Re: Bisphosphonates and osteonecrosis - from an OMFS
From: Meenan, Anna (annam@uic.edu)
Sun Jun 4 13:57:17 2006
Thank you so much for posting, Kim. Those have kind of been my gut
feelings since this story broke, and as a 52 y.o. thin, half-Danish
woman with a family history of osteoporosis and a T-score of minus
1.8 (4 years ago, and I'm too chicken to get another BMD now), this
affects me personally. I've really been in a quandary, because I
know it's gong to come up at my next annual. I also have an extreme
case of dentalphobia, and even the thought of someone digging dead
pieces of bone out of my jaw gives me the creeps.
Anna Meenan, MD
>I noted with interest that this topic is being discussed in OB-GYN
>forums and thought I would share what little we actually do know about
>this phenomenon. It is, unfortunately, very little but, as many of you
>have pointed out, the attorneys are ALL on to this already. It has been
>relatively well known in the oral surgery community for several years
>now but seems, only recently to have disseminated beyond that relatively
>small group of health care providers.
>
>1. Bisphosphonate related osteonecrosis (BRON) occurs in a very small
>percentage of patients on bisphosphonates but when it does occur it can
>be devastating.
>2. BRON is more common in patients receiving IV bisphosphonates but
>ABSOLUTELY DOES OCCUR in patients on oral medications only for the
>prevention of or treatment of osteoporosis.
>3. In many cases there is some minor oral injury (tooth extraction,
>denture sore, etc.) which precipitates the disease BUT THERE ARE ALSO
>CASES WHERE THIS OCCURS SPONTANEOUSLY.
>4. Taking patients off bisphosphonates may not lower their risk for an
>extended period of time or at all. We just don't know. We do know that
>bisphosphonates have a very long half life in bone.
>5. As of yet, there is no clear consensus on treatment though there is
>a great deal of work being done on clarifying and stratifying treatment
>modalities. It is still, quite often, a disease with extreme morbidity
>when it occurs.
>
>I believe that we will see increasing numbers of these cases reported.
>
>Personally, I have looked backward through my own cases and know of at
>least one case in the late 90's which must have been BRON. History is
>as follows. Otherwise healthy female (nurse at our hospital actually)
>in her late 50's whose only medication was a bisphosphonate. Saw her
>dentist, had tooth extracted, site didn't heal, tx'd with abx without
>resolution, referred to OMFS, multiple debridements without healing,
>referred to our teaching hospital where multiple services including ID
>were involved, workup for immune deficiency was negative, PICC line and
>long term abx failed to resolve issue....long story short she eventually
>lost almost half of her lower jaw.
>
>Since that time I have seen, treated or had colleagues in our practice
>treat several other cases. While the occurences are still relatively
>rare, as I stated before, when it is you or your patient, it is
>devastating.
>
>I am often asked by patients now what they should do about these drugs
>and my personal suggestions to patients at this point are as follows:
>
>First I share with them how little we actually know about this problem.
>For patients who will understand, I also provide copies of some of the
>landmark papers on the issue (Ruggerio et. al, Marx et. al.) I then
>share the following personal philosophies.
>
>1. No matter what your age now is the time to increase calcium intake,
>increase exercise and healthy life style choices, build bone mass now to
>prevent problems later.
>2. I would not personally take a bisphosphonate for prevention of
>osteoporosis.
>3. If I were already diagnosed with osteopenia or osteoporosis, I would
>look into nonbisphosphonate modalities such as Evista and HRT.
>4. IF *I* were on bisphosphonates I would discontinue them even knowing
>that we don't know if this is helpful or reduces risk long term.
>Teleologically it seems unlikely to reduce short term risk given the
>long half life of these drugs.
>5. For cancer patients who will be placed on IV bisphosphonates I urge
>restoration of dental health prior to beginning these drugs (as is also
>advised prior to beginning chemotherapy or XRT)and patient education to
>understand the risks/benefits of such drugs in these cases.
>6. I encourage patients to discuss these issues with the health care
>provider who is suggesting or prescribing bisphosphonates and always
>offer to discuss the OMFS literature and experience with those providers
>so that together with their health care providers they can make the best
>decision for their individual case.
>
>--
>Kim E. Goldman, D.M.D.
>Associates in Oral & Maxillofacial Surgery, PLC
>Asst. Clin. Prof. University of Louisville
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