Risk assessment of Bisphosphonate-Related Osteonecrosis of the Maxilla and Mandible

OBJECTIVE: To review the risk of osteonecrosis of the maxilla and mandible.

METHODS: A MEDLINE SEARCH (1996-September 2007). Search terms were avascular necrosis, diphosphonates, bisphosphonates, and osteonecrosis.

STUDY SELECTION AND DATA EXTRACTION: Articles associated with bisphosphonate-related osteonecrosis (BONJ) of the mandibular and maxillary jaws were reviewed and summarized. Inclusion criteria required that articles have a case report or case series study design. The modes of administration for bisphosphonates were oral and intravenous (IV). The primary diseases for therapy were metabolic bone diseases and skeletal metastatic solid tumors such as multiple myeloma and cancers of the breast, lung and prostate. Exclusion criteria were cases not identifying initialing events, type and mode of administration of bisphosphonates, and primary diseases. The research question was concerned with the association of local and systemic risk factors and the development of BONJ.

RESULTS: There were 211 cases with an age range of 36 to 89 years. Females (62.1%) out numbered males (37.9 %). Dental extractions (22 %) were the major precipitating event. The mandible was affected (52.6 %) of the time. There were 15 diseases indicated for bisphosphonate therapy. The duration of IV bisphosphonate therapy with the highest frequency of BONJ was 36 months. The primary diseases for skeletal metastatic solid tumors requiring bisphosphonate therapy were multiple myeloma (39 %) and breast cancer (34.1 %). The mandible (52.6 %) was the most frequent location for BONJ. The precipitating drugs were IV administrations. The most prescribed bisphosphonates were Pamidronate (35.5 %), Zoledronate (35.5%) and Pamidronate/Zoledronate (20.8 %).

CONCLUSIONS: The primary cause for BONJ was IV Pamidronate/Zoledronate therapy for multiple myeloma and breast cancer. The mandible was the primary site of occurrence for BONJ. Dental extractions were the primary precipitating event for BONJ. New clinical protocols are needed to control the impact of dentoalveolar interventions.