Fossy Jaw (plus photos) ~ Jaw Osteonecrosis Associated With Bisphosphonates

Discussion in 'Dental Archive' started by Joel M. Eichen, Mar 8, 2005.

  1. Interesting thread, thanks. I was sent an e-mail during the last
    go-round with this that a related condition is known as "Fossy Jaw."

    Here is some information from the 'net.

    Phosphorus is a necessary constituent of the bones and nerves. But we
    must supply it to the body as we find it in plants. Crude rock
    phosphorus as it comes from the earth, is a powerful poison. Laws now
    prohibit its use in the manufacture of matches, because of its
    poisonous character. It particularly affects the jaw bone producing a
    condition known as "Fossy jaw." Its continued use, as a medicine, even
    in small doses, produces anemia and emaciation. Although so vitally
    essential to bone and nerve, phosphorus, when not. "organized," as we
    find it in plants, is the most virulent poison of any of the normal
    elements of the human body. A man of average size contains, normally,
    about two pounds of phosphorus, but two grains of this "disorganized"
    (this may be done by calcination of a bone), given to a healthy man,
    produces great excitement, particularly of the brain. Delirium,
    inflammation and death may be the result in a single hour. Ten times
    this amount, taken as nature gives it to us in food, produces no such
    trouble.

    Phosphorus poisoning is characterized by nervous and mental symptoms,
    jaundice, vomiting, general fatty degeneration, the presence of bile
    pigments, albumen and other abnormal constituents in the urine,
    followed by death.

    Chronic phosphorus poisoning was quite common among workers in
    match-factories. Necrosis of the jaw bone was one of its frequent
    results. It ranks with mercury in its power to wreck the bones.

    Joel344
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    #4 Yesterday, 05:13 PM
    Sue
    Member Join Date: Oct 2004
    Posts: 1,663

    Medscape - March 4, 2005

    --------------------------------------------------------------------------------

    More info.

    To Print: Click your browser's PRINT button.
    NOTE: To view the article with Web enhancements, go to:
    http://www.medscape.com/viewarticle/500884


    Jaw Osteonecrosis Associated With Bisphosphonates in Some Cancer
    Patients

    Reuters Health Information 2005. © 2005 Reuters Ltd.
    By Lisa Richwine

    GAITHERSBURG, Md. (Reuters) Mar 04 - Novartis AG has received 875
    reports of jaw problems in cancer patients treated with two
    bisphosphonates, but it is not clear if the medicines are responsible,
    company officials told a U.S. advisory panel on Friday.

    A Food and Drug Administration official said there was a "highly
    plausible" sign the cases were related to the drugs, Zometa
    (zoledronic acid) and Aredia (pamidronate disodium). FDA officials
    urged further study to determine who might develop the problem and if
    steps could be taken to minimize the risk.

    Zometa and Aredia are used to treat multiple myeloma as well as bone
    metastases from solid tumors.

    Novartis added a warning to the labels of both drugs last year to
    alert doctors to the reports of osteonecrosis of the jaw, or ONJ. The
    severity of the condition varies but it can lead to disintegration of
    the jaw, Novartis officials and others told an FDA advisory panel.

    "We do not have an understanding of what is causing this to happen in
    a small number of cancer patients. Further investigation is
    necessary," said Dr. Diane Young, vice president and global head of
    clinical oncology development for Novartis.

    More than 1 million patients have been treated with Zometa since its
    launch in 2001, Novartis said. Aredia is available generically, and
    Novartis no longer promotes the brand name version.

    "These drugs have been shown to markedly reduce bone pain," while the
    risk of ONJ "is a minor one," said Dr. James Berenson, director of the
    multiple myeloma and bone metastases programs at Cedars-Sinai Medical
    Center in Los Angeles and a Novartis consultant.

    The FDA panel did not make any formal recommendations for regulatory
    action, but some members said Novartis should do more to alert
    dentists, patients and others to the issue. The company said it sent
    letters about the cases to physicians last year and contacted patient
    groups and printed brochures.

    Carol Pamer, a reviewer in the FDA's Office of Drug Safety, said ONJ
    is rare but the agency had received a steadily increasing number of
    reports of the condition in patients who were treated with Zometa or
    Aredia.

    "We believe these cases present a highly plausible safety signal" for
    the drugs, she said.

    Felice O'Ryan, an oral surgeon who traveled from California to testify
    before the panel, said she had seen an increase of ONJ cases in her
    practice recently, and some cases were severe.

    "I do not consider these problems minor or insignificant, nor do my
    patients. The FDA and Novartis have done a very poor job of informing
    people about this particular risk," she said.

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    #3 11-16-2004, 11:37 AM
    gocanes
    Member Join Date: Oct 2004
    Posts: 71



    --------------------------------------------------------------------------------

    As promised, here are the before and 6 months after-bx photos. There
    has been a slight amount of gingival growth around the exposed bone:
    Attached Images

    __________________



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    Last edited by gocanes : 11-16-2004 at 11:41 AM.

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    #2 11-05-2004, 01:41 PM
    Sue
    Member Join Date: Oct 2004
    Posts: 1,663



    --------------------------------------------------------------------------------

    Quote:
    Originally Posted by gocanes
    Biphosphonates such as Didronel, Fosamax and Zometa are popular drugs
    used to treat osteoporosis, Paget's disease, metastatic cancer, and
    hypercalcemia, among other things. These drugs inhibit bone turnover
    by interfering with osteoclastic activity. Because they bind to
    exposed bone at high levels and are not metabolized, they remain in
    the area in high concentrations for long periods of time.

    I recently had a female patient taking Zometa who abraded a small
    torus on her palate and the area would not heal. I sent her to my OS
    who levelled the torus and achieved primary closure. The microscopy
    was negative for anything beyond inflamed bone tissue. It has been
    over a month, the gingiva has sloughed and the area will not heal. She
    has about a 1cm X 1cm area of exposed bone on her posterior palate.
    The surgeon does not want to re-operate and is contemplating HBO
    therapy. I'll post the pictures next week.

    I post this as a warning to those who might have a patient on these
    drugs who requires any type of oral surgery, even simple extractions.
    Your patient is at risk for delayed healing and potential
    osteonecrosis. It would be wise to refer to an OMFS unless you know
    how to treat such complications.

    Here is a citation:

    Ruggiero SL, Mehrotra B, Rosenberg TJ, Engroff SL

    Osteonecrosis of the jaws associated with the use of bisphosphonates:
    a review of 63 cases.
    J Oral Maxillofac Surg. 2004 May;62(5):527-34.





    Craig,

    I read the article as I think that patients need to be advocates for
    their own health as well (and I have two friends that are on Fosamax
    so I was interested!). BTW, one of these is a male (osteoporosis can
    occur in men as well).

    My comment.

    Besides increased prevalence of post-surgical complications for these
    pts, even more disturbing (in my mind) is that for these patients,
    their lesions were refractory to conservative debridement and
    antibiotic therapy.

    Therefore your suggestion to refer these patients directly to OMFS
    should be taken very seriously, IMHO.

    Thank you for the information.
    -Sue

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    #1 11-04-2004, 08:00 PM
    gocanes
    Member Join Date: Oct 2004
    Posts: 71

    Osteonecrosis of the Jaws and Biphosphonates

    --------------------------------------------------------------------------------

    Biphosphonates such as Didronel, Aredia, Fosamax and Zometa are
    popular drugs used to treat osteoporosis, Paget's disease, metastatic
    cancer, and hypercalcemia, among other things. The manufacturer of
    these drugs is now recommending to physicians that a dental
    examination and preventive dentistry regimen be implemented prior to
    biphosphonate therapy for patients with "concomitant risk factors
    (e.g. cancer, chemotherapy, corticosteroids, poor oral hygiene)."

    The bisphosphonate class of drugs inhibit bone turnover by interfering
    with osteoclastic activity. Because these drugs bind to exposed bone
    at high levels and are not metabolized, they remain in the area in
    high concentrations for extended periods of time.

    I recently had a female patient taking Zometa who abraded a small
    torus on her palate and the area would not heal after several weeks. I
    sent her to my OS who removed the torus and achieved primary closure.
    The microscopy was negative for anything beyond inflamed bone tissue.
    It has been over a month, the gingiva has sloughed and the area has
    not healed. She has about a 1cm X 1cm area of exposed bone on her
    posterior palate. She does not complain of pain. The surgeon does not
    want to re-operate and is contemplating HBO therapy. I'll post the
    pictures next week.

    I post this for consideration and as a potential warning to those who
    might have a patient on these drugs who requires any type of oral
    surgery, even simple extractions. Your patient is at risk for delayed
    healing and potential osteonecrosis/osteomyelitis. It would be wise to
    refer to an OMFS unless you know how to treat such complications.

    Here is a relevant citation:

    Ruggiero SL, Mehrotra B, Rosenberg TJ, Engroff SL

    Osteonecrosis of the jaws associated with the use of bisphosphonates:
    a review of 63 cases.
    J Oral Maxillofac Surg. 2004 May;62(5):527-34.


    __________________



    --------------------------------------------------------------------------------
    Last edited by gocanes : 11-08-2004 at 08:32 AM.

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    Joel M. Eichen, Mar 8, 2005
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  2. Joel M. Eichen wrote:
     
    Mark & Steven Bornfeld, Mar 8, 2005
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  3. On Tue, 08 Mar 2005 15:02:50 GMT, Mark & Steven Bornfeld
    <> wrote:
    Thanks Steve.

    Very informative.

    Joel
     
    Joel M. Eichen, Mar 8, 2005
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