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Symptom Management and Supportive Care

Osteonecrosis of the Maxilla and Mandible in Patients with Advanced Cancer Treated with Bisphosphonate Therapy

^aDental Service, Department of Surgery, ^cDepartment of Epidemiology and Biostatistics, ^dSurgical Pathology Service, Department of Pathology, ^eNuclear Medicine Service, Department of Radiology, ^fEndocrinology Service, Department of Medicine, and ^gBreast Cancer Medicine Service, Department of Medicine, Memorial Sloan-Kettering Cancer Center, New York, New York, USA; ^bDepartment of Internal Medicine, University of Michigan Comprehensive Cancer Center, Ann Arbor, Michigan, USA

Key Words. Bisphosphonate therapy • Pamidronate • Zoledronic acid • Osteonecrosis of the jaw

Correspondence: Cherry L. Estilo, D.M.D., Dental Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, 1275 York Avenue, New York, New York 10021, USA. Telephone: 212-639-7644; Fax: 212-717-3601; e-mail: estiloc{at}mskcc.org

Received April 14, 2008; accepted for publication July 10, 2008; first published online in THE ONCOLOGIST Express on August 11, 2008.

Disclosure: C.L.E. is a participating investigator in a Novartis-sponsored zoledronic acid trial, CZOL446E2352. C.H.V.P. has served as a consultant for Amgen and Roche and is a participating investigator in a Novartis-sponsored zoledronic acid trial, CZOL446E2352. J.M.H. is a consultant to Novartis and a member of the Data Monitoring Committee for the zoledronic acid trial CZOL446E2352. A.F. is on the speaker's bureau for Novartis. The content of this article has been reviewed by independent peer reviewers to ensure that it is balanced, objective, and free from commercial bias. No financial relationships relevant to the content of this article have been disclosed by the authors, planners, independent peer reviewers, or staff managers.

Cases of osteonecrosis of the jaw (ONJ) have been reported with an increasing frequency over the past 5 years. ONJ is most often identified in patients with cancer who are receiving intravenous bisphosphonate (IVBP) therapy, but it has also been diagnosed in patients receiving oral bisphosphonates for nonmalignant conditions. To further categorize risk factors associated with ONJ and potential clinical outcomes of this condition, we performed a retrospective study of patients with metastatic bone disease treated with intravenous bisphosphonates who have been evaluated by the Memorial Sloan-Kettering Cancer Center Dental Service between January 1, 1996 and January 31, 2006. We identified 310 patients who met these criteria. Twenty-eight patients were identified as having ONJ at presentation to the Dental Service and an additional 7 patients were subsequently diagnosed with ONJ. Statistically significant factors associated with increased likelihood of ONJ included type of cancer, duration of bisphosphonate therapy, sequential IVBP treatment with pamidronate followed by zoledronic acid, comorbid osteoarthritis or rheumatoid arthritis, and benign hematologic conditions. Our data do not support corticosteroid use or oral health as a predictor of risk for ONJ. Clinical outcomes of patients with ONJ were variable with 11 patients demonstrating improvement or healing with conservative management. Our ONJ experience is presented here.

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