Dr.

Nader Elbokle, DDS, MSc, PhD

( Emory University and Medical college of Georgia, USA) A. Professor Maxillofacial Surgery, Cairo University, Head of Department, Maxillofacial surgery, MSA University Chairman & CEO Esthetica Hospital

Definition: A condition characterized by exposure of bone in the mandible or the maxilla for more than 8 weeks in a patient who has taken or currently taking a bisphosphonate and who has no history of radiation therapy of the jaws.

Dearden in 1899 described phosphate miners and match-factory workers in the US and Britain as developing non healing bone exposures in the mouth only, particularly those exposed to the heated phosphate vapors. (Phossy jaw).

100 years later, described by Marx and Stern in 2002 as a curious finding.

Later Marx in 2003 described 36 cases associated with IV bisphospohonates (Zometa).

Novartis company in their original clinical trial on 3600 patient had flaws in that they failed to inspect or look at exposed bone in the mouth before and after bisphosphonates therapy.

A study conducted at Miami University showed 180 cases of BRONJ as a result of Fosamax, 127 IV and 53 oral form. Over 1100 additional reports and 14 position papers have been written on BRONJ or BIONJ

1 in 3 women over 50 will suffer a fracture due to osteoporosis; this increases to 1 in 2 over 60. There are more than 14 million women in the US alone treated annually for osteoporosis with oral bisphosphonates. Bisphosphonates act by inhibiting bone resorption and hence bone turnover

Repeated doses of bisphosphonates accumulate in the bone matrix and are taken up by the osteoclast leading to cell apoptosis. The osteoclast lose its ruffled borders at howships lacunae and retract from the bone surface and die.

Without bone resorption, old bone is not removed and survives far beyond the programmed lifespan. Osteocyte is not an immortal cell, it eventually dies leaving dead bone behind.

Clinically presents as spontaneous exposure of alveolar bone or following dental surgical procedure such as tooth extraction or implant placement. This disease manifests itself in the jaws and has not been reported in other skeletal areas. Recent reports have identified femur fractures as caused by long term use of alendronate (Fosamax).

Usually it starts in the alveolar bone, then extends to the basilar bone or ramus. Early subclinical radiographic signs include: sclerosis of the lamina dura, loss of the lamina dura, and widening of periodontal ligament space especially in molars.

Why Alveolar bone?

Dixon et al in 1997 documented the rate of bone turnover at various sites: Alveolar bone remodels 10 times the rate of the tibia, and 5 times the rate of the mandible at the inferior border. Thus a greater uptake of bisphosphonates and readily accumulates at higher concentrations than any other bone

Alveolar bone can no longer respond to new bone formation from osteoclastic bone resorption followed by new bone formation and becomes necrotic.

Overlying mucosa becomes deprived of its blood supply, breaks down leading to exposed bone.

Stage 1: Characterized by exposed bone that is asymptomatic, with no evidence of significant soft-tissue inflammation

Stage 2: Exposed bone associated with pain, soft-tissue and/or bone inflammation or infection

Stage 3:

pathologic fracture; exposed bone associated with soft tissue inflammation/infection or pain that is not responsive to antibiotics; extraoral fistula.

Treatment Objectives in the Management of BRONJ

Eliminate pain
Manage or eliminate infection

Prevent additional exposure/necrosis

Treatment Recommendations-All patients (all stages) with established BRONJ

Consultation between OMSs, general dentists and the treating physician is strongly recommended Superficial bony debridement to reduce sharp surfaces and prevent further trauma to adjacent soft tissues

Protect exposed bone or adjacent tissues; a removable appliance or protective stent may be used
Avoid invasive dental procedures where possible

Concern over dental implants being contraindicated in patients with osteoporosis This is based on the assumption that osteoporosis affects the jaws in the same way as it affects other parts of the skeleton, such as the lumbar spine, femur, neck and forearm.

Earlier animal studies have described the deleterious effect of osteoporosis on the osseointegration process, mainly with regard to trabecular bone volume.

Osteoporosis acts on peri-implant bone is based on the decrease in both cancellous bone volume and bone-to implant contact, consequently reducing the bone tissue available to support dental implants

Recent papers / clinical trials and histomorphometric studies suggest that osteoporosis may not present a contraindication for implant placement, at least once osseointegration has been established.