Critical review: Updated recommendations for the prevention, diagnosis, and treatment of osteonecrosis of the jaw in cancer patients—May 2006

https://doi.org/10.1016/j.critrevonc.2006.12.005Get rights and content

Abstract

In light of recent reports of osteonecrosis of the jaw (ONJ) in cancer patients whose treatment regimens include an intravenous bisphosphonate, Novartis convened an international advisory board of experts in the fields of oral surgery and pathology, medical oncology, metabolic bone disease, and orthopedics to review existing data and provide updated recommendations on the clinical diagnosis, prevention, and management of ONJ in the oncology setting. Recommendations were developed to help guide healthcare professionals in early diagnosis and patient management. It is recommended that patients be encouraged to receive a dental examination prior to initiating bisphosphonate therapy and, if possible, complete any necessary dental procedures (e.g., tooth extraction) prior to initiating bisphosphonate therapy. Patients should receive regular dental visits during bisphosphonate therapy. Patients should be encouraged to practice good oral hygiene and minimize possible jaw trauma. If possible, patients should avoid dental surgery during treatment with bisphosphonates. If exposed bone is observed or reported in the oral cavity at any time (suspected ONJ), refer the patient to a dental professional immediately.

Section snippets

Background

Bisphosphonate compounds have been used for more than 15 years and have noticeably improved the lives of patients with bone metastases by reducing and delaying potentially life-threatening complications such as hypercalcemia of malignancy, pathologic fractures and spinal cord compression. This review discusses osteonecrosis of the jaw (ONJ), which is an uncommon event that has been reported in cancer patients receiving complex treatment regimens, including radiation, chemotherapy, and other

Clinical presentation and working diagnosis of ONJ

A two-stage approach is recommended to identify patients with ONJ.

  • (1)

    The clinical features of suspected ONJ: They are exposed bone in the maxillofacial area that occurs in association with dental surgery or occurs spontaneously, with no evidence of healing. Patients with these clinical features should be referred for appropriate dental evaluation and care as soon as possible.

  • (2)

    A working diagnosis of ONJ: It is made when there is no evidence of healing after 6 weeks of appropriate evaluation and

Severity and lesion size staging for ONJ

The staging criteria listed below in Table 1, Table 2 were supported by this advisory panel. This classification system was designed to be compatible with Adverse Event reporting for oncology clinical trials. The National Cancer Institute (NCI) Common Toxicity Criteria (CTC) system has a four-grade scale.

Updated recommendations for the prevention and management of ONJ in patients with cancer

The expert panel addressed a series of questions related to the prevention and management of ONJ in patients with cancer whose treatment regimens include IV bisphosphonates. In all cases, an open discussion between the treating physician and the patient is strongly recommended.

  • (1)

    For oncology patients, should a dental examination and preventive dentistry be performed before starting bisphosphonate therapy?

    • It is recommended that patients be encouraged to have a dental examination before they start

Conclusions and future directions

Bisphosphonate compounds have been used for more than 15 years and have noticeably improved the lives of patients with bone metastases by reducing and delaying potentially life-threatening complications such as hypercalcemia of malignancy, pathologic fractures, and spinal cord compression. Osteonecrosis of the jaw has been reported in cancer patients whose treatment regimens include IV bisphosphonates. As with all medical therapies, the potential risks and benefits of all treatments should be

Reviewers

Cesar A. Migliorati, Professor, Oral Medicine: NSU College of Dental Medicine, 3200 S. University Drive, Fort Lauderdale, FL 33328-2018, USA.

Luis A.M. Costa, Professor, Oncology Unit Hospital de Santa Maria PT-1649-035 Lisbon Portugal, Professor Jean-Jacques BODY, Department of Internal Medicine, Institute J. Bordet, Universite Libre de Bruxelles, rue Heger-Bordet 1, B-1000 Brussels, Belgium.

Robert E., Coleman, Professor, Medical Oncology, Head, Academic Unit of Clinical Oncology, Cancer

Acknowledgments

The authors wish to recognize the participants of the February, 2006 advisory board meeting who reviewed and commented on the contents of this manuscript: Dr. Douglas Joshua, Dr. Maico Melo, Dr. G. David Roodman, Dr. Jesus San Miguel, Dr. Catherine Von Poznak, and Dr. Orhan Sezer. In addition, the authors would like to extend their appreciation to Dr. Matti Aapro for his contributions and assistance with developing this manuscript.

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