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Thinning of the Jaw and Bisphosphonate Therapy

Contributed by: Jeneal Bennett, Pharm.D. Candidate

KU School of Pharmacy

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Text Box: Recently patients who are taking bisphosphonates, such as Fosamax TM, may have heard news about a condition commonly referred to as thinning of the jaw, dead jaw, or ONJ (osteonecrosis of the jaw). Osteonecrosis means cell death of the bone; ‘osteo’ meaning bone and ‘necrosis’ meaning tissue or cell death. In high risk patients the use of bisphosphonates can increase the risk of developing ONJ. Bisphosphonates have been approved for the treatment of osteoporosis, or thinning of the bone, and also to control high calcium levels in cancer patients who have a risk of the cancer metastasizing, or spreading, to the bone. Many of the more common cancers, such as lung, prostate, and breast cancer, carry a high risk of spreading to the bone. Multiple myeloma, cancer of the bone marrow, is also treated with bisphosphonates to decrease the spread of the cancer to further bone. Many patients who are not taking bisphosphonates can develop ONJ as this disease is not a direct cause of bisphosphonate therapy. However, there have been recent reports of cancer patients who are already receiving doses of chemotherapy, radiation and corticosteroids along with bisphosphonates who have experienced ONJ. Patients who are not receiving the above therapies but who are on bisphosphonates do not appear to be at the highest risk of developing ONJ. The suppressive properties of the cancer treatments act along with bisphosphonates to decrease the regenerative ability of the bone tissue,

Text Box: particularly around the upper and lower jaw. This means that if any damage should occur to the bone, for example, during a tooth extraction, then the ability of the tissue to heal itself is decreased. This can result in ONJ or “dead jaw” over time. Certain formulations of bisphosphonates show a much higher probability than others for precipitating ONJ in high risk patients. The intravenous formulations, namely Aredia TM (pamidronate) and Zometa TM (zoledronic acid), may carry a higher risk than oral formulations. Most intravenous bisphosphonates are given to a patient every three months under medical supervision. Patients who receive greater than six months of bisphosphonate therapy also carry a higher risk for ONJ than those who receive treatment for shorter periods of time. Most patients using bisphosphonates for osteoporosis are taking oral formulations, such as Fosamax TM (alendronate) and Actonel TM (risedronate). Boniva TM (ibandronate) is supplied orally or intravenously. To date, the intravenous forms of the bisphosphonates have shown the highest incidence of ONJ, however, cases of ONJ have been reported for both oral and intravenous formulations.

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