Title Dental Preventive Treatments Can Reduce The Risk Of Developing Osteonecrosis Of The Jaw In Cancer Patients Receiving IV Bisphosphonate
Clinical Question Should cancer patients that require IV bisphosphonate therapy complete preventive dental treatment prior to initiating the bisphosphonate treatment, as opposed to not receiving prior dental treatments, in order to decrease the patients’ risk of developing osteonecrosis of the jaw (ONJ)?
Clinical Bottom Line Study has shown that in cancer patients that require bisphosphonate therapy, completing preventive dental treatment prior to initiating the bisphosphonate treatment decreases the development of osteonecrosis of the jaw.
Best Evidence  
PubMed ID Author / Year Patient Group Study type
(level of evidence)
18647964Ripamonti/2009966 cancer patients receiving I.V. bisphosphonateHeterogeneous Cohort and Case-Control Study
Key resultsThe researchers observed a decrease in the incidence of ONJ from 3.2 % to 1.3 % when dental preventive measures were implemented before bisphosphonate treatment (either IV Pamidronate or Zoledronic Acid). These preventive measures included scaling and root planing, root canal therapy and extractions. For patients receiving specifically zoledronic acid, implementation of dental preventive measures led to an even more substantial reduction in ONJ, that is, 7.8% in the group without preventive dental treatment and 1.7 % in the group with preventive dental treatment prior to bisphosphonate treatment. (IR ratio = 0.30, 95% confidence interval 0.03-1.26).
Evidence Search “osteonecrosis of the jaw” AND “dental preventive measures”
Comments on
The Evidence
The post-prevention (patients receiving bisphosphonate treatment after dental preventive measures) group of this study started similarly and was treated in a similar way. The post-prevention group consists of cancer patients with bone metastases that were prescribed IV bisphosphonate treatment. Patients were prescribed either pamidronate or zoledronic acid. Each drug was infused according to a fixed schedule among all patients receiving the same drug. However, as the authors of this research pointed out, while the study observes the post prevention patients prospectively, they were only able to gather data on ONJ onset of the pre-prevention group retrospectively and non-systematically. This probably led to an underestimation of ONJ onset of this group. Another potential contributor of error is the relatively short duration (median follow-up time 9.3 months) of the prospective part of the study (observation on the post-prevention patients). This may lead to an underestimation of ONJ onset among the post-prevention group. However, despite the weakness of this study, it does show that the implementation of preventive dental measures can significantly reduce the development of ONJ for patients receiving zoledronic acid.
Applicability These findings are applicable to cancer patients preparing to receive bisphosphonate therapy, especially those planning to receive intravenous bisphosphonates. This study was conducted on cancer patients with pre-existing bone metastases, and demonstrates that dental preventive measures can reduce the risk of developing ONJ if performed prior to bisphosphonate therapy. This study did not describe if or how risk of progression bone metastases during delay of bisphosphonate therapy was assessed. In fact, there are no studies that specifically address risk of metastatic progression due to delay of bisphosphante treatment. However, dental care can be administered in one to two days therefore risk of metastases progression during dental treatment is unlikely. This study supports the current recommendations advising health care providers to identify and treat dental disease prior to initiation of bisphosphonate therapy.
Specialty (Oral Medicine/Pathology/Radiology) (Endodontics) (General Dentistry) (Oral Surgery) (Periodontics) (Dental Hygiene)
Keywords Bisphosphonates, osteonecrosis of the jaw, ONJ, dental preventive measures, dental preventive treatments
ID# 2265
Date of submission 04/20/2012
E-mail yangy6@livemail.uthscsa.edu
Author Yen-Han Yang
Co-author(s) e-mail
Faculty mentor Cara Gonzales, PhD, DDS
Faculty mentor e-mail gonzalesc5@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?)
None available
Comments and Evidence-Based Updates on the CAT
None available