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Diagnosis and Treatment of the BRONJ Case

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Revisit the Case Presentation and Clinical Evaluation

This case is presented by: 

  • Dr. Eric T. Stoopler, D.M.D., FDS RCSEd, FDS RCSEng
  • Dr. Juan M. Bugueno, D.D.S.
  • Dr. Kevin Sweeney, D.D.S.
  • Dr. David C. Stanton, D.M.D., M.D., F.A.C.S 

We would like to thank all our dentists who submitted their responses to the diagnosis and treatment challenge.

Case Diagnosis

The Clinical diagnosis was bisphosphonate-related osteonecrosis of the maxilla.

Treatment

  • The patient’s oncologist discontinued the ZA therapy.
  • The patient was evaluated by an oral and maxillofacial surgeon who recommended surgical debridement of the affected areas and the patient underwent the procedure five months after cessation of ZA therapy.
  • A subperiosteal dissection was completed through a modified Lefort I incision to expose the bone of the anterior maxilla. Extensive necrotic bone was found along the anterior maxilla, involving the nasal floor and piriform rim (Fig 4).
Figure 4

Fig 4. Intra-operative view of extensive maxillary
necrosis

  • The nasal mucosa was separated from the necrotic bone without perforation and a 6cm segment of the anterior maxilla, including retained implants, was removed in its entirety (Fig 5).
Figure 5

Fig 5. Resected bone from anterior maxilla

 

 

 

 

 

 

 

 

 

  • Following the debridement of all the necrotic bone, the mucosa of the nasal floor bilaterally was clearly visualized and ~ 2 cm2 diameter communications were noted into the maxillary sinuses bilaterally (Fig 6). 
Figure 6

Fig 6. Bilateral communications with the maxillary sinuses

 

 

 

 

 

 

 

 

  • Large inflammatory polyps and infectious mucosa were noted within the maxillary sinuses and removed with a sinus curette. 
  • Bilateral pedicled buccal fat pad flaps were developed and utilized to provide an initial layer of closure over the sinus communications. 
  • The labial and buccal mucosa was undermined widely to develop a large advancement flap to allow tension-free, watertight closure. 
  • The patient’s final tissue cultures grew anaerobic gram negative rods and few anaerobic gram positive rods (speciation not performed). Fungal, mycobacterial, and acid fast bacilli cultures were negative. 
  • The bone pathology specimen revealed necrotic bone with acute and chronic inflammation with cell debris, bacteria and actinomyces. 
  • The histopathologic examination of the sinus contents revealed fragments of necrotic bone and sinonasal mucosa with acute and chronic inflammation without evidence of carcinoma.
  • The patient completed a four week course of oral levofloxacin and metronidazole, followed by a four week course of penicillin.
  • Two months post-operatively, the patient was noted to have persistent bilateral oral-nasal communications. Under local anesthesia, another flap closure was performed, but a small oral-nasal communication persisted and an obturator was fabricated to restore function.
  • The patient’s infection resolved (Fig 7) and she resumed chemotherapy for her metastatic disease. One year later, she developed bisphosphonate-related osteonecrosis in her left maxilla and mandible and is currently being monitored by an oral and maxillofacial surgeon.
Figure 7

Fig 7. Maxillary arch two months status-post surgical procedures

 

Additional Resources

American Association of Oral and Maxillofacial Surgeons’ Position Paper: Medication-Related Osteonecrosis of the Jaw—2014 Update (PDF)

 

What some dentists are saying about this case…

Bisphosponate-associated osseous necrosis IV bisphosphonates have a higher incidence of osseous necrosis, and in a medically compromised individual also showing evidence of significant alveolar bone loss in the remaining mandibular teeth, this likely indicates past or present history of chronic periodontitis and their associated pathogens. Management would likely involve resection of the compromised necrotic maxillary bone and likely the four dental implants. There may be some benefit to the use of hyperbaric oxygen for healing.

 Separator

Bisphosphonate-related osteonecrosis of the maxillae. I do not think that it is appropriate to blame the placement of implants since the extractions probably would have been a greater risk factor in the development of BRONJ. There are reports of successful immediate implant placement in patients who have had systemic bisphosphonates. J Periodontol. 2010 Apr;81(4):479-84. doi: 10.1902/jop.2009.090587.

 Separator

I obviously don’t know the circumstances of why the dentist chose to do an implant supported CUD as opposed to a standard CUD, but with a patient having had IV bisphosphonates (known to be a contraindication for implant placement), I’m thinking he regrets his decision…

Separator 

Likely osteochemonecrosis as a result of bone exposure after having been treated with Zometa (za) a high potency bisphosphonate. How do I know? I wrote an article during my perio graduate studies and have recently been involved in a case between a patient and Novartis pharmacy in the USA regarding a patient treated almost 10 years ago who recently died (his family sued the drug company). He had multiple myeloma and Zometa and Aridia were used to reduce metastasis of the cancer.

 Separator

The zoledronic acid in endovenous subministration often give this side effect when extractions and oral surgeries are close. Not to exclude a metastatic lactation of breast adenocarcinoma

 Separator

This appears to be an unfortunate case of osteonecrosis related to high dosages of bisphosphanse intraoral venous ZA. Had a similar case last December, a 78-year old on oral bisphosphanse treating osteoporosis. She had abnormally large mandibular tori. The tissue covering them was very thin and stripped off from trauma during mastication. The exposed yellowish bone refuses to heal over, even after a tori reduction. Very frustrating but at least she is asymptomatic, has no discomfort.

 Separator

I suspect there are multiple factors involved in this case that would need addressing, with the medical history being a complicating factor. I presume from the extractions that sharp spikes were left that helped to prevent soft tissue coverage (have seen it before in non-medically compromised patients).

If I see correctly, there is a perforation of the implant in the 1.4 area, exposed threading on a couple implants. 

I suspect artificial bone was placed around the implants to fill in voids and it did not take in all areas, leaving sharper bits of bone.

As a result of all of the above, soft tissue retracted from site rather than healing over, resulting in the exposed bone and chronic inflammation.

In order to treat, I would further research her past medical treatment for potential assistance with tissue management techniques to ensure healing. Provided nothing out of the ordinary, I would look at likely removing the implants, smoothing down all the bone to remove necrotic tissue and providing a more ideal surface for the tissue to adhere to and work towards primary closure if possible. And when I say “I”, I would actually be referring this patient to a specialist, as this is more extensive than cases I have treated with similar issues (2-3 socket sites is very different than a full arch). Very unfortunate turnout overall and would love to hear other people’s ideas, especially on the cause from sources other than “operator error”.

 Separator

Almost certainly this is osteonecrosis of the jaw (ONJ).

The question is how to treat it…

Resection of the dead bone is likely the only option and the use of doxycycline with a fluorescent light during surgery (e.g. Velscope) to identify live and dead bone during surgical resection. Primary closure of a flap after resection is important. Recurrence is handled in the same way until it ‘burns’ out…

 Separator

Zoledronic acid is in a class of medications called bisphosphonates. This 64-year-old Caucasian female patient has Bisphosphonate-associated osteonecrosis of the jaw. However, this patient also has “moth-eaten” appearance to the maxillary alveolar ridge which is typical of metastatic cancer.

Separator

 

Osteonecrosis, resulting from cancer and bisphosphonates… almost always cancer is involved. Meanwhile, I’m almost shocked at the number of patients who advise me at their recall appointment, that they’ve started taking these medications. Bisphosphonates are a new therapy. It can take many years before the varieties and dosages are perfected. There’s lots we don’t know. Necrosis of bone in people on a therapy that’s supposed to be good for bone density?  Pretty scary, if you ask me.

  • What Am I supposed to do with this new factor?
  • How does this alter my “expert” oral health advice?
  • What can I tell my patients?
  • How do I answer: “My M.D. told me to tell you that I’m taking…..

Would love some info/direction here!

 

5 comments

  1. Kelly Manning, DDS

    Thanks for presenting this case. I often think of this outcome when I come across IV bisphosphonate patients who require extractions and are looking toward restoration post-extraction. As well my concern is with head and neck cancer patients receiving radiation. It brings to mind the importance of pre-treatment dental assessment which is often lacking in smaller communities. A team approach, which includes the dentist and oral surgeon, is so important to successful long term medical outcomes, and quality of life.

  2. When treating a patient undergoing or having undergone BRONJ therapy:

    – As a general dentist, I consider the duration of the Bisphopshonate therapy and the key factirs pertient to the route of administration prior to choosing to continue dental treatment. As well, I consider other systemic factors and use the information provided by American Association of Oral and Maxillofacial Surgeons Position Paper on Bisphosphonate-Related Osteonecrosis of the Jaw—2009 Update Approved by the Board of Trustees January 2009.

    – What to tell your patients? Prevention (importance of oral hygiene) and education: They need to know that if they are prescribed a new bisphosphonates medication for osteoporosis by their physician, they must try to get a dental consult, in conjunction with the physician soon enough. This will allow the two professionals to apply the necessary modifications prior to starting the medication in order to minimise any oral sequelae. Do not make any modifications to patient’s existing medications without consulting the physician or the patient.

    – Preferably the physician prescribing the bisphosphonates must recommend the completion of any invasive dental procedure prior to the administration of IV or oral bisphosphonates.

    – If the patient is already on bisphosphonates either oral or IV and has not had a prior dental consult, then it is pertinent to consider the duration of medications and route of administration prior to dental treatment.

    – Consider if the patient on bisphosphonate therapy is symptomatic or asymptomatic and other systemic issues, both scenarios will alter the sequence and timing of the treatment plan.

    – If the patient needs urgent dental treatment during the treatment with IV bisphosponates; best option for the general dentist is to consult with specialists within their field or perform conservative restorative dentistry with caries control or emergency endodontic therapy (with decoronation of teeth with guarded prognosis and defer any invasive surgical procedures with appropriate referrals).

    We all shall appreciate any new updates to the link below since 2009.

    Reference article: American Association of Oral and Maxillofacial Surgeons Position Paper on Bisphosphonate-Related Osteonecrosis of the Jaw—2009 Update Approved by the Board of Trustees January 2009

    http://www.aae.org/uploadedfiles/publications_and_research/endodontics_colleagues_for_excellence_newsletter/bonj_aaoms_statement.pdf

  3. I made the “mistake” of removing a tooth from a female patient in her 70s approx 15 months ago. Prior to removing the tooth the patient and I discussed her oral bisphosphonate usage and potential implications of wound healing. I was disappointed the patient didn’t elect for a root canal and 3 surface restoration but due to financial reasons elected to have the tooth removed (even with potential complications).

    I saw the patient again approx 2 months ago for her annual recall and the socket had still not completely closed so I referred the patient to a OMFS office – she elected not to go because of finances. Based on the position paper above when I read it approx 2 months ago I believe she’s stage 1 so I provided her with appropriate treatment & encouraged her to see the OMFS but have lost her to follow up for the time being due to her taking a trip.

    I’m just glad I did a proper preoperative consult and had the discussion prior to providing treatment. Side effects can happen to even those who are low risk with oral bisphosphonates and taking out a simple max premolar.

  4. The RCDSO said in 2010 it is a gm -ve biofilm coverage of bone that does not allow healing. We need 3000X the level in the saliva of Metronidazole(gm-ve), Nystatin for yeast and Amox for Aa. These bacteria/fungi are always associated with BRONJ. I have a conflict of interest as a dentist that uses this rinse and own shares in the co that makes it. However it is a rinse/spit technique vs pill that is swallowed. You get 30000X the concentration in the saliva compared to swallowing a pill. It destroys this biofilm if it is used 3 days before surgery and for 10 days after. Breath odours are controlled and bleeding goes down 88%/pockets shrink on average 2 mm in two weeks because the pathogens causing perio/breath/gingiviits/BRONJ are controlled. See oravital.com for more info or contact me.

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