Bisphosphonate related osteonecrosis of the jaws associated with denture and dentoalveolar surgery

Objectives: The aim of this article was to present and discuss the diagnosis, management, and follow up of a patient treated with zoledronic acid because of a metastatic prostate adenocarcinoma, that developed bilateral mandibular ONJ.
Discussion: Biphosphonates are synthetic analogues of pyrophosphate. Two types of biphosphonates share a common phosphorus–carbon–phosphorus backbone: alkylbiphosphonates, such as clodronate, etidronate and tiludronate, which are devoid of amine function on the lateral chain; and aminobiphosphonates, such as alendronate, pamidronate, zoledronate, risedronate, or ibandronate. Bisphosphonates are used in cancer patients to decrease and delay complications associated with metastasis, thanks to their binding activity to hydroxyapatite and their capacity to inhibit bone turnover by interfering with osteoclastic activity.
Therefore, bisphosphonates are used to prevent and reduce hypercalcemia, pain, and pathologic fractures. Nevertheless, bisphosphonates may be associated with a considerable risk for the development of osteonecrosis of the jaw (ONJ).
Different etiological factors have been reported to determine ONJ, such as dental extractions, the placement of dental implants, and the use of dental prosthesis.
Conclusions: The management protocol for MRONJ is challenging and remains a controversial topic. However, the treatment protocol should be always individualized according to the condition stage and symptoms. Multiple treatment approaches have been proposed to try to control ONJ, including conservative treatment, surgical debridement, and resection of the lesions. Anyway, the improvement of oral hygiene, the treatment of existing dental and periodontal disease, mouth rinses, and systemic antibiotic therapy all play an important role in the management of ONJ.
Clinical significance: A great attention should be made to all risk factors for ONJ, as our case shows. Dental practitioners should take care of both dentoalveolar surgery and dentures in patients that assume bisphosphonates.

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