WBR0767

Author	[[PageAuthor::Yazan Daaboul, M.D. (Reviewed by Will Gibson and Yazan Daaboul, M.D.)]]
Exam Type	ExamType::USMLE Step 1
Main Category	MainCategory::Pharmacology
Sub Category	SubCategory::Musculoskeletal/Rheumatology
Prompt	[[Prompt::A 58-year-old woman presents to the physician's office for a mandibular lesion. Her past medical history is significant for breast cancer. She is currently receiving zoledronic acid for osteoporosis. The physician suspects the patient is having zoledronic acid-related osteonecrosis of the jaw. Which risk factor is associated with the development of this patient's condition?]]
Answer A	AnswerA::History of dental extractions
Answer A Explanation	AnswerAExp::Personal history of either dental extractions, tooth infections, or surgery of the maxillofacial region is the main risk factor for development of BRONJ.
Answer B	AnswerB::History of high-grade breast cancer
Answer B Explanation	AnswerBExp::A personal history of breast cancer is not a risk factor for the development of BRONJ. However, breast cancer often metastasizes to bone and is associated with the development of osteolytic lesions.
Answer C	AnswerC::History of corrosive esophagitis
Answer C Explanation	[[AnswerCExp::Corrosive esophagitis may be an adverse event of bisphosphonate use. To prevent corrosive esophagitis, patients are usually asked to take bisphosphonates in the morning in a standing position while drinking plenty of water. Patients are instructed to stay standing for several minutes before lying in a supine position.]]
Answer D	AnswerD::Active heavy smoking
Answer D Explanation	AnswerDExp::Smoking is not a risk factor for the development of BRONJ.
Answer E	AnswerE::Caucasian race
Answer E Explanation	AnswerEExp::While Caucasian race is a risk factor for the development of osteoporosis, it is not an independent risk factor for development of BRONJ.
Right Answer	RightAnswer::A
Explanation	[[Explanation::Bisphosphonates are pyrophosphate analogues that bind to hydroxyapatite in the bone, thereby inhibiting osteoclast activity. Bisphosphonates are indicated for the treatment of osteoporosis, whereby inhibition of osteoclast-driven bone breakdown results in increased bone strength. Bisphosphonates are also indicated in Paget's disease to inhibit the abnormal cycling of osteoblastic and osteoclastic activity. Bisphosphonate-related osteonecrosis of the jaw (BRONJ) is an adverse drug event that rarely occurs with bisphosphonate use. The main risk factor for BRONJ is a history of dental procedures and/or poor dental hygiene. Patients who develop BRONJ often report a recent history of either dental extractions, tooth infection, or surgery of the maxillofacial region. Other secondary factors that also seem to be associated with BRONJ are corticosteroid therapy, radiotherapy, diabetes mellitus, and peripheral vascular disease. Educational Objective: Development of bisphosphonate-related osteonecrosis of the jaw (BRONJ) is associated with a personal history of dental extractions, tooth infections, and surgery of the maxillofacial region. References: Maerevoet M, Martin C, Duck L. Osteonecrosis of the jaw and bisphosphonates. N Engl J Med. 2005;353(1):99-102. First Aid 2015 page 445]]
Approved	Approved::Yes
Keyword	WBRKeyword::Dental extraction, WBRKeyword::Tooth infection, WBRKeyword::Tooth extraction, WBRKeyword::Mandibular lesion, WBRKeyword::Osteoporosis, WBRKeyword::Ostenoecrosis of the jaw, WBRKeyword::Bisphosphonate, WBRKeyword::Zoledronic acid, WBRKeyword::Risk factor, WBRKeyword::Predisposing factor, WBRKeyword::BRONJ
Linked Question	Linked::
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