Osteonecrosis of the jaw medical therapy

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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. Although an effective treatment for bisphosphonate-associated bone lesions has not yet been established, 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.

Medical Therapy

Staging and Recommended Management

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.
• 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.

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