Institute for Reproductive Medicine and Endocrinology, Clinical Faculty, University of Texas Medical School at Houston; L.G. St-Marie, MD, CSPQ, Endocrine Service and Centre de recherche du Centre hospitalier de l’Université de Montréal; J. Brown, MD, FRCPC; A.W. Evans, DDS; L. Rios, MD; J.E. Compston, Professor of Bone Medicine, University of Cambridge, Department of Medicine, School of Clinical Medicine and Addenbrooke’s NHS Trust.
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