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Update on Osteonecrosis of the Jaw
Published: Mar 30, 2009

AAOMS Updates BRONJ Position Paper

 
The American Association of Oral and Maxillofacial Surgeons has revised its 2006 landmark position paper on Bisphosphonate-Related Osteonecrosis of the Jaw to reflect the most current research and thought on this condition. BRONJ appears as a non-healing exposed bone in the maxillofacial region and may affect patients undergoing intravenous cancer-related bisphosphonate therapy or more rarely, patients treated with oral or IV bisphosphonates for osteoporosis.
Written by the members of the distinguished AAOMS Task Force on BRONJ who prepared the original paper, the 2009 BRONJ Position Paper updates the staging and management strategies for BRONJ, and highlights the status of basic science research relating to this condition. The 2009 Position Paper retains the case definition of BRONJ:
  1. The patient is or has been treated with a bisphosphonate.
  2. Exposed bone has been present in the maxillofacial region for more than eight weeks; and
  3. There is no history of radiation therapy to the jaws.
While there is strong evidence supporting an association between IV bisphosphonate therapy for cancer-related conditions and BRONJ, the 2009 BRONJ Position Paper stresses that the relationship between oral or IV bisphosphonates for treating osteoporosis and BRONJ is more difficult to establish. Specifically, the 2009 BRONJ Position Paper observes that the risk of developing BRONJ is linked to:
  1. The potency the bisphosphonate used in therapy; and
  2. The length of exposure to bisphosphonates.
Other factors that may increase the risk of developing BRONJ include:
  • A history of inflammatory dental disease, such as periodontal disease and dental abscesses;
  • Increased age;
  • Other systemic factors or conditions, such as renal dialysis, low hemoglobin, obesity and diabetes; and
  • In some cases, there may be a genetic predisposition to developing BRONJ. The 2009 BRONJ Position Paper offers some strategies for preventing BRONJ in cancer patients treated with IV bisphosphonates.
  • Prior to initiation of cancer-related IV bisphosphonate treatment, patients should have a thorough dental examination and complete the necessary procedures to achieve optimal periodontal health.
  • Given the long-term biologic activity of IV bisphosphonates noted in the literature, the 2009 Position Paper suggests that alternative dosing regimens that reduce bisphosphonate exposure may be effective in decreasing the risk for BRONJ.
Changes to the staging system include the addition of Stage 0, which includes patients exposed to bisphosphonates and who present with non-specific symptoms, or clinical and radiographic abnormalities.
 
BRONJ is painful and difficult to treat. While osteonecrosis of the jaw has been recognized by dental and medical practitioners for many years, the identification of bisphosphonates as a contributory factor to the condition was first reported by oral and maxillofacial surgeons about five years ago when they noticed an increase in the number of patients exhibiting the signs of ONJ. A review of these cases indicated that bisphosphonate therapy was a common thread.
In 2006, the American Association of Oral and Maxillofacial Surgeons appointed the Task Force on BRONJ to review the existing literature and prepare a position paper that synthesized the findings for the dental and medical communities. In late 2008, the Task Force on BRONJ was reconstituted to review the research conducted in the intervening two years. The 2009 BRONJ Position Paper is the result of their efforts. The complete 2009 BRONJ Position Paper is available at aaoms.org.
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