Impact of communication between physicians and dentists on the incidence of jaw osteonecrosis caused by bone anti-resorptives

A common African proverb states that “when two elephants fight, it is the grass that suffers”. It means that the foot stamping that goes on back and forth between the fighting animals will destroy the grass leaving an indelible patch of barren land within the grassland. When considering the issues of osteoporosis, anti-resorptive therapies and the complication of osteonecrosis of the jaw (ONJ), it is not a case of just “two elephants” but three. So if these three are not properly balanced, patients’ health and quality of life will be compromised.

Osteoporosis is a major skeletal disorder that affects over 10 million individuals worldwide¹. It is projected that the healthcare burden of osteoporosis will rise astronomically by 2050 due to the aging population¹. Many osteoporosis patients are treated with anti-resorptive drugs such as bisphosphonates and denosumab, both of which have been associated with the complication of ONJ. Anti-resorptives are highly efficacious and have been used successful in the management of osteoporosis and skeletal events of cancer metastasis^2,3. They also provide many drug options to choose from as well as different dosing regimens. Unfortunately ONJ is a major complication of anti-resorptives^4–6. It is recalcitrant and unpredictable, which has alarmed the medical community into prescribing anti-resorptives with caution. There is still no clear understanding of ONJ pathophysiology, and management regimens are still confusing at best^7,8.

The increasing incidence of osteoporosis due to the aging population combined with reliance on anti-resorptive therapies means a balance must be struck to improve osteoporosis while limiting the occurrence of ONJ so that patient outcomes can be improved. Many local and systemic etiological factors that promote osteoporosis also induce alveolar bone loss⁹; hence the direct effects of osteoporosis coupled with the administration of anti-resorptive drugs further heightens the concerns about ONJ. There is a need to balance osteoporosis therapy with prevention of ONJ, but this has caused several controversies between different medical and dental professionals. Some have proposed that withdrawal or dose reduction of anti-resorptive therapy will reduce the incidence of ONJ^10–12 but this theory has not been clearly proven. Notwithstanding, some dental healthcare providers as reported by Taguchi et al. often request physicians to withdraw anti-resorptive therapy before major dental procedures¹³. Unfortunately, this approach increases the chances of causing osteoporosis adverse events including skeletal fractures that will further jeopardize the health of the patient.

The paper by Taguchi et al. highlights the possibility that lack of cooperation between physicians and dentists during the management of osteoporosis may in fact cause an increase in osteoporosis related fractures and ONJ¹³. In a previous study the authors used a questionnaire-based survey of Japanese physicians and determined that discontinuation of anti-resorptives before dental extractions increased osteoporosis adverse events but did not prevent the development of ONJ¹⁴. As this study was conducted among physicians in private clinics with limited sample size (n = 209), the authors conducted a follow up study using a larger sample size (n = 629) of physicians in an academic environment¹³. The paper reported that many Japanese dentists continued to request discontinuation of anti-resorptives before dental extractions. The authors also showed that there were 3.6% and 0.7% cases of osteoporosis-related adverse events and ONJ respectively within 3 months of discontinuing the use of anti-resorptives. However, these increased to 5.3% and 1.6% respectively when the anti-resorptives were discontinued for more than 3 months¹³.

The confounding factor was that 62% of respondents did not request dental evaluation prior to commencement of anti-resorptive therapy, which made it unclear whether this had an impact on the outcome of dental extractions performed after discontinuation of anti-resorptives. The authors also state that physicians who refused discontinuation of anti-resorptives did not report any case of ONJ but it was also not clear whether these patients received routine dental care before and during the use of anti-resorptives.

In spite of the confounding factors, Taguchi et al. conclude that these results support their earlier data and strengthen the assertion that cooperation between physicians and dentists treating patients with osteoporosis is vital for prevention of both osteoporosis related fractures and ONJ¹³. Additionally, these results also clearly emphasize the limited value of the “drug holiday” theory that discontinuation of anti-resorptives will reduce occurrence of ONJ. Another cogent point from this study is the reported lack of cooperation between physician and dentists when managing osteoporosis patients. Since treatment guidelines have been established by several medical and dental societies and academies^15,16, clear communication between physicians and dentists should foster sharing of information on current management regimens for both osteoporosis and ONJ. Just as “two fighting elephants cause the grass to wither”, lack of communication between physicians and dentists managing osteoporosis patients may hamper patient care outcomes. It is vital to keep the lines of communication open among healthcare providers when managing patients with osteoporosis.

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Declaration of funding

This work was supported by National Institutes of Health grant R21DE022826 from the National Institute of Dental and Craniofacial Research (NIDCR) and grant K22CA169089 from the National Cancer Institute (NCI).

Declaration of financial/other relationships

S.O.A. and E.V.H. have disclosed that they have no significant relationships with or financial interests in any commercial companies related to this study or article.