ORAL HEALTH EVIDENCE-BASED PRACTICE PROGRAM
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Title Intermittent Low-Dose Parathyroid Hormone [rhPTH(1-34)] Is Useful As Adjunctive Therapy For Bisphosphonate-Related Osteonecrosis Of The Jaw (BRONJ)
Clinical Question In patients with bisphosphonate-related osteonecrosis of the jaw, is intermittent low-dose parathyroid hormone [rhPTH(1-34)] used as adjunctive therapy a more effective treatment than local measures alone?
Clinical Bottom Line Intermittent, low-dose parathyroid hormone [rhPTH(1-34)] has an anabolic effect on bone and may be useful as adjunctive therapy when bisphosponate-related osteonecrosis of the jaw develops. However, since there have only been a small number of cases reported in which teriparatide [rhPTH(1-34) was successfully used as adjunctive therapy for treatment of BRONJ, further research is necessary to confirm its efficacy. (See Comments on the CAT below)
Best Evidence (you may view more info by clicking on the PubMed ID link)
PubMed ID Author / Year Patient Group Study type
(level of evidence)
#1) 17307613Harper/200775 yr old Caucasian FemaleCase Study
Key resultsPatient with BRONJ discontinued fosamax and was treated with teriparatide rhPTH(1-34) at 20 μg subcutaneous daily. After a 3-month course clinical signs of soft tissue healing were apparent and the radiographs showed an increase in extraction site healing. After a 10-month course of the hormone the panoramic x-ray showed healed extraction sites with a moderate degree of sclerosis. At that time the patient presented with normal mucosa, had no ulcerations, and was pain free.
#2) 20415805Narongroeknawin/201063 yr old Caucasian maleCase study
Key resultsThe patient was treated with alendronate for osteoporosis and developed BRONJ after extraction of maxillary teeth. The treatment changed from alendronate to 20 μg teriparatide rhPTH(1-34) daily and the BRONJ resolved. Radiographs showed osseous regeneration with increased bone densisty.
#3) 20950167Cheung/201088 yr old FemaleCase study
Key resultsPatient was treated with 70 mg alendronate weekly for 10 years and subsequently developed BRONJ. Patient was given subcutaneous teriparatide at a dose of 20 μg per day. After 8 weeks of treatment, her symptoms resolved, with healing of the osteonecrosis.
#4) 17307613Tsai/200972 yr old femaleCase Study
Key resultsPatient had taken alendronate weekly for 4 years and developed a painful fistula. Conventional therapies failed to improve her BRONJ. After 5 months of treatment with 20 μg teriparatide, significant bone regeneration was found and the mandibular fistula was healing. At 10 month follow-up, the panoramic radiograph showed complete resolution of the necrotic region.
#5) 19671824Lau/200956 yr old Caucasian femaleCase Study
Key resultsPatient was being treated for osteoporosis since 1995 and was prescribed several bisphophonate-containing drugs including pamidronate and zoledronate. In 2005 she developed maxillary osteonecrosis. She discontinued the zoledronate and began taking 20 μg teriparatide daily. After 2 months of treatment, she noticed improvement in pain and ulcer healing. After an 18 month course of teriparitide, oral ulcers were completely healed with negligible pain.
Evidence Search Pubmed search using “Osteonecrosis"[Mesh] AND "Teriparatide"[Mesh]
Comments on
The Evidence
There are only a few case studies in which BRONJ was successfully treated with Teriparatide [rhPTH(1-34)]. However, a randomized controlled study testing the efficacy of Teriparatide in the treatment of BRONJ is still necessary before any confident claims can be made.
Applicability This applies to patients with BRONJ and their doctors.
Specialty/Discipline (Public Health) (Oral Medicine/Pathology/Radiology) (General Dentistry) (Oral Surgery) (Orthodontics) (Periodontics) (Prosthodontics) (Restorative Dentistry)
Keywords Bisphosphonate, osteonecrosis, parathyroid hormone, teriparatide, alendronate
ID# 864
Date of submission: 04/14/2011spacer
E-mail porterac@uthscsa.edu
Author Chris Porter
Co-author(s)
Co-author(s) e-mail
Faculty mentor/Co-author Jack Vizuete, DDS
Faculty mentor/Co-author e-mail VizueteJ@uthscsa.edu
Basic Science Rationale
(Mechanisms that may account for and/or explain the clinical question, i.e. is the answer to the clinical question consistent with basic biological, physical and/or behavioral science principles, laws and research?)
post a rationale
None available
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Comments on the CAT
(FOR PRACTICING DENTISTS' and/or FACULTY COMMENTS ON PUBLISHED CATs)
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by Mark Lewis, Chase Nesloney (San Antonio, TX) on 10/03/2014
A PubMed and Trip Database search in October 2014 found a new case report by Ohbayashi 2013, PubMed: 23246226. This case report confirmed the answer that parathyroid hormone [rhPTH(1-340] therapy is a useful treatment for BRONJ. This study also used bone scintinography as further evidence of the increased turnover rate of bone in the affected area. The article also mentions as the CAT does that further research is needed as the only evidence are case reports at this time.
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