Patients taking oral bisphosphonates bear a risk of developing nonhealing exposed bone (bisphosphonate-induced osteonecrosis) following an invasive oral surgical procedure and present a challenge to the practitioner managing such osteonecrosis once it develops. Oral bisphosphonate–induced osteonecrosis of the jaws differs significantly from intravenous bisphosphonate–induced osteonecrosis: the osteonecrosis from oral bisphosphonates—primarily alendronate, (Fosamax) and to a lesser degree residronate (Actonel)—is less severe, more responsive to therapy, and its risk is predictable. Moreover, its incidence is judged to be 0.007% to 0.01% as compared to 0.8% to 12% for intravenous bisphosphonate–induced osteonecrosis. This presentation describes a simple blood test that can be used to assess the risk of patients on oral bisphosphonate therapy for developing osteonecrosis before they undergo any elective oral surgical procedures. This test can also be used in patients with established oral bisphosphonate–induced osteonecrosis and those who have not yet begun a prescribed course of bisphosphonate therapy to guide decision-making about the appropriateness of recommending a “drug holiday” to the patient’s treating physician or the timing of necessary dental procedures. Specific protocols for managing patients with exposed bone and recommendations for preventive measures will also be presented.
Robert E. Marx, DDS, is professor of surgery and chief of the Division of Oral and Maxillofacial Surgery at the University of Miami School of Medicine. His areas of research include the use of hyperbaric oxygen following radiation therapy, the development of platelet-rich plasma, and the relationship between smoking and carcinogenesis. Dr Marx has received numerous awards, including the Harry S. Archer Award, the William J. Gies Award, the Paul Bert Award, and the Donald B. Osbon Award. His recent textbook, Oral and Maxillofacial Pathology: A Rationale for Diagnosis and Treatment (Quintessence, 2002), won the American Medical Writers Association’s Best Medical Book of the Year Award for 2003.