How are bisphosphonates used in children? Review of the literature and guidelines for dental management

This summary is based on the article published in the Australian Dental Journal: The use of bisphosphonates in children: review of the literature and guidelines for dental management (March 2014)

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RN Bhatt, SA Hibbert, CF Munns

Context

Bisphosphonates are inhibitors of osteoclastic bone resorption with therapeutic benefit in a variety of bone disorders in both adults and children. While these agents have been routinely used in adults for the past three decades, their more recent introduction into paediatric medicine means there is a paucity of data on long-term safety and effects on dental development.

There is uncertainty regarding the dental management of children treated with bisphosphonates, particularly when invasive dental procedures, such as extractions and oral surgical procedures, are required.

There are limited data with which to make recommendations about the dental management of patients treated with bisphosphonates, and there are no published recommendations that specifically address paediatric patients.

Purpose of the Review

This paper aims to outline paediatric uses and adverse effects of bisphosphonates and present recommendations on the dental management of children receiving bisphosphonates.

Key Messages

The successful and potential uses of bisphosphonates in children are more diverse than in adults and include: (1)

• Primary structural defects in type I collagen and other structural bone proteins (e.g. osteogenesis imperfecta).
• Fibrous dysplasia of bone (e.g. McCune-Albright syndrome).
• Bone abnormalities resulting from systemic disease or the effects of systemic treatment (e.g. steroid treatment of chronic disease or immobilization).
• Bone matrix abnormalities (e.g. osteoporosis pseudoglioma syndrome).
• Conditions with a primary defect in bone mineralization (e.g. idiopathic juvenile osteoporosis).
• Malignancy associated hypercalcaemia.
• Focal orthopaedic disorders (e.g. traumatic avascular necrosis of the femoral head).

There are two main potential dental complications for children receiving these agents: the possibility of BRONJ, and the effect that inhibition of resorption may have on the development of the dentition and the occlusion. Potential effects on orthodontic tooth movement is also of interest.

Given the action of bisphosphonates on inhibition of bone resorption, the potential for these agents to delay tooth eruption is of interest.

The impact of bisphosphonates on orthodontic tooth movement is of interest as osteoblastic and osteoclastic activity is necessary for orthodontic tooth movement to occur, and bisphosphonates inhibit osteoclastic activity and may also decrease the microcirculation.

For all children treated with these agents, the primary focus must be avoiding the need for invasive  dental procedures and emergency dental treatment once bisphosphonate treatment has commenced. Therefore, the goals should be: 

• Comprehensive dental assessment, and elimination of dental disease or foci of oral infection, prior to commencement of bisphosphonates.
• Patient education for maintenance of optimal dental health.
• Postponement of bisphosphonate therapy until dental health is optimized, or at least until any surgical sites have healed. (2)

Basic principles: 

• All patients should be referred to a dentist for dental examination prior to commencing bisphosphonate treatment. 
• Comprehensive clinical and radiographic examination should be undertaken to identify teeth with a poor or questionable prognosis. Panoramic radiographs are advised for an overview of the entire jaw and to allow assessment and identification of pathology or anomalies that may necessitate invasive dental treatment at the present time, or at some stage in the future. 
• Preventive advice must be given to patients and their carers encompassing oral hygiene instruction, dietary counselling, and attendance for regular dental review.
• Attempts should be made to complete all necessary invasive dental procedures prior to commencement of intravenous bisphosphonates. (3) Three weeks would be considered ideal to allow adequate time for healing. (4) Consideration should be given to extracting all teeth of questionable prognosis if bisphosphonate treatment has not yet started.
• In the event of a true dental emergency, invasive dental treatment need not be withheld.

Recommendations for oral surgical procedures:

• Whether bisphosphonate treatment has already commenced?
• Whether bisphosphonate treatment will be shortterm or long-term therapy?
• Whether dental treatment is immediately required, or can be deferred?

Where uncertainty arises, practitioners should liaise with the appropriate medical specialists, or consider referral to a tertiary hospital facility where such children are usually managed.

References

1. Batch JA, Couper JJ, Rodda C, Cowell CT, Zacharin M. Use of bisphosphonate therapy for osteoporosis in childhood and adolescence. J Paediatr Child Health 2003; 39:88–92.
2. Patel V, McLeod NM, Rogers SN, Brennan PA. Bisphosphonate osteonecrosis of the jaw–a literature review of UK policies versus international policies on bisphosphonates, risk factors and prevention. Br J Oral Maxillofac Surg 2011;49: 251–257.
3. Khan AA, Sandor GK, Dore E, et al. Canadian consensus practice guidelines for bisphosphonate associated osteonecrosis of the jaw. J Rheumatol 2008; 35:1391–1397.
4. Ruggiero SL, Dodson TB, Assael LA, Landesberg R, Marx RE, Mehrotra B. American Association of Oral and Maxillofacial Surgeons position paper on bisphosphonate-related osteonecrosis of the jaws–2009 update. J Oral Maxillofac Surg 2009; 67 (5 Suppl):2–12.

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