Title Nonsurgical Root Canal Treatment Is an Appropriate Alternative to Extraction in Patients with BRONJ and/or on Bisphosphonate Therapy
Clinical Question What are the endodontic implications for managing patients with bisphosphonate-related osteonecrosis of the jaw (BRONJ)?
Clinical Bottom Line In treating patients with a history of bisphosphonate administration, it is imperative to collect a medical history and class of bisphosphonate given for patients at risk for BRONJ. Preventive dental treatments and nonsurgical endodontic therapy should be considered instead of surgical options (including extractions or surgical endodontic treatment). This should be started before bisphosphonate therapy to reduce the risk of subsequent osteonecrosis. Pain related to osteonecrosis may mimic pain of odontogenic origin and should be considered in the differential diagnosis. During root canal therapy, clinicians need to take special precautions to minimize trauma to the marginal (rubber dam clamp placement) and apical (length of instrumentation and obturation) periodontal tissues. Root canal treatment may be considered a safe and realistic alternative to extraction in patients with BRONJ and on bisphosphonate therapy.
Best Evidence  
PubMed ID Author / Year Patient Group Study type
(level of evidence)
16249730Katz/20053 patients with BRONJCase Series
Key resultsCases showed that the nitrogen-containing bisphosphonate class of drugs (zolendronate) had a greater potential for causing osteonecrosis. Hyperbaric oxygen therapy or extensive antibiotic treatment did not appear to promote healing in these cases. Nonsurgical endodontic therapy should be considered instead of surgical options. Patients’ teeth were isolated, accessed, cleaned, and shaped using the step-back and crown-down methods with rotary NiTi files. The canal systems were obturated with cold lateral compaction of Resilon and temporized. Patients became comfortable 2 days following endodontic therapy and remained without symptoms at a 6-month follow-up.
16683515Goodell/20062 patients with BRONJCase Series
Key resultsIn both cases, osteonecrosis of the jaws occurred. For patients on bisphosphonate treatment, nonsurgical root canal treatment should be performed as soon as possible when pulpal disease is identified in order to prevent osteonecrosis. Both these cases illustrate that timing and accurate pulpal and periradicular tests are paramount before proceeding with endodontic treatment as a method of prevention for osteonecrosis.
19840641Hsiao/200934 teeth from 28 patients with BRONJ. 38 control teeth from 30 patients without BRONJ. Retrospective Cohort Study
Key resultsNonsurgical root canal treatment and retreatment were performed on 34 teeth with preoperative periradicular radiolucencies in 28 patients undergoing oral bisphosphonate therapy. Thirty-eight control teeth were selected from patients not taking bisphosphonates. In the bisphosphonate group, 73.5% of the lesions healed, whereas the control cases had a healing rate of 81.6%. There was no statistically significant difference between the groups (p > 0.05). The results suggest that patients taking long-term oral bisphosphonates can expect a satisfactory outcome with evidence of periradicular healing after conventional root canal treatment.
16249730Gallego/201154-year-old woman with BRONJCase Report
Key resultsTrauma to periodontal and marginal bone tissues by rubber dam clamp position in dental conservative treatments represents a risk factor for BRONJ development. Although non-surgical endodontic treatment (or retreatment) should be considered as the alternative to extraction, special care should be taken during those procedures. Avoiding trauma related to rubber dam clamp use or minimizing periodontal trauma from its position represents an important goal for BRONJ prevention.
Evidence Search Endodontic[All Fields] AND Implications[All Fields] AND ("bisphosphonate-associated osteonecrosis of the jaw"[MeSH Terms] OR ("bisphosphonate-associated"[All Fields] AND "osteonecrosis"[All Fields] AND "jaw"[All Fields]) OR "bisphosphonate-associated osteonecrosis of the jaw"[All Fields] OR ("bisphosphonate"[All Fields] AND "associated"[All Fields] AND "osteonecrosis"[All Fields] AND "jaws"[All Fields]) OR "bisphosphonate associated osteonecrosis of the jaws"[All Fields])
Comments on
The Evidence
All four articles were published in the Journal of Endodontics. The four articles give evidence to what implications need to be considered in treating patients with bisphosphonate-related osteonecrosis of the jaw and the prevention of osteonecrosis. The special implications that need to be considered are the use of preventive measures such as regular dental prophylaxis, fluoride, and 0.12% chlorhexidine to reduce the potential for tooth extractions because of caries or periodontal conditions. When implicated, treat irreversible pulpitis early on with nonsurgical endodontic therapy to reduce the risk of osteonecrosis. In a patient with a history of intravenous bisphosphonates, extractions should be avoided because osteonecrosis is often related to a site of previous extraction. Special caution should be taken to avoid trauma to the periodontal tissues when using the rubber dam clamp. The evidence presented suggests that patients taking long-term bisphosphonates can expect a satisfactory outcome following nonsurgical root canal therapy with little risk of osteonecrosis development.
Applicability I believe the research is highly applicable because it does not require implementation of different endodontic methods. Standard methods used in nonsurgical endodontic therapy proved to be effective in treating irreversible pulpitis and the healing of periradicular lesions in patients with BRONJ. All cases showed no onset of osteonecrosis following nonsurgical root canal therapy but rather an increased risk when extraction or surgical endodontic therapy was performed. However, it is always necessary to consider the risks and benefits of any treatment being prescribed. Clinicians should be aware of the benefits of bisphosphonates in significantly reducing the risk of fractures, which are a cause of marked morbidity and mortality, and should weigh this against the risk for ONJ.
Specialty (Endodontics) (General Dentistry) (Interprofessional CATs)
Keywords bisphosphonates, osteonecrosis, endodontics, root canal, BRONJ
ID# 3220
Date of submission 04/10/2017
E-mail jonesat@livemail.uthscsa.edu
Author Andre Jones
Co-author(s) Anne C. Jones, DDS
Co-author(s) e-mail JONESAC@uthscsa.edu
Faculty mentor Kenneth Hargreaves, DDS, PhD
Faculty mentor e-mail HARGREAVES@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