Re: Bisphosphonates and osteonecrosis - from an OMFS
From: Rafael Haciski (haciski@earthlink.net)
Mon Jun 5 00:25:11 2006
Isn't that a bit of an emotional response, and an illogical one at that?
Being fully cognizant of the unpleasantness of osteonecrosis, and
also acknowledging the probable underreporting of the incidence, the
facts remain:
... ONJ is an exceedingly RARE event, (my understanding of the
reported incidents is that there were approx. 6 cases out of 300 who
were taking oral bisphosphonates, the rest were on IV);
... the denominator are the millions of patients on oral bisphosphonates
... on the other hand, the incidence of bone fractures related to
osteoporosis is close to 1,500,000 per year in the US
... in menopause, fatalities due to complications of hip fracture
reach 30% within the year of fx
... Evista, HRT carry also the risk of DVT (you do not like what
osteonecrosis may feel like, but how about drooling out of your
mouth, being a paralyzed vegetable due to DVT?)
If your logic were sound in trying to avoid this exceedingly uncommon
complication, then you should avoid the much more common risks of
other medications you mention, and indeed, you probably should stay
at home and never venture out, as driving is the single most
dangerous activity we undertake. Yet we choose to do it every day.
We really have to moderate our knee jerk reactions, especially as
those reactions filter out to the public who become totally confused
by our fears and lack of understanding. WHI comes to mind - the
premature release of incompletely digested and understood data caused
much confusion and has been a disservice to our patients, and an
added burden to us trying to explain to our patients what is going on
and what they should do.
At present, all I can tell my patients are the risks as we best
understand them of BOTH sides of the equation, and let them choose.
--
Rafael Haciski MD FACOG
Palmetto, FL
On Jun 4, 2006, at 2:59 PM, 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
