Osteonecrosis of the jaw (ONJ) is a serious and painful condition that can significantly affect the quality of life for patients, particularly those receiving bone resorption inhibitors as part of osteoporosis treatment. This issue was a central topic at the 2024 French Congress of Rheumatology in Paris, where experts discussed the growing importance of collaboration between rheumatologists and dentists in managing the condition.
What is ONJ?
ONJ is characterized by the exposure of necrotic bone in the jaw for more than eight weeks, and it is associated with symptoms such as chronic pain, infection, and other complications. Early stages of ONJ may appear as a simple fistula, while more severe cases involve deeper, hidden necrosis.
Medications Linked to ONJ
The medications most commonly linked to drug-induced ONJ include:
- Bisphosphonates
- Denosumab
- Anti-angiogenic agents (such as sunitinib, bevacizumab, and aflibercept)
- Tumor necrosis factor inhibitors (adalimumab and etanercept)
- Romosozumab
The risk of developing ONJ is influenced by various factors, including the duration of the medication regimen and the type of medication. While the incidence of ONJ among osteoporosis patients using these treatments is low (ranging from 0.001% to 0.050%), the risk is significantly higher in cancer patients treated with the same drugs (ranging from 1% to 15%).
Key Risk Factors
- Long-term use: The risk of ONJ slightly increases in patients who have been on bisphosphonates for more than five years.
- Corticosteroids and immunosuppressants: These drugs are known to increase the risk of ONJ.
- Oral health: Poor oral health is a major risk factor for ONJ, with dental infections, ill-fitting dentures, peri-implantitis, and tooth extractions contributing to the development of the condition.
The Role of Dental Care
Dental care is critical in preventing ONJ. Before beginning treatment with bone resorption inhibitors, patients should undergo a dental evaluation to identify any existing oral health issues. This pre-treatment assessment helps educate patients on potential bone and oral risks, and supports them in maintaining good oral hygiene and nutrition.
Maintaining oral barrier integrity is a priority for patients on bone resorption inhibitors. Dental procedures such as endodontic therapy, root canals, and crown reconstructions help maintain the oral health necessary to promote bone healing and prevent ONJ. Restoring periodontal health is also crucial, as untreated gingivitis and periodontitis can contribute to the development of ONJ.
Minimally Invasive Procedures
While dental procedures should not delay the start of bone resorption therapy, they should be performed as minimally invasively as possible. If necessary, antibiotics may be administered as a preventive measure. Both American and French guidelines recommend specific protocols for surgical interventions.
Dental implants, contrary to some concerns, are not contraindicated for patients receiving bone resorption inhibitors, though careful monitoring for peri-implantitis is necessary. Implant-based rehabilitation is especially safe for those who have been treated with bisphosphonates for less than three years.
Early Detection and Monitoring
New imaging tools, such as cone beam computed tomography (CBCT), allow for early detection of ONJ, sometimes before clinical symptoms appear. Routine monitoring can help manage and mitigate the risks of this potentially debilitating condition.
Need for Collaboration
The lack of a universal consensus on the best approach to ONJ management highlights the importance of ongoing collaboration between rheumatologists and dentists. Both specialties must work together to assess individual risks and tailor treatment strategies for patients undergoing bone resorption inhibitor therapy.
Establishing trust and coordinated care between rheumatologists and dentists, through interprofessional training programs, is essential. By combining their expertise, these healthcare providers can help minimize ONJ risks and ensure the best outcomes for patients.
In conclusion, effective management of ONJ requires a multidisciplinary approach that prioritizes dental health, early intervention, and the establishment of clear communication between rheumatologists and dentists. This collaboration is crucial to improving patient care and reducing the incidence of ONJ.
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