Osteonecrosis of the Jaw (ONJ): Information on Causes, Diagnosis & Treatments

Jaw Breaks Done Rare Condition Osteonecrosis of The Jaw (ONJ), or dead jaw syndrome, is a serious but rare condition that relates to the destruction or severe loss of the jawbone. The syndrome is known to disrupt the supply of blood to the jawbone which leads to tiny breaks and eventually severe damage to the affected area and total bone collapse. This includes a loss of teeth. Osteonecrosis can develop in a single bone, or in many bones throughout the body including the jaw, knee, or hip.

Medical science has identified the underlying cause of osteonecrosis of the jaw to develop from injury or taking specific medications, especially cortisone-like drugs including prednisone. There are many reports of individuals developing dead jaw syndrome after receiving oral or intravenous bisphosphonate medications for the treatment of numerous conditions other than osteonecrosis.

Usually, the dead or necrotic bone is detected when the jaw bone is exposed after the extraction of a tooth or when dentures cause and irritation when the dental device rubs against mucosa (skin) inside the mouth. Usually, patients with necrotic bone suffer extreme pain anytime the affected area is touched. The affected area tends to heal very slowly over time.

Who Is at Risk for Osteonecrosis of The Jaw?

Medical science has yet to determine the exact reason why some individuals develop ONJ and others do not. Only a small percentage (1% to 2%) of individuals who take denosumab or bisphosphonate medications will develop osteonecrosis of the jaw during their lifetime. The risk is significantly lower (1 out of 100,000) for individuals who are taking the medication for the treatment of osteoporosis.

The likely reason the percentage is of risk is significantly last for individuals being treated for osteoporosis is the dosage is much less than those who are being treated for cancer. Other people at risk for developing osteonecrosis of the jaw are individuals with multiple myeloma or those who have had a dental surgical procedure while taking these drugs.

There are steps patients can take to reduce the potential risk of developing osteonecrosis of the jaw including maintaining optimal oral health to ensure the gums and teeth remain healthy. Before beginning any dose of these medications, it is essential to visit the dentist and have any major dental surgery like an extraction or implant completed prior to taking the drug. In addition, the mouth will need to heal completely, which might take months, before taking any of the drugs, to avoid complications involving the development of osteonecrosis of the jaw.

If the patient needs dental surgery when taking the medications, it is essential to have a discussion with the oncologist to minimize the potential chance of developing the serious syndrome.

Known risk factors associated with owning include:

  • Chemotherapy

  • Head or neck radiation therapy

  • Infections

  • Low blood count (anemia)

  • Blood-related disorders

  • Poor nutrition

  • Poor oral health

  • Cigarette smoking

  • Excessive alcohol consumption

  • Dental surgery and Gum disease

  • Cancers including metastatic bone disease or multiple myeloma

  • Corticosteroid treatments

  • Osteoporosis

  • Paget’s disease involving brittle and enlarged bones

  • Clotting issues

  • Poor blood circulation

Some doctors are prescribing bisphosphonate medications for off-label reasons, including for participation in clinical trials. It is important to discuss with the doctor the serious side effects of taking the medication each to avoid the development of osteonecrosis of the jaw.

Common Symptoms

The symptoms often associated with osteonecrosis of the jaw include:

  • Loose teeth

  • Bleeding gums that never heal

  • Gum or jaw infections

  • Swollen and painful jaw or gums

  • Draining because caused by jaw abscess

  • Exposed jawbone where gum tissue is missing

  • A sense of heaviness or numbness in the jaw area

Many individuals with osteonecrosis of the jaw do not experience symptoms for many weeks or months after its initial onset. In some cases, the condition only reveals itself after the bone is exposed during a tooth extraction or dental procedure.

Diagnosing Osteonecrosis of the Jaw

An accurate diagnosis of osteonecrosis of the jaw is usually verified by a physician, oral surgeon, or dentist. The medical professional will typically perform a comprehensive examination of the interior of the mouth in order tests and x-rays to identify an infection that is often verified after taking a microbial culture. The doctor may also order other tests that include:

  • CTX (C-Telopeptide) laboratory tests that measure the bone turnover rate. The results of the test can determine the level of risk of developing ONJ.

  • Other Laboratory Tests – The doctor might order a variety of laboratory studies to rule out other potential causes of damage to the bone that could include osteomyelitis, benign bone lesions, primary malignancy, or metastatic lesions. The test usually involves a biopsy where a small sample of tissue is removed and evaluated in a laboratory setting.

Treating the Condition

Unfortunately, osteonecrosis of the jaw is an irreversible syndrome, meaning medical science has yet to develop a cure for the condition. To manage symptoms and minimize complications, the doctor will prescribe antibiotics, removable dental appliances, and chlorhexidine mouthwashes. In addition, the dentist may perform minor adjustments to the patient’s dental work to eliminate sharp edges of bones that have been damaged by the condition and remove any tissue that has become injured as a result of action and irritation.

Research indicates that stopping the damaging medications is not effective at minimizing the destruction the drugs are causing. There is no evidence of proof on how long the damage caused by osteonecrosis of the jaw will continue. However, the dentist or treating physician might recommend the patient stop taking the medication a few months prior to invasive dental procedures and afterward, up to six months or a year, or longer.

There are preventative methods that can minimize many of the risks associated with osteonecrosis of the jaw. This includes practicing optimal oral hygiene and ensuring the patient receives regular dental care. However, every visit to the dental office should be preceded by a discussion of how the patient is taking oral bisphosphonate drugs, especially when undergoing a tooth extraction, root canal therapy, or routine dental cleaning.

Some doctors recommend that patients suffering from osteonecrosis of the jaw consume up to 1200 mg of calcium each day and add vitamin D to their daily diet. In addition, the patient should quit smoking, engage in weight training and exercise, minimize alcohol intake and reduce levels of daily caffeine.

Oftentimes, the patient will be required to begin a course of antibiotics before having any dental surgery, and the dentist will take precautions at avoiding any injury to soft tissue in the mouth when providing care. Good oral hygiene followed by routine dental care to treat gum (periodontal) disease and prevent infections is one solution for lowering the risk of developing osteonecrosis of the jaw.

Many clinical trials are conducted throughout the United States by medical professionals who specialize in treating metabolic bone disorders. However, not every patient is an ideal candidate for every clinical trial. Individuals suffering from osteonecrosis of the jaw who are interested in participating in a clinical trial should discuss every available option for alternative treatments with their oncologist to determine the benefits they might receive.

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Sources:

http://www.mayoclinic.org/medical-professionals/clinical-updates/endocrinology/osteonecrosis-jaw-onj-update

https://my.clevelandclinic.org/health/articles/avascular-necrosis

https://view.officeapps.live.com/op/view.aspx?src=https://www.cdc.gov/nchs/ppt/icd9/att4_osteonecrosis_sep06.ppt

https://www.rheumatology.org/I-Am-A/Patient-Caregiver/Diseases-Conditions/Osteonecrosis-of-the-Jaw-ONJ

http://ascopubs.org/doi/full/10.1200/jco.2005.02.8670

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