Re: Bisphosphonates and osteonecrosis - from an OMFS
From: Garry E. Siegel, M.D. (garrys@mindspring.com)
Sun Jun 4 14:50:07 2006
Dr. Goldman:
A well thought out post that is so informative for us is deeply
appreciated.
Garry
At Sun, 4 Jun 2006, Meenan, Anna wrote:
>
>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
--
Garry E. Siegel, M.D.
Private Practice
Roswell, GA
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