Dental Preclearance and Careful Tracking Can Prevent Osteonecrosis of the Jaw Due to Bisphosphonates

BOSTON—Bisphosphonates are an important part of managing bony metastasis of prostate, breast, lung, and other cancers but can cause osteonecrosis of the jaw (ONJ) in some patients. The condition usually occurs after minor trauma such as dental procedures involving tooth extractions.

Oncology nurses at the Helen F. Graham Cancer Center at the Christiana Care Health System, Newark, Delaware, are part of a new program designed to prevent this emerging problem.

Cynthia Waddington, RN, MSN, AOCN, described this initiative at the Oncology Nursing Society 31st Annual Congress (abstract 9).

The Nurse's Role

"The nurse's role in patient education, supporting patient decision-making, and coordination of prebisphosphonate dental evaluations, is integral to patient safety and outcome management," Ms. Waddington said. "Completion of thorough assessments and prompt recognition of complications during and after bisphosphonate therapy are also essential."

She stressed that the process used at the Helen F. Graham Cancer Center can be modified to facilitate efforts of pre-bisphosphonate dental evaluations at other institutions.

Dental Clearance Required

A dental examination and clearance from the dentist are required before the patient can begin bisphosphonate therapy. At Ms. Waddington's institution, the pretreatment assessment includes consideration of the patient's type of cancer, history of treatment with steroids, presence of diabetes, and smoking history.

"If the dentist says that the patient is not cleared to begin bisphosphonate treatment, he or she also reports which dental procedures the patient is scheduled to undergo," she said.

Community dentists are generally aware of the problem of bisphosphonate-related ONJ and were very receptive to the new program, which began with an evening educational program for dentists. "We had an overwhelming turn-out from the dental community," Ms. Waddington said.

Nurse Coordinator

When patients are scheduled for bisphosphonate treatment, the first step is oncology referral to a nurse coordinator, she said. This triggers communications with the patient and dental staff, and coordination of dental evaluations.

The nurse coordinator maintains close contact until interventions such as teeth cleaning, completion of necessary fillings, extractions of nonrestorable teeth, and elimination of sepsis are completed, and the patient receives a "dental clearance."

The nurse coordinator also provides the patient's treating physician with continual communication regarding the status of this stage of the dental evaluation, making use of such tools as dental letters, dental report forms, and follow-up forms.

After dental clearance, the patient begins bisphosphonate treatment and then is re-examined every 6 months for signs of osteonecrosis such as oral cavity swelling, infection, pain, or exposed bone (see box below).

A databank tracks referrals, risk factors, type of dental work completed, length of time to obtain dental clearance, and results of follow-up evaluations, and data are reviewed every 6 months, she noted.

Ms. Waddington said that currently 65 patients are in the monitoring program at the Graham Cancer Center. Only a few have missed their recommended 6-month dental re-evaluations, and so far there have been no cases of osteonecrosis of the jaw.

Co-author of the ONS presentation was Constance Hill, APRN-BC, of Medical Oncology Hematology Associates, Newark, Delaware.

Bisphosphonate-Related ONJ

Woo et al (Systematic review: Bisphosphonates and osteonecrosis of the jaw. Ann Intern Med 144:753-761, 2006) found that most cases of osteonecrosis of the jaw (ONJ) occurred in patients who had multiple myeloma or breast cancer metastatic to bone and who had been taking IV zoledronic acid (Zometa) or pamidronate (Aredia) monthly for several years.

The highest risk was associated with frequent, typically monthly, infusions of IV zoledronic acid. Osteonecrosis developed after a mean of 9 to 14 months of bisphosphonate treatment.

The typical ONJ lesion has areas of exposed yellow-white hard bone, sometimes with associated extraoral or intraoral sinus tracts and with painful ulcers in the adjacent soft tissue.