Prevalence of Osteonecrosis of the Jaw [ONJ].

[pjoshea13]

New study below [1].

I think that some are blindsided by ONJ. The risk is significant with bisphosphonates & Xgeva, & might not be properly explained before treatment. And one's dentist might not be on the ball.

In the U.S., Xgeva is now approved for multiple myeloma, having been found non-inferior to Zometa. My wife has a recurrent solitary plasmacytoma, which is a rare condition related to MM. She has been approved for Xgeva, but recently had dental work. The risk of ONJ is much on our minds.

The new study involved "69 {PubMed} articles comprising 29,437 patients".

"Nine-hundred fifty-one cases of jaw necrosis were described. The overall ONJ-prevalence was 2.09% in the breast cancer group, 3.8% in the prostate cancer group, and 5.16% for multiple myeloma patients."

There is probably a good paper somewhere that offers sound medical advice on the subject, & the following is just my take on the issue.

Before starting a bisphosphonate or Xgeva, get your mouth looked at by someone who understands the problem.

Delay usage of the drug until remedial work has occurred, but I would delay for at least 3 months. Recovery from an extraction can take a while.

If already on the drug & an extraction, say, becomes necessary, stop the drug but delay treatment for at least 3 months. Meanwhile, treat with an antibiotic if necessary. Wait at least another 3 months before resuming the drug.

The problem with a bisphosphonate is the long half-life. A year after one stops the drug there is still residual risk.

With a very cautious approach, that 3.8% risk of ONJ might be significantly lowered.

-Patrick

[1] ncbi.nlm.nih.gov/pubmed/295...

Dent J (Basel). 2016 Sep 27;4(4). pii: E32. doi: 10.3390/dj4040032.

Prevalence of Medication-Related Osteonecrosis of the Jaw in Patients with Breast Cancer, Prostate Cancer, and Multiple Myeloma.

Rugani P1, Walter C2, Kirnbauer B3, Acham S4, Begus-Nahrman Y5, Jakse N6.

Author information

1

Divison of Oral Surgery and Orthodontics, Medical University of Graz, 8010 Graz, Austria. [e-mail].

2

Oral and Maxillofacial Surgery of the Mediplus Clinic, 55128 Mainz, Germany. [e-mail].

3

Divison of Oral Surgery and Orthodontics, Medical University of Graz, 8010 Graz, Austria. [e-mail].

4

Divison of Oral Surgery and Orthodontics, Medical University of Graz, 8010 Graz, Austria. [e-mail].

5

Konzept Pharma Service GmbH, 31084 Freden, Germany. [e-mail].

6

Divison of Oral Surgery and Orthodontics, Medical University of Graz, 8010 Graz, Austria. [e-mail].

Abstract

Medication-related osteonecrosis of the jaw is a known side-effect of antiresorptive therapy in patients with malignant diseases. Nevertheless, the exact pathogenesis is still unknown and published prevalences show a significant range. The aim of the presented paper was to assess the prevalence of osteonecrosis (ONJ) in breast cancer, prostate cancer, and multiple myeloma patients receiving parenteral antiresorptive therapy. For this reason a PubMed search was performed and 69 matching articles comprising 29,437 patients were included in the analysis. Nine-hundred fifty-one cases of jaw necrosis were described. The overall ONJ-prevalence was 2.09% in the breast cancer group, 3.8% in the prostate cancer group, and 5.16% for multiple myeloma patients.

KEYWORDS:

bisphosphonate; breast cancer; denosumab; multiple myeloma; osteonecrosis; prostate cancer

PMID: 29563474 DOI: 10.3390/dj4040032

[pjoshea13]

Not a new study (2016) - but new to PubMed. -Patrick

[Hidden]

It was recently proven that 12 week infusions are just as beneficial as every 4 weeks.

am.asco.org/zoledronic-acid...

[Dan59 in reply to Hidden]

Sartor put me on 3 month zometa to minimize possibility of ONJ in 2007, He must have known then. I wish I knew if xgeva 3 month is as effective as every 4 week xgeva.

[Dan59]

Thank You Patrick for your never ending research. This is important, ONJ is no fun.

[Kuanyin]

I recently was diagnosed with an abscessed tooth that had to be extracted. My dentist was aware that I was receiving Xgeva shots, but insisted that the tooth had to come out because the toxins released by the infection were poisoning my entire body. What brought the matter into sharp focus for me was that we were scheduled to leave for a trip abroad. He was afraid that even if he gave me antibiotics for the entire trip (almost three weeks), should something go south on me, I could really be in trouble (as if I weren't already). My last Xgeva injection had been almost exactly three months ago (three weeks ago). I asked him to contact my oncologist who ordered a CTX (C-terminal telopeptide) test for me. My CTX level was slightly above 149 ng/ml, indicating that I was relatively safe from developing osteonecrosis of the jaw bone (ONJ). It just so happened that I was scheduled for an appointment with the oncologist. He took another CTX reading. On the day I was scheduled for the tooth extraction/surgery, I received an email from my oncologist telling me NOT to go ahead with the surgery unless it was absolutely necessary: my latest CTX was 49! How the value went from 150 to 49 when I had been off Xgeva an additional two weeks is a mystery to me. My dentist insisted that I have the procedure. Again, dentist and oncologist consulted and the oncologist said that I should go ahead with the surgery. Well, that was ten days ago. The stitches were removed two days ago. The wound, the dentist tells me, is healing quite well. His receptionist (the dentist's wife is a graduate in chemistry) tells me that with a “little CTX” in my system, the bone will be stronger for the upcoming implant. It appears that I will be off Xgeva for the foreseeable future. Meanwhile, any random pain in that area results in a concomitant rise in blood pressure. I really don't know whether or not I am out of the woods. After that craziness with the CTX values, what is one to believe? Like everything else with our disease, there's a lot of luck at play.

[JeffLikesBikes]

I will begin Xgeva within the next 2 weeks and ONJ is one of my concerns. Appreciate you doing this research on the subject, Patrick. As I understand it, one should be mindful of any changes or abnormalities in their oral health i.e. bleeding, toothache or jaw pain, loose teeth etc. I'm hoping luck is with me on this one.

[Stevemarr]

My dentist says 85% of patients cand do ok if tooth needs to be pulled, hope he is right if I have trouble.

[paulofaus]

Thanks (as always) Patrick. I started Xgeva 3 months ago and had a clean oral bill of health (I had two dodgy teeth pulled about 1 year before I went on Xgeva). So far so good, but it is still a concern. I asked my Radiation Oncologist about fillings and he said they should be OK, as long as they are not deep and stay away from the root. He also said the lower jaw is the main problem, upper jaw, not so much. Cheers Paul.

[tarhoosier]

The two-five percent of patients in those retrospective studies who developed ONJ seems a small percentage but for those patients who were on bisphoshonates AND had extractions/implants/ root canal, etc. the percentage is much higher. It is the combination that has the true risk.

[DFZ4835]

I have Osteonecrosis-of-the-Jaw-ONJ from xgeva. There is no good way to treat ONJ. The oral surgeon I am seeing has me on a antibiotic and a RX mouth wash. My ONJ is in the lower jaw bone. There is 1" to 2" inches of bone exposed on the right side and about 1/2" of new bone exposed on the left. There isn't much pain involved yet and I hope it stays that way. It's a scary thought knowing ONJ is killing my jawbones.

Dennis

[j-o-h-n]

All I can add is "GEEZAMACRIPE" another thing to add to my worry bag. Gotta find those worry beads again.

Good Luck and Good Health.

j-o-h-n Monday 03/26/2018 6:27 PM EDT

[Rottney]

Hi, I was "blindsided" by ONJ... don't think my urologist or oncologist or dentist had seen a case. Being treated with Lupron/Xgeva for ~2 years and began having problems with rear molar. Went forward with root canal, which eased pain, but not completely. Had to have root canal repeated, which just aggravated ONJ. Finally did some research on my own and convinced my dentist to refer me to an oral surgeon. Stopped taking Xgeva and it seemed to be healing but recently flared up again. Question for the group.... does ONJ go away and is there any treatment for it?

[pjoshea13 in reply to Rottney]

Hi Rottney,

The thread is 9 months old. I got notification of your post because I started the thread. No-one else will have read it.

I would suggest that you repost as a new thread. I think you will get plenty of responses. It's a good question.

My feeling is that ONJ has to be treated by an expert, & this may involve travel - they are few & far between.

Best, -Patrick