Managing osteonecrosis of the jaw

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Published: 26 Jul 2017
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Dr Robert Marx - University of Miami Hospital, Miami, USA

Dr Marx speaks with ecancer at NOSCM 2017 to discuss osteonecrosis of the jaw.

He outlines the cancer drugs linked to disease onset, and gives the perspective of facial/dental surgeons in minimising adverse events and promoting therapy adherence.

In terms of managing infection, Dr Marx recommends penicillin-based antibiotics or anthracyclines, and in the case of advanced disease he describes how surgical interventions can preserve appearance and quality of life.

My talk today was on drug induced osteonecrosis of the jaw. This is a complication of two main drugs – denosumab and bisphosphonates of which you’re basically talking about zoledronic acid and pamidronate. These we have found in the oral and maxillofacial surgery speciality and dental specialty to cause dead bone of the jaw called osteonecrosis of the jaws. In a bottom line sense these are medications that are good for the cancer patient up to a limited point. At some point the dose gets to be too much for the jaw and the jaws develop exposed dead bone causing pain, causing secondary infections which may limit the treatment and maybe the discontinuation of the drug.

My talk today was focussed in on showing the oncology professors that this is a real entity and that we in the dental oral and maxillofacial surgery profession are on their side because we want to take care of these patients and not let this exposed bone of the jaw limit their treatment.

There are three ways we can manage this. If we see the patient before the oncologist starts one of these medications we can get the dental community to take out the bad teeth, to clean up the infections in the jaws, to treat dental decay and get the mouth in top condition so that during treatment problems don’t arise. Then during treatment if the oncologist is examining their patients be on the lookout for patients who complain of jaw pain, dental tooth pain, sinus pain, they have facial swellings or they have difficulty swallowing. Those are some of the red flags to be alert for so if the oncologist sees any of these in their patients send them to an oral and maxillofacial surgeon who can look at that with a trained eye and be able to treat that before it becomes a significant problem.

Then for those individuals who already have the exposed dead bone in the jaws I tell the patients that the dead bone is dead, it’s not painful by itself. However, it becomes painful when the bacteria of the mouth settle in, become a colonisation of infection. For those patients the two best drugs are either penicillin, whether it’s amoxicillin or penicillin-VK, inexpensive, minimal side effects, will be a good treatment to reduce their pain, reduce any infection. Doxycycline, which is a type of tetracycline also works very well – again, minimal side effects, hardly a big cost to it, it’s a relatively inexpensive medication and, of course, in the penicillin allergic patient you would rather use doxycycline. For either of those two medications if they do not work up to what you would expect if you add metronidazole to it, 500mg three times a day, it will add to it and usually resolve any pain or any secondary infection.

Then the last thing is that for those individuals who have advanced disease, their jaw breaks or pathologic fracture, radiographically there’s what we call osteolysis or bone dissolution to the inferior border, or these antibiotics are just not working to your standards, we often have to do a surgery. What I tried to show in my lecture recently is that no matter how aggressive this surgery looks with modern titanium plates and reconstructive efforts we can reconstruct these people at the time we remove the dead bone which will cure their pain, resolve their infection, get them back to a normal quality of life without creating a deformity.

So the bottom line that I tried to illustrate through my lecture today is that if the professions of oncology and oral and maxillofacial surgery and dentistry can work together we can reduce the incidence of osteonecrosis of the jaw; we can reduce the severity of people who develop it and we can resolve it in those people who do develop it.