Osteonecrosis of the jaw (ONJ): diagnosis and management in 2015

Abstract

Osteonecrosis of the jaw (ONJ) has been associated with the use of aminobisphosphonates and denosumab. The vast majority (>90 %) of cases occur in the oncology patient population receiving high doses of intravenous bisphosphonates or subcutaneous denosumab. The incidence of ONJ in the osteoporosis patient population is very low and is estimated at 1–90 per 100,000 patient-years of exposure. In the oncology patient population the incidence appears to be related to dose and duration of exposure, and prevalence has been estimated to be as high as 18.6 %. A number of risk factors in addition to antiresorptive therapy have been identified. These include the presence of periodontal disease, oral surgical procedures with extractions or implants, radiation therapy, chemotherapy, diabetes, glucocorticoid use, and smoking. Antiangiogenic agents appear to contribute to the risk of ONJ, however, data at this time are limited and further evidence is required prior to confirming a causal relationship. ONJ may be prevented with optimization of oral hygiene, the use of oral antimicrobial mouth rinses, as well as systemic antibiotic therapy. Individuals not responding to conservative management or in the advanced stages of ONJ may be considered for surgery, as data over the past several years have demonstrated surgical success in this patient population. Case reports have indicated that teriparatide may enhance healing. A number of experimental therapies are being evaluated and include the use of bone marrow stem cell intralesional transplantation, local application of platelet-derived growth factor, hyperbaric oxygen, tissue grafting, and low-level laser therapy. This paper summarizes the current research as well as the international consensus on the diagnosis and management of ONJ.

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Correspondence to A. Khan.

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Conflicts of interest

I, Dr. Aliya Khan would like to declare that I am a member of the advisory board with Amgen and Lilly. I have received honorarium from Amgen and Lilly. I am currently participating in a clinical trial with Amgen and Merck; I have recently completed a clinical trial for NPS pharmaceuticals.

I, Dr. Archie Morrison would like to confirm that I have no conflicts of interest.

I, Dr. Angela Cheung would like to declare that I received honoraria and grants (to institution) from Amgen and Eli Lilly.

I, Dr. Juliet Compston would like to confirm that I have no conflicts of interest.

I, Dr. Waleed Hashem would like to confirm that I have no conflicts of interest.

Members of the International Osteonecrosis of the Jaw Task Force

A.A. Khan, Department of Medicine, Divisions of Endocrinology and Metabolism and Geriatrics, McMaster University, Hamilton, ON, Canada

A. Morrison, Division of Oral and Maxillofacial Surgery, Dalhousie University, Halifax, NS, Canada

D.A. Hanley, Departments of Medicine, Community Health Sciences and Oncology, University of Calgary, Calgary, AB, Canada

D. Felsenberg, Centre of Muscle & Bone Research, Charité-University Medicine Berlin, Campus Benjamin Franklin, Free University & Humboldt-University Berlin, Berlin, Germany

L.K. McCauley, Department of Periodontics and Oral Medicine, University of Michigan School of Dentistry, Ann Arbor, MI, USA

F. O’Ryan Kaiser, Permanente Medical Center, Oakland, CA, USA

I.R. Reid, Department of Medicine, University of Auckland, Auckland, New Zealand

S. Ruggiero, New York Center for Orthognathic and Maxillary Surgery, Lake Success, NY, USA

A. Taguchi, Department of Oral and Maxillofacial Radiology, School of Dentistry, Matsumoto Dental University, Shojiri, Japan

S. Tetradis, Division of Diagnostic and Surgical Sciences, UCLA School of Dentistry, Los Angeles, CA, USA

N.B. Watts, Mercy Health Osteoporosis and Bone Health Services, Cincinnati, OH, USA

M.L. Brandi, Department of Surgery and Translational Medicine, University of Florence, Florence, Italy

E. Peters, University of Alberta, Edmonton, Alberta, Canada

T. Guise, Department of Medicine, Division of Endocrinology at Indiana University, Indianapolis, IN, USA

R. Eastell, Department of Human Metabolism, University of Sheffield, Sheffield, UK

A.M. Cheung, University of Toronto, Toronto, ON, Canada

S.N. Morin, Department of Medicine, McGill University, Montreal, Quebec, Canada

B. Masri, Jordan Osteoporosis Center, Jordan Hospital & Medical Center, Amman, Jordan

C. Cooper, MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton, UK; NIHR Nutrition Biomedical Research Centre, University of Southampton, Southampton, UK; NIHR Musculoskeletal Biomedical Research Unit, University of Oxford, Oxford, UK

S. Morgan, University of Alabama at Birmingham Osteoporosis Prevention and Treatment Clinic, Division of Clinical Immunology and Rheumatology, Birmingham, AL, USA

B. Obermayer-Pietsch, Medical University Graz, Div. Endocrinology and Metabolism, Department of Internal Medicine, Graz, Austria

B.L. Langdahl, Department of Endocrinology and Internal Medicine, Aarhus University Hospital, Aarhus, Denmark

R. Al Dabagh, Faculty of Dentistry , University of Toronto, Toronto, Canada

K.S. Davison, Department of Graduate Studies, University of Victoria, Victoria, BC, Canada

D. Kendler, Department of Medicine, Division of Endocrinology, University of British Columbia, Vancouver, BC, Canada

G.K. Sándor, Department of Oral and Maxillofacial Surgery, Oulu University Hospital, University of Oulu, Oulu, Finland

R.G. Josse, Division of Endocrinology and Metabolism, University of Toronto, Toronto, ON, Canada

M. Bhandari, Division of Orthopaedic Surgery, Department of Surgery and Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON, Canada

M. El Rabbany, Faculty of Dentistry, University of Toronto, Toronto, ON, Canada

D.D. Pierroz, International Osteoporosis Foundation (IOF), Nyon, Switzerland

R. Sulimani, College of Medicine, King Saud University, Riyadh, Saudi Arabia

D.P. Saunders, Department of Dental Oncology, Northeast Cancer Centre/Health Science North, Sudbury, ON, Canada

J.P. Brown, Laval University, Quebec, Quebec, Canada

J. Compston, Cambridge Biomedical Campus, Cambridge, UK

R. Rizzoli, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland

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This article was written on behalf of the International Osteonecrosis of the Jaw Task Force. A full list of the members of this body can be found at the end of the article.

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Khan, A., Morrison, A., Cheung, A. et al. Osteonecrosis of the jaw (ONJ): diagnosis and management in 2015. Osteoporos Int 27, 853–859 (2016). https://doi.org/10.1007/s00198-015-3335-3

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Keyword

  • Denosumab
  • Osteonecrosis
  • Diagnosis
  • Treatment
  • Bisphosphonates