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The second group of medications is without the nitrogen side chain; and are considered less
potent. This category includes etidronate, clodronate, and tiludronate.
Bisphosphonates induce osteoclast cell death by formation of cytotoxic metabolites of ATPbisphosphonate analogs that interfere with intracellular metabolic enzymes. These medications
are widely used among many medical disciplines with remarkable improvement in the overall
quality of life in several conditions, including osteoporosis, Paget's disease, otosclerosis,
immobilization due to malignancy-related hypercalcemia, fibrous dysplasia and osteolytic bone
lesions of malignant myeloma and malignant diseases in which bone resorption is the main
component of the disease.
Reports of Bisphosphonate-Related Osteonecrosis of the Jaw (BRONJ) were recognized as early
as 2003. Currently, the American Academy of Oral & Maxillofacial Surgeons (AAOMS) define
BRONJ as
1. Current or previous treatment with a bisphosphonate;
2. Exposed, necrotic bone in the maxillofacial region that has persisted for more than eight
weeks; and
3. No history of radiation therapy to the jaws.
BRONJ may be mistaken for several other conditions including alveolar osteitis, sinusitis,
gingivitis/periodontitis, caries, periapical pathology and TMJ disorders.
Overall, the risk of developing BRONJ is estimated to be between 0.01% and 34%. Increased
risk of developing BRONJ is increased with the potency of the medications and the duration of
the therapy. Additionally, dentoalveolar surgery, extraction, dental implants, periapical, and
other jaw surgeries are known local risk factors in causing the disease.
Optimum OHI should be always emphasized, at all times, whether the patient is on or
will be taking the medication. Patients who report history of diabetes, alcohol and
tobacco usage taking corticosteroids or those receiving chemotherapeutic agents are
considered at higher risk for developing BRONJ.
Prior to treatment with IV bisphosphonates, a thorough oral examination with extraction
of unsalvageable teeth, as well as the performance of any other invasive surgical
procedures, should be completed.
Discontinuation of oral bisphosphonates for a period of three months prior to and three
months following elective invasive dental surgery may lower the risk of BRONJ. It is
important, however, to remember that this medication is given for the presence of
advanced metastatic carcinoma and multiple myeloma, among other serious conditions.
Additionally, responses to discontinuing the medication vary with no concrete
guarantees.