“I think the paper is highly cited because it was the first paper about bisphosphonate-associated osteonecrosis of the jaw to appear in a general medical journal.”

I think the paper is highly cited because it was the first paper about bisphosphonate-associated osteonecrosis of the jaw to appear in a general medical journal. Prior to that, reports of this condition appeared mainly in the dental journals (especially the oral and maxillofacial surgery journals) and the oncology journals and many in the medical profession either were not aware of this condition, or were skeptical of its existence. The paper reviewed 368 cases gleaned over only a two- to three-year period and brought attention and awareness of this condition to both the medical and dental communities in a focused way.

It summarizes the findings and theories of etio-pathogenesis of a new condition that is an adverse side effect of taking bisphosphonates. This is a class of medications that is used by millions of people for treatment of osteoporosis, Paget’s disease of bone, multiple myeloma, and metastatic cancers to the bone. Exactly how this occurs is still not well understood at this time.

Bisphosphonates are drugs used to treat bone conditions where the bone becomes "porous" or "thinned" or "eaten away." These conditions include osteoporosis, Paget’s disease of bone, multiple myeloma, and metastatic cancer to the bones. Bisphosphonates help to increase bone density and therefore reduce fractures, pain, and high levels of calcium in the blood associated with these bone conditions. However, in some patients, especially those with cancer taking high doses of bisphosphonates intravenously, portions of the jaw bones die and become exposed in the mouth.

This condition may become infected leading to a jaw infection (osteomyelitis), or in the most severe cases, even to a jaw fracture. It is often triggered by a surgical procedure such as a tooth extraction. Patients should be aware that this is a potential complication that occurs in five to ten percent of patients with cancer taking the most potent forms of this drug.

One way of reducing the risk of this occurring is seeing their dentist and getting all their dental care completed either before the start of bisphosphonate therapy or very soon after, to minimize the future need for a dental surgical procedure.

If you are a patient with osteoporosis taking bisphosphonates and are concerned about this side effect, you should discuss the benefits of taking this drug (fracture reduction) and the risks (jaw necrosis) with your internist.

I became involved in this research because we were seeing many patients with this condition at our hospital from 2004 onward.

At this time, oncologists are working to find out if lower and/or fewer doses of these medications, or changing to a bisphosphonate with lower potency at some point during treatment, can still be beneficial to the patient in reducing pain, fractures, and high levels of calcium in the blood, while reducing the occurrence rate of this condition. We are also hoping to find out why some patients get this condition and others do not, and whether the levels of bone metabolism markers, or specific radiographic signs, can help predict the risk of developing this condition.

There are economic and quality-of-life issues involved. Although this condition primarily affects patients with cancer in the bones, the largest market for bisphosphonates is patients with osteoporosis, who number in the tens of millions worldwide, although they are affected to a much lesser degree primarily because they take lower doses. The presence of exposed dead bone in the mouth negatively impacts the quality of life for patients with cancer taking these drugs.