Risk of osteonecrosis of the jaw in cancer patients taking bisphosphonates

PURPOSE: The risk of osteonecrosis of the jaw (ONJ) associated with bisphosphonate use in patients with cancer is reviewed. SUMMARY: ONJ is a relatively new complication of supportive care in cancer. Bisphosphonate-associated ONJ can be generally defined as necrotic bone exposure to the oral cavity and inflammatory reactions of the surrounding soft tissue in patients receiving bisphosphonates but not radiotherapy to the head and neck. The risk of development of ONJ varies with the type of bisphosphonate used and the duration of exposure, with more potent agents increasing the risk with shorter durations of exposure. From the current evidence, the incidence of this disorder in cancer patients receiving bisphosphonates can be as high as 10% when patients have more than one risk factor. Risk factors include type of bisphosphonate, duration of exposure, concomitant medications, comorbidities (e.g., hypertension, dyslipidemia, diabetes, rheumatoid arthritis, lupus), and lifestyle behaviors (e.g., smoking, obesity). To minimize the risk of ONJ, patients initiated on bisphosphonates should optimize routine dental care and have their baseline oral cavity status evaluated by both clinical and radiographic examinations before initiation of bisphosphonate therapy. Current management of ONJ is difficult and empirical. At present, a conservative approach is recommended, including systemic antibiotics, antiseptic oral rinses, pain control, and limited debridement. CONCLUSION: Cancer patients receiving bisphosphonates are at risk for developing ONJ. Clinicians should evaluate patients' oral integrity and existing risk factors before initiating bisphosphonate therapy. Once treatment is started, patients should be closely monitored for signs and symptoms of ONJ.