Osteonecrosis of the jaw medical therapy

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

Treatment

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 cases of advanced oral ischemic osteoporosis and/or ONJ that are not bisphosphonates related, clinical evidence has shown that surgically removing the damaged marrow, usually by curettage and decortication, will eliminate the problem (and the pain) in 74% of patients with jaw involvement.[1] Repeat surgeries, usually smaller procedures than the first, may be required, and almost a third of jawbone patients will need surgery in one or more other parts of the jaws because the disease so frequently present multiple lesions, i.e. multiple sites in the same or similar bones, with normal marrow in between. In the hip, at least half of all patients will get the disease in the opposite hip over time; this pattern occurs in the jaws as well. Recently, it has been found that some osteonecrosis patients respond to anticoagulation therapies alone. The earlier the diagnosis the better the prognosis. Research is ongoing on other non-surgical therapeutic modalities that could alone or in combination with surgery further improve the prognosis and reduce the morbidity of ONJ. A greater emphasis on minimizing or correcting known etiological factors is necessary while further research is conducted on chronic ischemic bone diseases such as oral osteoporosis and ONJ.

In patients with bisphosphonates-associated ONJ, the response to surgical treatment is usually poor.[2] Conservative debridement of necrotic bone, pain control, infection management, use of antimicrobial oral rinses, and withdrawal of bisphosphonates are preferable to aggressive surgical measures for treating this form of ONJ.[3] Although an effective treatment for bisphosphonate-associated bone lesions has not yet been established,[4] 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.[5]

Staging and Recommended Management[6]

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.[7][8][9]
  • 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.[10]
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

Antimicrobial regimen

  • 1. Bacterial Infection [11]
  • Preferred regimen (1): Penicillin VK 500 mg PO q6–8h for 7–10 days (maintenance: 500 mg PO bid)
  • Preferred regimen (2): Amoxicillin 500 mg PO q8h for 7–10 days (maintenance: 500 mg PO bid)
  • Alternative regimen (1): Clindamycin 150–300 mg PO qid
  • Alternative regimen (4): Azithromycin 500 mg PO single dose THEN 250 mg PO qd for 4 days
  • 2. Fungal Infection
  • Preferred regimen (1): Nystatin oral suspension 5–15 mL swish qid
  • Preferred regimen (2): Fluconazole 200 mg PO qd THEN 100 mg q24h
  • Preferred regimen (3): Clotrimazole 10 mg PO tid for 7–10 days
  • 3. Viral Infection
  • Preferred regimen (1): Acyclovir 400 mg PO bid

References

  1. Bouquot JE, Christian J. Long-term effects of jawbone curettage on the pain of facial neuralgia. J Oral Maxillofac Surg 1995; 53:387-397.
  2. Zarychanski R, Elphee E, Walton P, Johnston J. Osteonecrosis of the jaw associated with pamidronate therapy. Am J Hematol. 2006 Jan;81(1):73-5.
  3. 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.
  4. 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
  5. 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
  6. "http://www.aaoms.org/docs/position_papers/mronj_position_paper.pdf?pdf=MRONJ-Position-Paper" (PDF). External link in |title= (help)
  7. 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)
  8. 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)
  9. 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)
  10. 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.
  11. Gilbert, David (2015). The Sanford guide to antimicrobial therapy. Sperryville, Va: Antimicrobial Therapy. ISBN 978-1930808843.

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