This document discusses bisphosphonate-related osteonecrosis of the jaws (BRONJ) and provides guidance on dental management of patients taking bisphosphonates. It notes that bisphosphonates are commonly used to treat osteoporosis and bone metastases but can increase the risk of BRONJ, especially after dental surgery. The document recommends conservative dental treatment and antibiotic prophylaxis for high-risk patients. It identifies risk factors for BRONJ and advises monitoring of bone turnover markers like CTX to further assess surgical risk. The goal is to minimize but not eliminate the low risk of BRONJ from oral bisphosphonate use through preventative dental care and cautious management of invasive procedures.

1. DONE BY : Weam Mahmaoud
Faroun
Fourth year dental student
BRONJ
DONE BY WEAM MAHMOUD FAROUN

2. DONE BY WEAM MAHMOUD FAROUN

3.  Bisphosphonates are adsorbed on to
hydroxyapatite and can prevent or
signifcantly slow the normal
osteoclastic activity responsible
for the resorption of bone; they can
lead to a 50% reduction in fractures
(including hip and spine) compared
with women taking calcium only
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4.  There seems to be a correlation
between osteoporosis and excessive
alveolar bone loss in the elderly.
 Jaw osteoporosis is particularly a
problem in women.
 Systemic treatment of osteoporosis may
improve jaw bone density.
 . Bisphosphonates, especially if used
intravenously, may induce osteonecrosis
of the jaws.
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5.  Bisphosphonates are pyrophosphate
analogues
 that block the 3-hydroxy-3-
methylglutaryl-coenzyme A (HMG-
CoA)reductase pathway
(mevalonate path) and inhibit
osteoclasts, There by decreasing
bone resorption. However,
bisphosphonates remain in bone for
years and have an extremely long-
Mechanism of Action
Bisphosphonates
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6. Indications of
bisphosphonate therapy
 Osteoporosis
 Paget’s disease
 Malignant hypercalcemia
 Bone metastasis
 Multiple myeloma
 Primary hyperparathyroidism
 Osteogenesis imperfecta
 Carcinoma of breast.
 Gaucher disease
 Langerhans histiocytosis.
 management of periodontal diseases ( inhibiting the
osteoclastic bone resorption ,as a host modulating factor
for prevention of bone loss)
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7.  Intravenous bisphosphonates such as
pamidronate and zoledronate used in
cancer patients are a particularly high
risk for producing bisphosphonate-
induced osteonecrosis of the jaws
(BIONJ; ranging from one in ten to one
in 100 patients).
 How-ever, in osteoporosis, in which the
doses used are an order of magnitude
lower, the prevalence appears to be very
much lower.
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8.  Oral bisphosphonates such as
alendronate used for > 3 years have a
risk between one in 10 000 to one in
100 000, the lowest risk being with the
lower potency agents etidronate and
tiludronate.
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9. BIONG
 an area of exposed bone in the
maxillofacial region that did not heal within
8 weeks after identifcation by a health care
worker, in a patient who was receiving or
had been exposed to a bisphosphonate
and had not had radiation therapy to the
craniofacial region
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10.  Eighty per cent of cases of BIONJ
present after surgery, as exposed
necrotic bone, primarily mandibular
alveolar bone
 Lamina dura sclerosis or loss, and
widening of the periodontal ligament
space may well be early manifestations.
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12.  Prevention of BIONJ is by avoiding elective oral
surgery, or treatment should be carried out well
before commencing bisphosphonates or after a
drug holiday for 6 months.
 The patient must be counselled about risks and a
risk assessment carried out.
 Risk factors include bisphosphonate type and
dose (intravenous is worst), and dental co-
morbidities (increase risk).
 Bone turnover tests – low turnover as shown by
low CTX (C-terminal cross-linking type 1 collagen
telopeptides) increases risk.
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14.  Dental Management of Patients Receiving
Oral Bisphosphonate Therapy The
recommendations focus on conservative
surgical procedures, proper sterile
technique, appropriate use of oral
disinfectants and the principles of
effective antibiotic therapy. Because of a
paucity of clinical data on the dental
management of patients on oral
bisphosphonate therapy, these
recommendations primarily are based on
expert opinion, intended to help dentists
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15.  Routine dental treatment generally should not be
modified solely due to use of oral bisphosphonates.
 All patients should receive routine dental examinations.
 All patients taking the drug should be informed that:
Oral bisphosphonate use places them at very low risk
for developing BRONJ
The low risk for developing BRONJ may be minimized
but not eliminated.
An oral health program consisting of sound oral hygiene
practices and regular dental care may be the optimal
approach for lowering the risk for developing BRONJ.
There is no validated diagnostic technique currently
available to determine if patients are at increased risk for
developing BRONJ.
Discontinuing bisphosphonate therapy may not
eliminate any risk for developing BRONJ.DONE BY WEAM MAHMOUD FAROUN

16.  If dental extractions become
unavoidable in a patient taking
bisphosphonates, the use of
prophylactic antibiotics may
beconsidered, but there are no
controlled studies to support their use.
The decision depends on the clinician’s
level of concernrelative to the individual
patient and his or her specifc situation,
including concomitant risk factors (e.g.
prolonged use oforal bisphosphonates,
intravenous bisphosphonates, older age
concomitant use of oestrogen or
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17.  Therefore, whenever possible, dentists
should avoid performing extractions and
elective oral surgery in patients taking
bisphosphonates.
 If surgery is essential, the dentist must
counsel the patient about the risks of
use of intravenous or oral
bisphosphonates taken for more than 3
years.
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18. Risk factors for Osteo-necrosis of jaw
 Poor oral hygiene
 Dental procedures (tooth extractions, RCT,
Periodontal surgery implants)
 Chemotherapy,
 Corticosteroid use
 Immunosuppression
 Local cancerous invasion
 Local radiation therapy
 Heavy nicotine use
 Oral herpes infection.
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19.  Prophylactic antibiotics after a surgical
procedure should be based on the risk
of an infection and NOT because the
patient is taking a bisphosphonate.
There is no evidence that the use of
antibiotics is effective in preventing
BRONJ.
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20.  CTX testing Recently, the use of serum levels of
the collagen breakdown product, C-terminal
cross-linking telopeptide of type I collagen (CTX),
has been advocated as a risk predictor for
developing BON. Serum CTX and urinary N
telopeptide of type I collagen (NTX) are
considered markers for bone resorption. Higher
levels of these markers are associated with active
bone turnover. Reports suggest that dental
treatment decisions should be based on the
results of serum CTX/NTX levels
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21. References
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 Dental management of patients receiving
bisphosphonate therapy - A review Rafiya Nazir
Khan1*, Suhail Majid Jan2 , Tahira Ashraf1 ,
Rashidat-Ul-Khairat1 (February, 2017)
 Medical problem dentistry , 6 th edition , Scully