Guest Editorial: The Magic of Modern Medicine: A Dilemma for Dentistry?

Editorial:

The magic of modern medicine has given us remarkable benefits for patients suffering from serious diseases with improvements in both the quality and quantity of their lives. As with most new agents, side effects often emerge of which we must be aware. As you undoubtedly know, since late 2003 there have been a large number of reports regarding bisphosphonate associated osteonecrosis of the jaws. This was the subject of a position paper by the Academy of Oral Medicine1 published in the Journal of the Dental Association in December of 2005. Although it clinically resembles osteoradionecrosis, it nonetheless does not respond to treatments such as debridement, antimicrobial therapy or hyperbaric oxygen. In fact, at the present time, there is no good therapeutic approach to the management of this unfortunate condition. Bisphosphonate associated osteonecrosis of the jaws has been reported in our professional literature in approximately two hundred patient cases. Since these drugs are widely prescribed and their usage is increasing, there is concern that the cases already reported may just be the tip of the iceberg,
Bisphosphonates are currently prescribed to over twenty-seven million Americans and have made a remarkable difference in averting fractures, especially in the elderly. Current indications include osteoporosis, Paget's disease, multiple myeloma, and metastatic cancer from breast, lung and prostate. These powerful agents combine with bone and stabilize osseous tissue by interfering with osteoclastic activity, thereby preventing bone remodeling. They also seem to reduce the vascularity of bone. Bisphosphonates are bound to bone at the cellular level and remain for many years, if not indefinitely. The majority of cases of bisphosphonate osteonecrosis are associated with intravenous administered potent agents such as pamidronate and zoledronic acid. These reports resulted in the publication of guidelines by Novartis Pharmaceutical Corporation2, the manufacturer of Zometa and Aredia, regarding the dental management of patients on the intravenous use of these drugs. These recommendations include avoiding all surgical procedures if possible in these patients. Such precautions are necessary for those taking the intravenous form of bisphosphonates who represent the majority of those at risk for osteonecrosis of the jaws.
Clearly at issue still is what to do with the vast majority of individuals who are taking oral bisphosphonates for prevention of osteoporosis. Oral agents include etidronate, risedronate, tiludronate, alendronate and ibandronate. Of the millions of people using these agents, there are few reported cases of osteonecrosis of the jaws. There are currently no specific guidelines.  What should we do? What is the relative risk to our patients? Should we avoid extractions? Should we not provide implants? We know that depriving patients of needed care is not a good solution.
As a common sense answer, we need to make a risk assessment for each patient based upon the agent taken, the reason for bisphosphonate prescription, the mode of administration, dosage, duration of therapy, and whether the patient is currently taking the medicine. Similarly, we need to determine through oral examination whether the patient requires any treatment that is likely to place them at risk for osteonecrosis. We also know that it is the patient's right to expect treatment, and therefore, it is unethical to deny needed care because of a possible but unlikely risk. There have been many times in the history of our profession when newly emergent diseases or medication side affects have resulted in virtual hysteria and overreaction on the part of our profession. Look at what happened in the 1980s.  It was virtually impossible to find a dental practitioner willing to treat patients with late stage HIV infection. We now know that the risk of transmission from patient to health care provider is virtually nonexistent. In actuality, the HIV epidemic has resulted in the safest possible health care environment for patients and dentists by insuring the use of universal precautions and informed consent. We may find a parallel in bisphosphonate associated osteonecrosis. However, particularly in the absence of specific guidelines at the present time, the patient must be a part of the decision process. We must advise our patients of the current state of knowledge of this group of drugs and the potential side effects before rendering treatment.  We need to consult with their physicians regarding our concerns. Most importantly, we need to obtain consent from our patients for whatever course of care we recommend. Informed consent is much more than just obtaining a signature on a piece of paper. Informed consent is just what it sounds like. It is the process of advising the patient of options, risks, alternatives, and jointly making a decision about what will be done. Developments in the area of bisphosphonates-related osteonecrosis are developing rapidly. Guidelines from the American Dental Association at www.ada.org have just been published. In the meantime, we recommend that you treat your patients with care, caution, and with their consent, as you would prefer to be treated in similar circumstances.
    Joseph L. Konzelman Jr., D.D.S.
    Wayne W. Herman, D.D.S., M.S.
    Professors, Oral Medicine
    Medical College of Georgia
      School of Dentistry
References
  1.    Migliorati CA, Casiglia J, Epstein J, Jacobsen PL, Siegel MA, Woo S-B: Managing the care of patients with bisphosphonate-associated osteonecrosis: an American Academy of Oral Medicine position paper. JADA 2005; 136:1658-1668.
2.    Expert panel recommendations for the prevention, diagnosis, and treatment of osteonecrosis of the jaws. June 2004: Professional education material. East Hanover, N.J.: Novartis Pharmaceutical Company; 2004.