What Patients Should Know About The Signs And Symptoms As Well As Diagnosis Staging

As reported previously, there is increasing attention being paid to the association between the use of oral bisphosphonates such as Fosamax and osteonecrosis of the jaw (ONJ), a serious side effect which is also called jaw bone decay or jaw death. 

In part one of this series, sub-titled "What Are The Current Causation Theories And Which Patients Are At An Increased Risk", we considered two recent medical journal articles that provide information about how osteonecrosis of the jaw (ONJ) may be caused by Fosamax and other bisphosphonates as well as identify some of the predisposing, or risk, factors for developing ONJ.

Those same two medical journal articles give some important information about the early signs and symptoms of osteonecrosis of the jaw (ONJ) as well as the extent, or staging, of ONJ upon diagnosis.

To begin, we take a concise description of ONJ caused by bisphosphonates from an article published in the November 30, 2006 edition of The New England Journal of Medicine (NEJM) called "Osteonecrosis of the Jaw — Do Bisphosphonates Pose a Risk?", by Dr. John P. Bilezikian:

Osteonecrosis of the jaw is characterized clinically by an area of exposed bone in the mandible, maxilla, or palate that typically heals poorly or does not heal over a period of 6 to 8 weeks….

The lesion is painful in many, but not all, patients, and infection is often present. Approximately two thirds of cases involve the mandible and the rest involve the maxilla.

For some discussion about the early signs and symptoms of ONJ we turn to an article published in Hematology 2006 called "Bisphosphonate Complications Including Osteonecrosis of the Jaw":

Typical presentation is in the form of a nonhealing extraction socket, presence of exposed bone, gingival swelling or purulent discharge, when local debridement and antibiotics are ineffective. Often, a nonhealing ulcer or exposed bone may be detected on routine oral care that may remain asymptomatic, until superinfection sets in when swelling, pain, loosening of teeth and discharge may develop. Occasionally, pain in the jaw bone may be the only symptom without any evidence of radiological abnormalities. Eighty percent of patients report an antecedent dental procedure prior to presentation. Median age in one series was 68 years, mandible as the site of involvement is seen in two-thirds of the patients and maxillary involvement is in a third.

This same article about osteonecrosis of the jaw (ONJ) in Hematology 2006 also sets forth a basic explanation about the extent, or staging, of this condition upon diagnosis:

Oral surgical colleagues have reported a staging system from I to III based on the presence of symptoms such as pain, degree of swelling, ulceration, exposure of bone, response to topical antibiotic rinses, requirement for debridement and requirement of intravenous antibiotics….

Staging ONJ appropriately based on clinical and radiographic findings may be used to direct specific local and systemic therapy. Stage I disease as characterized by asymptomatic detection of exposed bone without soft tissue infection, may be managed conservatively with a non-surgical conservative approach to avoid further osseous injury….  Stage II disease characterized by presence of symptoms around the area of exposed bone secondary to soft tissue swelling and/or bone infection may require culture-directed long-term and maintenance antimicrobial therapy, analgesic management, in addition to conservative measures outlined for stage I disease….  Stage III disease is characterized by the presence of a pathological fracture (not related to metastatic disease), exposed bone associated with soft tissue infection, which is not manageable with antibiotics alone due to the volume of necrotic bone.

Although dentists and oral surgeons are becoming more aware of the association between oral bisphosphonates such as Fosamax and osteonecrosis of the jaw (ONJ), patients using these drugs should be knowledgeable about the symptoms of this serious side effect and what treatment is appropriate for them if they are, unfortunately, diagnosed with ONJ.

(Posted by: Tom Lamb)