Patients with osteoporosis are often prescribed medications that can help prevent severe bone fractures. These antiresorptive drugs, which are designed to slow the loss of bone density and promote healthy bone formation, also can limit or prevent the spread of cancer to the bones.
Antiresorptive drugs such as bisphosphonates, denosumab, alendronate (Fosamax), and zoledronic acid (Zometa) can improve a patient’s quality of life and even save their life. But like all medications, they carry a risk of side effects. These medications are typically used in patients with cancer-related conditions such as bone metastasis in prostate cancer, breast cancer, multiple myeloma, osteoporosis and Paget’s Disease.
One of those is osteonecrosis of the jaw, or ONJ, an uncommon, potentially serious complication that causes death of the jawbone tissue. ONJ can lead to painful symptoms, such as:
- Oral swelling
- Gum infections
- Jawbone fractures
- Loose or lost teeth
While ONJ can be serious, it is treatable under the care of a specialist. The average doctor or dentist may see one or two cases of this uncommon condition a decade. UT Southwestern dentistry and oral surgery specialists have become a national referral center for ONJ, treating about 150 patients with this complication each year.
The severity and symptomology of ONJ is diverse, and each patient needs a personalized care plan. We work closely with UT Southwestern’s mineral metabolism team – a national leader in clinical research for bone disorder treatment – and our oncology colleagues to halt and cure ONJ, restoring our patients’ quality of life.
Diagnosing and treating ONJ
The jaws and teeth are disproportionately affected by antiresorptive medications. These drugs target and inhibit osteoclasts, the cells that break down bone tissue due to bone-degenerating diseases, such as osteoporosis, or as part of the body’s normal healing process.
Jaws regenerate more often than other bones, so more medication directs there. The teeth are separated from the jaw only by a small ligament, and as a result, less bone healing and building occurs in the jaws and teeth.
ONJ risk to patients who take antiresorptive medication for cancer is between 1-5%. People with osteoporosis get lower doses, so their risk is smaller – less than 0.1%. ONJ can also arise from trauma to the gums or jaw.
ONJ symptoms eventually disrupt quality of life, driving patients to see their dentist or primary care provider. We diagnose the condition as ONJ if damaged, exposed bone persists in the upper or lower jaw for at least eight weeks.
Once all the tissue in a bone die, we can’t revive it. But we can help reduce bone loss if we catch ONJ early. Your treatment plan will depend on the stage of ONJ at diagnosis:
- Stage 0: You are on an antiresorptive medication and have nonspecific jaw pain, but we do not detect dead bone.
- Stage 1: You have exposed dead bone in your mouth, but there is little to no pain.
- Stage 2: You have exposed dead bone that is infected and painful.
- Stage 3: The dead bone has spread beyond the bone adjacent to your teeth.
We will discuss your treatment options and work with you to find the best choice for your health and your life.
Approximately half of patients with Stage 1 ONJ will heal through nonsurgical debridement to halt further bone loss and promote oral tissue healing. Debriding means gently scrubbing the exposed bone to remove dead cells. We’ll prescribe an antiseptic mouth rinse – we call it super-powered Listerine – to use for debriding twice a day with a Q-tip or a soft toothbrush. The gums will regrow underneath the dead bone and pop it off, much like the skin drives out small splinters over time.
Those who don’t heal from frontline treatment progress to Stages 2 or 3, which brings increased pain and recurrent infections, usually need surgery to remove the dead bone. An oral surgeon with expertise in ONJ will remove the dead bone, any teeth that touch it, and a sliver of healthy tissue to ensure no diseased bone cells are left behind. If the dead bone extends into the sinuses, we’ll collaborate with our ear, nose, and throat (ENT) colleagues to perform the surgery.
During surgery, we inject platelet-rich fibrin into the wound, using growth factor made from your own blood to promote faster healing. This advanced treatment is not widely available at other centers.
After surgery, you will stay overnight to get three doses of IV antibiotics to reduce the risk of post-surgical infection. Approximately 92% of patients who have surgery will be cured. The gums will heal and cover the healthy exposed bone. If you have future dental work – such as having a tooth pulled or developing new gum disease – there is a risk of ONJ returning, with a need for a second surgery.
Some patients with Stage 1 ONJ choose to have surgery instead of nonsurgical debridement, which can take up to three years for full healing. Along with twice-daily cleanings, you’ll need to visit the dental and oral surgery team every three months to make sure no more bone tissue dies.
Reducing your risk of ONJ
Proactive dental care before and during antiresorptive drug therapy can reduce the risk of developing ONJ by 50%. If your doctor recommends an antiresorptive medication for cancer or osteoporosis, you may also be referred to an oral surgery specialist for advanced care.
We will examine your dental health and recommend oral care, such as treating gum disease, prior to starting your medication. Our experts will talk with you about potential changes to your daily dental routine to maintain or improve your tooth and gum health.
If your teeth, jaws, or gums require extensive care, antiresorptive medication may not be a safe choice for your osteoporosis or cancer treatment. Working closely with the mineral metabolism team, your oral health and oncology specialists can collaborate to find a lower-risk option to help rebuild healthy bone tissue.
Specialized care from the ONJ experts
Before coming to UT Southwestern, many patients with ONJ see multiple providers without getting a proper diagnosis or treatment plan. Our specialists see a much higher volume of ONJ cases than most health care centers – we can give you a precise diagnosis and personalized treatment plan. Because you are being treated at an academic medical center, your care should be covered by your primary health insurance rather than your dental insurance.
My current research is focused on deepening our understanding of how to prevent osteonecrosis of the jaw, as well as refining our leading-edge treatment options. Daily advances in medical oncology and mineral metabolism are improving the safety profiles of bone cancer and osteoporosis medications.
If you or a loved one experiences unexplained jawbone pain or exposed bone in the mouth, talk with a specialist as soon as possible. Time saved is bone saved – the earlier we diagnose and treat ONJ, the better your outcomes can be.