From the AAE Web Site
Bisphosphonates are an important class of drugs that have widespread use in managing osteoporosis and treating
certain cancers. A recently recognized adverse effect, bisphosphonate-associated osteonecrosis of the jaws (ONJ),
has important medical and dental implications. The American Association of Endodontists offers this Position
Statement to help make our members aware of these implications. It is, of course, up to the individual endodontist
to determine what course of treatment to undertake with respect to any given patient.
Bisphosphonates are commonly used to treat certain resorptive bone diseases such as osteoporosis, Paget’s disease
and hypercalcemia associated with certain malignancies such as multiple myeloma and bone metastasis from the
breast or prostate (Lipton 2003; Licata 2005; Lipton 2005). Bisphosphonates inhibit bone resorption by inhibiting
osteoclast activity (Lindsay and Cosman 2001), although other actions such as inhibition of angiogenesis have also
been reported (Wood et al. 2002; Santini et al. 2003; Vincenzi et al. 2005).
Bisphosphonate-Associated Osteonecrosis of the Jaws
There is growing recognition that bisphosphonates may be associated with a rare adverse event called
osteonecrosis of the jaws (ONJ). Several case reports, letters to the editor, reviews and position statements from
the U.S. FDA and interested pharmaceutical companies have been published on bisphosphonate-associated ONJ
(Carter and Goss 2003; Marx 2003; Migliorati 2003; Hellstein and Marek 2004; Ruggiero and Mehrotra 2004; Carter
et al. 2005; Cheng et al. 2005; Durie et al. 2005; Katz 2005; Markiewicz et al. 2005; Marx et al. 2005; Melo and Obeid
2005; Melo and Obeid 2005; Migliorati 2005; Migliorati et al. 2005; Migliorati et al. 2005; Novartis Pharmaceuticals
Corporation 2005; Purcell and Boyd 2005; Sarathy et al. 2005; Wooltorton 2005; Zarychanski et al. 2006). Because
there currently are no available randomized controlled trials or higher levels of clinical evidence, the following
information is presented based on retrospective analysis of case reports and expert opinions.
Patients presenting with bisphosphonate-associated ONJ typically present with at least some of the following signs
• An irregular mucosal ulceration with exposed bone in the mandible or maxilla
• Pain or swelling in the affected jaw
• Infection, possibly with purulence
• Altered sensation (e.g., numbness or heavy sensation).
Additional important issues related to bisphosphonate-associated ONJ include:
• The site of occurrence of the osteonecrosis is the jaws, and presentation occurs more frequently in the
mandible than in the maxilla. The reasons for the presentation of osteonecrosis in the jaws versus other parts of
the skeleton are unknown at this time.
AAE Position Statement
Endodontic Implications of Bisphosphonate-Associated
Osteonecrosis of the Jaws
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