Dilemma in Management of Bisphosphonate-Related Osteonecrosis of the Jaw

Geist, Shin-Mey Rose, Sara Gordon, and James Geist

Bisphosphonates have been related to osteonecrosis of the jaw (ONJ) since 2003. These drugs inhibit bone resorption and are used to prevent bone metastases and in the treatment of bone cancer and osteoporosis. Most ONJ cases have followed IV infusion of pamidronate (Aredia®) or zoledronic acid (Zometa®), but some cases involved patients who received alendronate (Fosamax®) orally. Although a causal relationship has not been established, many patients have discontinued the medication and have been advised against invasive dental treatment. This poses problems for patients who require surgical dental care. Furthermore, bisphosphonates are effective, and discontinuance of their use without strong evidence may adversely affect the patient.

We report a case of a patient who had had used Zometa to prevent breast cancer metastasis and developed jaw bone necrosis. Her oncologist discontinued her bisphosphonate therapy after the onset of oral discomfort. Her jaw bone necrosis was well controlled; however, she was concerned about the risk of bone metastasis since she was no longer taking bisphosphonates. She lived in fear everyday until she died in July 2006 due to metastasis.

The importance of accurate diagnosis and satisfactory management of the jaw bone necrosis is addressed in this case report, as well as concerns regarding discontinuing the use of bisphosphonates. The dilemma of whether bisphosphonates should be discontinued, temporarily withheld, or continued after the development of ONJ remains unsolved. In May 2006 Novartis stated that for patients at high risk of hypercalcemia of malignancy (HCM) or skeletal-related events (SRE), consideration should be given to maintaining bisphosphonate therapy.