Bisphosphonate-related osteonecrosis of the jaws: a potential alternative to drug holidays

In 2011, the American Dental Association Council on Scientific Affairs released an update by their expert panel on managing the care of patients receiving antiresorptive therapy for the prevention and treatment of osteoporosis. In this report, the panel found no study results that confirmed the effectiveness of drug holidays to prevent antiresorptive agent-induced osteonecrosis of the jaws without increasing the risks of low bone mass. The purpose of this article is to provide suggestions for a pattern of patient care for individuals who desire or require an invasive surgical procedure of the jaws, but who also have a skeleton that is at risk for osteoporotic fracture. The authors reviewed pertinent literature related to basic bone histology, the pharmacokinetics of the aminobisphosphonates (nBP), diagnostic criteria for osteopenia/osteoporosis, and clinical applications of the antiresorptive agents. The skeletal system demonstrates a mixture of resting surfaces (osteocytes, 85%), resorbing surfaces (osteoclasts, 2%), and forming surfaces (osteoblasts, 10%-12%). Deposition of nBP is not uniform, and is highly concentrated in areas of bone remodeling. A full understanding of bone remodeling and the pharmacokinetics of nBP allow for the modification of the antiresorptive therapy and the timing of the oral surgical procedure in a manner that minimizes the prevalence of osteonecrosis while at the same time continuing to protect the patient's skeleton from osteoporotic fracture. The lack of support for drug holidays by the ADA's expert panel is strongly consistent with the science behind bone remodeling and nBP pharmacokinetics. In spite of this, creative interdisciplinary patient care has the potential to dramatically reduce the prevalence of bisphosphonate-related osteonecrosis (BRON), while at the same time continuing to protect the skeleton of the osteoporotic patient. Creative interdisciplinary patient care may prove to be an effective intervention to reduce the prevalence of BRON of the jaws.