In the December JADA cover story by Dr. Cesar Migliorati and colleagues, "Managing the Care of Patients With Bisphosphonate-Associated Osteonecrosis: An American Academy of Oral Medicine Position Paper" (
JADA 2005; 136:1658–68
) the authors state, "Bone turnover becomes profoundly suppressed and, over time, the bone shows little physiologic remodeling.1,2 The bone becomes brittle and unable to repair physiologic microfractures that occur in the human skeleton with daily activity.3,4 In the oral cavity, the maxilla and mandible are subjected to constant stress from masticatory forces.2 Thus, it is expected that physiologic microdamage and microfractures occur daily in the oral cavity. It is theorized that in a patient taking a bisphosphonate, the resulting microdamage is not repaired, setting the stage for oral osteonecrosis to occur.
"The need for repair and remodeling is increased greatly when there is infection in the maxilla or mandible, and/or when an extraction is performed. In some patients using bisphosphonates, the bone is unable to meet these increased needs, both because of its reduced ability to remodel and turn over and because of hypovascularity, which results in osteonecrosis."5,6
This article, and the two related cover articles,7,8 prompt a few questions that I hope the authors will be able to address.
It would seem advisable to tell our patients to stay away from things that require repetitive chewing, such as gum. Additionally, patients should reduce chewing exceptionally hard foods such as nuts and raw carrots. Do you feel this is a valid area of investigation or implementation?
Do you feel that we should put this group of patients on chlorhexidine mouthrinse therapy before the potential onset of a problem, instead of after the problem occurs? The articles presented indicate there is a six- to 18-month period, on average, before a problem starts, depending on which of the two intravenous drugs are used. Should we, therefore, at six months begin prescribing a rinse when the patient is taking pamidronate, and at 18 months for those taking zoledronic acid?
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