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What Fosamax Patients Should Know About Symptoms of Osteonecrosis of the Jaw (ONJ)

An Introduction To How Doctors Determine Diagnostic Rating, Or Staging, For Patients Diagnosed With Jaw Bone Decay

There has been increased attention over the past couple of years given to the association between the use of oral bisphosphonates such as Fosamax and the serious side effect osteonecrosis of the jaw (ONJ). It is understandable, therefore, that Fosamax patients want to know the early signs and symptoms of ONJ, which is sometimes referred to as jaw bone decay. Furthermore, the unfortunate patient diagnosed with this type of osteonecrosis should know how the extent of their condition determines the staging of ONJ upon diagnosis as well as their course of treatment thereafter.

As a starting point, we take this basic description of osteonecrosis of the jaw (ONJ) from a medical journal article titled "Osteonecrosis of the Jaw -- Do Bisphosphonates Pose a Risk?", which was published in the November 30, 2006 edition of The New England Journal of Medicine (NEJM). According to the author, Dr. John P. Bilezikian:

Osteonecrosis of the jaw is characterized clinically by an area of exposed bone in the mandible, maxilla, or palate that typically heals poorly or does not heal over a period of 6 to 8 weeks....

The lesion is painful in many, but not all, patients, and infection is often present. Approximately two thirds of cases involve the mandible and the rest involve the maxilla.

We move, next, to the early signs and symptoms of drug-induced ONJ. For this we draw from anoter medical article, this one published in Hematology 2006 and titled "Bisphosphonate Complications Including Osteonecrosis of the Jaw":

Typical presentation is in the form of a nonhealing extraction socket, presence of exposed bone, gingival swelling or purulent discharge, when local debridement and antibiotics are ineffective. Often, a nonhealing ulcer or exposed bone may be detected on routine oral care that may remain asymptomatic, until superinfection sets in when swelling, pain, loosening of teeth and discharge may develop. Occasionally, pain in the jaw bone may be the only symptom without any evidence of radiological abnormalities. Eighty percent of patients report an antecedent dental procedure prior to presentation. Median age in one series was 68 years, mandible as the site of involvement is seen in two-thirds of the patients and maxillary involvement is in a third.

This same Hematology 2006 article regarding ONJ continues with an explanation about how the diagnosing doctor uses the degree of the jaw bone decay found to determine the diagnostic rating, or staging, of ONJ:

Oral surgical colleagues have reported a staging system from I to III based on the presence of symptoms such as pain, degree of swelling, ulceration, exposure of bone, response to topical antibiotic rinses, requirement for debridement and requirement of intravenous antibiotics....

Staging ONJ appropriately based on clinical and radiographic findings may be used to direct specific local and systemic therapy.

  • Stage I disease as characterized by asymptomatic detection of exposed bone without soft tissue infection, may be managed conservatively with a non-surgical conservative approach to avoid further osseous injury....
  • Stage II disease characterized by presence of symptoms around the area of exposed bone secondary to soft tissue swelling and/or bone infection may require culture-directed long-term and maintenance antimicrobial therapy, analgesic management, in addition to conservative measures outlined for stage I disease....
  • Stage III disease is characterized by the presence of a pathological fracture (not related to metastatic disease), exposed bone associated with soft tissue infection, which is not manageable with antibiotics alone due to the volume of necrotic bone.

While Fosamax patients should be on the look-out for the symptoms ONJ, those people who are in the process of deciding whether or not Fosamax and other oral bisphosphonates are a good choice for them may are probably more interested in knowing some of the predisposing, or risk, factors for developing ONJ.

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