Gerald S. Fine, D.D.S.
Oral and Maxillofacial Surgery
In January a 74-year-old woman was referred to my office for a tooth extraction. The patient's medical history was significant for metastatic cancer, thyroid disease, and mitral valve prolapse. Her primary care physician told me that our patient had been treated for metastatic cancer with a combination approach of surgery, radiation therapy and three chemotherapeutic drugs. The "cocktail" chemotherapeutic agents used included the bisphosphonate, Zometa. The development of osteonecrosis was now of concern.
Bisphosphonates are a class of compounds used for the treatment of many different medical conditions. Their efficacy in reducing bone pain in patients with metastatic breast cancer, multiple myeloma, and other bone metastasizing tumors has been well documented. Bisphosphonates are also widely used for the treatment of postmenopausal osteoporosis. Among the oral bisphosphonates used most often are, Alendronate (Fosamax), Risedronate (Actonel), and Ibandronate (Boniva). The intravenous bisphosphonates, Pamidronate (Aredia) and Zoledronate (Zometa) are typically administered monthly in patients with metastatic bone disease. Bisphosphonates are potent chemical agents, not without potentially significant side effects. The development of osteonecrosis of the jaw is now associated with all bisphosphonates, including the oral preparations.
When osteonecrosis develops it may remain asymptomatic for many weeks or months and may only be recognized by the presence of pain or exposed bone in the oral cavity. The necrosis may occur spontaneously or, more commonly, at the site of a tooth extraction. Although we do not consider oral bisphosphonate therapy an absolute contraindication in patients who require elective dental alveolar surgery, it is suggested that patients be informed of the small potential risk of compromised bone healing.
My patient was pre-medicated because of her cardiac status of mitral valve prolapse and the tooth was removed under local anesthesia. She was recently re-examined and demonstrated a complete and unremarkable healing with no evidence of osteonecrosis.
Gerald S. Fine, D.D.S.
Practice limited to oral & maxillofacial surgery