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==Overview==
==Overview==
The treatment should be tailored to the individual patient according to the etiological factors involved and the severity of the disease process. With oral osteoporosis the emphasis should be on educating the patient to achieve good [[nutrient]] absorption and metabolic wastes elimination through a healthy gastro-intestinal function, effective hepatic [[metabolism]] of toxicants such as exogenous estrogens, endogenous acetaldehyde and heavy metals, a balanced diet, healthy lifestyle, assessment of factors related to potential [[Coagulopathy|coagulopathies]], and treatment of periodontal diseases and other oral and dental infections.  In patients with bisphosphonates-associated ONJ, conservative debridement of necrotic bone, pain control, infection management, use of antimicrobial oral rinses, and withdrawal of bisphosphonates are preferable to aggressive surgical measures.<ref> Abu-Id MH, Acil Y, Gottschalk J, Kreusch T. [Bisphosphonate-associated osteonecrosis of the jaw.] [Article in German]. Mund Kiefer Gesichtschir. 2006 Mar;10(2):73-81.</ref>  Although an effective treatment for bisphosphonate-associated bone lesions has not yet been established,<ref> Merigo E, Manfredi M, Meleti M, Corradi D, Vescovi P. Jaw bone necrosis without previous dental extractions associated with the use of bisphosphonates (pamidronate and zoledronate): a four-case report. J Oral Pathol Med. 2005 Nov;34(10):613-7 [http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16202082&query_hl=18&itool=pubmed_docsum PMID: 16202082]</ref> and this is unlikely to occur until this form of ONJ is better understood, there as been clinical reports of some improvement after 6 months or more of complete cessation of bisphosphonate therapy.<ref> Simon D J Gibbs, John O'Grady, John F Seymour, H Miles Prince. Bisphosphonate-induced osteonecrosis of the jaw requires early detection and intervention. MJA 2005; 183 (10): 549-550 </ref>
The treatment should be tailored to the individual patient according to the etiological factors involved and the severity of the disease process. With oral osteoporosis the emphasis should be on educating the patient to achieve good [[nutrient]] absorption and metabolic wastes elimination through a healthy gastro-intestinal function, effective hepatic [[metabolism]] of toxicants such as exogenous estrogens, endogenous acetaldehyde and heavy metals, a balanced diet, healthy lifestyle, assessment of factors related to potential [[Coagulopathy|coagulopathies]], and treatment of periodontal diseases and other oral and dental infections.  In patients with bisphosphonates-associated ONJ, conservative debridement of necrotic bone, pain control, infection management, use of antimicrobial oral rinses, and withdrawal of bisphosphonates are preferable to aggressive surgical measures.<ref> Abu-Id MH, Acil Y, Gottschalk J, Kreusch T. [Bisphosphonate-associated osteonecrosis of the jaw.] [Article in German]. Mund Kiefer Gesichtschir. 2006 Mar;10(2):73-81.</ref>  Although an effective treatment for bisphosphonate-associated bone lesions has not yet been established,<ref> Merigo E, Manfredi M, Meleti M, Corradi D, Vescovi P. Jaw bone necrosis without previous dental extractions associated with the use of bisphosphonates (pamidronate and zoledronate): a four-case report. J Oral Pathol Med. 2005 Nov;34(10):613-7 [http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16202082&query_hl=18&itool=pubmed_docsum PMID: 16202082]</ref> and this is unlikely to occur until this form of ONJ is better understood, there as been clinical reports of some improvement after 6 months or more of complete cessation of bisphosphonate therapy.<ref> Simon D J Gibbs, John O'Grady, John F Seymour, H Miles Prince. Bisphosphonate-induced osteonecrosis of the jaw requires early detection and intervention. MJA 2005; 183 (10): 549-550 </ref>
==Medical Therapy==
===Staging and Recommended Management<SMALL><SMALL><SMALL><ref name="AAOMS">{{Cite web  | last =  | first =  | title = http://www.aaoms.org/docs/position_papers/mronj_position_paper.pdf?pdf=MRONJ-Position-Paper | url = http://www.aaoms.org/docs/position_papers/mronj_position_paper.pdf?pdf=MRONJ-Position-Paper | publisher =  | date =  | accessdate = }}</ref></SMALL></SMALL></SMALL>===
{| style="font-size: 85%;"
! style="width: 80px; background: #4479BA; text-align: center;"|{{fontcolor|#FFF|Stage}}
! style="width: 720px; background: #4479BA; text-align: center;"| {{fontcolor|#FFF|Recommended Management}}
|-
| style="background: #F5F5F5; padding: 5px; text-align: center;"| '''Stage 0'''
| style="background: #DCDCDC; padding: 5px;"| Antibiotic treatment and pain management
|-
| style="background: #F5F5F5; padding: 5px; text-align: center;"| '''Stage 1'''
| style="background: #DCDCDC; padding: 5px;"| Patient education, antibiotic mouth rinse, consider discontinuing biphosmonate therapy
|-
| style="background: #F5F5F5; padding: 5px; text-align: center;"| '''Stage 2'''
| style="background: #DCDCDC; padding: 5px;"| Debridement, oral antibiotic therapy plus antibiotic mouth rinse and pain management
|-
| style="background: #F5F5F5; padding: 5px; text-align: center;"| '''Stage 3'''
| style="background: #DCDCDC; padding: 5px;"| Debridement or resection for better infection control, oral antibiotic therapy plus antibiotic mouth rinse and pain management
|}
===Antibiotic Therapy===
* Patients who have exposed necrotic bone associated with superimposed infection and disrupted bone remodeling may benefit from the use of antiseptic mouthwash (such as [[chlorhexidine gluconate|0.12% chlorhexidine gluconate]]) in combination with antibiotic therapy. Most of the isolated flora are susceptible to the [[beta-lactam]]s. For patients that are allergic to [[penicillin]]s, [[clindamycin]], [[doxycycline]], [[erythromycin]], [[azithromycin]], [[quinolone]]s, and [[metronidazole]] have been used with success.<ref name="Woo-2006">{{Cite journal  | last1 = Woo | first1 = SB. | last2 = Hellstein | first2 = JW. | last3 = Kalmar | first3 = JR. | title = Narrative [corrected] review: bisphosphonates and osteonecrosis of the jaws. | journal = Ann Intern Med | volume = 144 | issue = 10 | pages = 753-61 | month = May | year = 2006 | doi =  | PMID = 16702591 }}</ref><ref name="Ruggiero-2006">{{Cite journal  | last1 = Ruggiero | first1 = SL. | last2 = Fantasia | first2 = J. | last3 = Carlson | first3 = E. | title = Bisphosphonate-related osteonecrosis of the jaw: background and guidelines for diagnosis, staging and management. | journal = Oral Surg Oral Med Oral Pathol Oral Radiol Endod | volume = 102 | issue = 4 | pages = 433-41 | month = Oct | year = 2006 | doi = 10.1016/j.tripleo.2006.06.004 | PMID = 16997108 }}</ref><ref name="Marx-2005">{{Cite journal  | last1 = Marx | first1 = RE. | last2 = Sawatari | first2 = Y. | last3 = Fortin | first3 = M. | last4 = Broumand | first4 = V. | title = Bisphosphonate-induced exposed bone (osteonecrosis/osteopetrosis) of the jaws: risk factors, recognition, prevention, and treatment. | journal = J Oral Maxillofac Surg | volume = 63 | issue = 11 | pages = 1567-75 | month = Nov | year = 2005 | doi = 10.1016/j.joms.2005.07.010 | PMID = 16243172 }}</ref>
* Long-term maintenance antibiotics and a course of [[intravenous]] therapy according to the culture and sensitivity data may be considered for refractory cases.
* The table below describes the recommended antimicrobial regimens for the treatment of secondary infection in the osteonecrosis of the jaw.<ref name="pmid20871729">{{cite journal| author=Ruggiero S, Gralow J, Marx RE, Hoff AO, Schubert MM, Huryn JM et al.| title=Practical guidelines for the prevention, diagnosis, and treatment of osteonecrosis of the jaw in patients with cancer. | journal=J Oncol Pract | year= 2006 | volume= 2 | issue= 1 | pages= 7-14 | pmid=20871729 | doi= | pmc=PMC2794643 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20871729  }} </ref>
{|
| valign=top |
{| style="background: #FFFFFF;"
| valign=top |
{| style="float: left; cellpadding=0; cellspacing= 0; width: 500px;"
! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center | {{fontcolor|#FFF|Bacterial Infection}}
|-
| style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=center | '''''Preferred Regimen'''''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Penicillin VK]] 500 mg PO q6–8h for 7–10 days (maintenance: 500 mg PO bid)'''''<BR> OR <BR> ▸ '''''[[Amoxicillin]] 500 mg PO q8h for 7–10 days (maintenance: 500 mg PO bid)'''''
|-
| style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=center | '''''Alternative Regimen (If Allergic to Penicillin)'''''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Clindamycin]] 150–300 mg PO qid'''''<BR> OR <BR> ▸ '''''[[Doxycycline]] 100 mg PO qd'''''<BR> OR <BR> ▸ '''''[[Erythromycin]] 400 mg PO tid'''''<BR> OR <BR> ▸ '''''[[Azithromycin]] 500 mg PO for 1 dose, then 250 mg PO qd for 4 days'''''<BR> OR <BR> ▸ '''''[[Levofloxacin]] 500 mg PO qd'''''<BR> OR <BR> ▸ '''''[[Moxifloxacin]] 400 mg PO qd'''''
|}
|}
| valign=top |
{| style="background: #FFFFFF;"
| valign=top |
{| style="float: left; cellpadding=0; cellspacing= 0; width: 500px;"
! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center | {{fontcolor|#FFF|Fungal Infection}}
|-
| style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=center | '''''Preferred Regimen'''''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Nystatin|Nystatin oral suspension]] 5–15 mL swish qid'''''<BR> OR <BR> ▸ '''''[[Fluconazole]] 200 mg PO qd, then 100 mg q24h'''''<BR> OR <BR> ▸ '''''[[Clotrimazole]] 10 mg PO tid for 7–10 days'''''
|-
! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center | {{fontcolor|#FFF|Viral Infection}}
|-
| style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=center | '''''Preferred Regimen'''''
|-
| style="height: 137px; font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left valign=top | ▸ '''''[[Acyclovir]] 400 mg PO bid'''''<BR> OR <BR> ▸ '''''[[Valacyclovir]] 0.5–2.0 g PO bid'''''
|}
|}
|}


==References==
==References==

Revision as of 20:36, 11 February 2015

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Overview

The treatment should be tailored to the individual patient according to the etiological factors involved and the severity of the disease process. With oral osteoporosis the emphasis should be on educating the patient to achieve good nutrient absorption and metabolic wastes elimination through a healthy gastro-intestinal function, effective hepatic metabolism of toxicants such as exogenous estrogens, endogenous acetaldehyde and heavy metals, a balanced diet, healthy lifestyle, assessment of factors related to potential coagulopathies, and treatment of periodontal diseases and other oral and dental infections. In patients with bisphosphonates-associated ONJ, conservative debridement of necrotic bone, pain control, infection management, use of antimicrobial oral rinses, and withdrawal of bisphosphonates are preferable to aggressive surgical measures.[1] Although an effective treatment for bisphosphonate-associated bone lesions has not yet been established,[2] and this is unlikely to occur until this form of ONJ is better understood, there as been clinical reports of some improvement after 6 months or more of complete cessation of bisphosphonate therapy.[3]

Medical Therapy

Staging and Recommended Management[4]

Stage Recommended Management
Stage 0 Antibiotic treatment and pain management
Stage 1 Patient education, antibiotic mouth rinse, consider discontinuing biphosmonate therapy
Stage 2 Debridement, oral antibiotic therapy plus antibiotic mouth rinse and pain management
Stage 3 Debridement or resection for better infection control, oral antibiotic therapy plus antibiotic mouth rinse and pain management

Antibiotic Therapy

  • Patients who have exposed necrotic bone associated with superimposed infection and disrupted bone remodeling may benefit from the use of antiseptic mouthwash (such as 0.12% chlorhexidine gluconate) in combination with antibiotic therapy. Most of the isolated flora are susceptible to the beta-lactams. For patients that are allergic to penicillins, clindamycin, doxycycline, erythromycin, azithromycin, quinolones, and metronidazole have been used with success.[5][6][7]
  • Long-term maintenance antibiotics and a course of intravenous therapy according to the culture and sensitivity data may be considered for refractory cases.
  • The table below describes the recommended antimicrobial regimens for the treatment of secondary infection in the osteonecrosis of the jaw.[8]
Bacterial Infection
Preferred Regimen
▸ Penicillin VK 500 mg PO q6–8h for 7–10 days (maintenance: 500 mg PO bid)
OR
▸ Amoxicillin 500 mg PO q8h for 7–10 days (maintenance: 500 mg PO bid)
Alternative Regimen (If Allergic to Penicillin)
▸ Clindamycin 150–300 mg PO qid
OR
▸ Doxycycline 100 mg PO qd
OR
▸ Erythromycin 400 mg PO tid
OR
▸ Azithromycin 500 mg PO for 1 dose, then 250 mg PO qd for 4 days
OR
▸ Levofloxacin 500 mg PO qd
OR
▸ Moxifloxacin 400 mg PO qd
Fungal Infection
Preferred Regimen
▸ Nystatin oral suspension 5–15 mL swish qid
OR
▸ Fluconazole 200 mg PO qd, then 100 mg q24h
OR
▸ Clotrimazole 10 mg PO tid for 7–10 days
Viral Infection
Preferred Regimen
▸ Acyclovir 400 mg PO bid
OR
▸ Valacyclovir 0.5–2.0 g PO bid

References

  1. ↑ Abu-Id MH, Acil Y, Gottschalk J, Kreusch T. [Bisphosphonate-associated osteonecrosis of the jaw.] [Article in German]. Mund Kiefer Gesichtschir. 2006 Mar;10(2):73-81.
  2. ↑ Merigo E, Manfredi M, Meleti M, Corradi D, Vescovi P. Jaw bone necrosis without previous dental extractions associated with the use of bisphosphonates (pamidronate and zoledronate): a four-case report. J Oral Pathol Med. 2005 Nov;34(10):613-7 PMID: 16202082
  3. ↑ Simon D J Gibbs, John O'Grady, John F Seymour, H Miles Prince. Bisphosphonate-induced osteonecrosis of the jaw requires early detection and intervention. MJA 2005; 183 (10): 549-550
  4. ↑ "http://www.aaoms.org/docs/position_papers/mronj_position_paper.pdf?pdf=MRONJ-Position-Paper" (PDF). External link in |title= (help)
  5. ↑ Woo, SB.; Hellstein, JW.; Kalmar, JR. (2006). "Narrative [corrected] review: bisphosphonates and osteonecrosis of the jaws". Ann Intern Med. 144 (10): 753–61. PMID 16702591. Unknown parameter |month= ignored (help)
  6. ↑ Ruggiero, SL.; Fantasia, J.; Carlson, E. (2006). "Bisphosphonate-related osteonecrosis of the jaw: background and guidelines for diagnosis, staging and management". Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 102 (4): 433–41. doi:10.1016/j.tripleo.2006.06.004. PMID 16997108. Unknown parameter |month= ignored (help)
  7. ↑ Marx, RE.; Sawatari, Y.; Fortin, M.; Broumand, V. (2005). "Bisphosphonate-induced exposed bone (osteonecrosis/osteopetrosis) of the jaws: risk factors, recognition, prevention, and treatment". J Oral Maxillofac Surg. 63 (11): 1567–75. doi:10.1016/j.joms.2005.07.010. PMID 16243172. Unknown parameter |month= ignored (help)
  8. ↑ Ruggiero S, Gralow J, Marx RE, Hoff AO, Schubert MM, Huryn JM; et al. (2006). "Practical guidelines for the prevention, diagnosis, and treatment of osteonecrosis of the jaw in patients with cancer". J Oncol Pract. 2 (1): 7–14. PMC 2794643. PMID 20871729.
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