Bisphosphonate-Related Osteonecrosis of the Jaw

Bisphosphonate-related osteonecrosis of the jaw (BRONJ) adversely affects the quality of life and produces significant morbidity in afflicted patients. Oral and maxillofacial surgeons have been responsible for counseling, managing, and treating a majority of these patients. The strategies set forth in this position paper were developed by a Task Force appointed by the American Association of Oral and Maxillofacial Surgeons (AAOMS). The Task Force was composed of clinicians with extensive experience in caring for these patients, clinical epidemiologists, and basic science researchers offering a broad range of experience and background. The strategies are based on an analysis of the existing literature and the clinical observations of the expert Task Force members. AAOMS considers it vitally important that this information be disseminated to other dental and medical specialties. It is understood that the strategies and treatment algorithms outlined in this article are starting points based on our current understanding of BRONJ. As the knowledge base and experience in addressing BRONJ evolves, future modifications and refinements of the current strategies will necessarily be required.

Purpose

The purpose of this position paper is to provide:

• Perspectives on the risk of developing BRONJ and the risks and benefits of bisphosphonates in order to facilitate medical decision-making of both the treating physician and the patient;
• Guidance to clinicians regarding the differential diagnosis of BRONJ in patients with a history of treatment with intravenous (IV) or oral bisphosphonates; and
• Guidance to clinicians on possible BRONJ prevention measures and management of patients with BRONJ based on the presenting stage of the disease.

Cheek and tongue biting

Patient: RHONDA H

Chief complaint:

-Rhonda complains of biting the inside of her cheek on the left side and this annoys her. Cannot bite into an apple.

-Her husband says she has a somewhat “grumpy” appearance, lower lip in front of upper lip and biting upper lip

 

History of chief complaint:

-Sore mouth for approx 4 years, sometimes biting tongue as well

-Rhonda has sought 3 other opinions. Dr Calavassy was the first to come up with a definitive treatment plan

 

Rhonda would like to get rid of cheek and tongue biting and if we could eliminate “grumpy” look (partly due to lower jaw protrusion) it would be good

 

Medical History:

-Numerous joint replacement surgeries…both hips, both knees, both shoulders

-NO TMJ clicking, crepitus or pain

-Uses a walking stick

 

Extraoral examination:

-Class 111 skeletal with mandibular protrusion

-Mild deviation of mandible to right when viewed from the front

-Excessive submental fat

 

Intraoral examination:

-Class 111 malocclusion

-Numerous restorations (generally sound), 17 may need some attention

-Overcontoured restorations on distal of 34 and 45 (intentional)

-Generalised slacing lower arch

-Very slight forward functional shift of mandible CR to CO

-Negative overjet 1 mm in CR

-Signs of some wear/bruxing

 

Periodontal examination:

-Probing levels normal

-Marginal gingivitis 32, 44

-1-2 mm recession 34 44

 

Radiographic examination:

-Lateral Ceph: Mandibular prognathism

-OPG/bite wings/periapicals: Generally good