Dental management of osteoporosis patients on anti-resorptive therapy can be challenging for both the dentist and physician because of the risk of osteonecrosis of the jaw (ONJ). This editorial reflects on the paper written by Tagushi et al that expressed a relative lack of communication between health care providers when treating osteoporosis patients. Osteoporosis-related bone fractures can be debilitating and occasionally lethal, but management with anti-resorptives is vital while cognizant of the complication of ONJ that can also negatively impact patient’s quality of life

Akintoye, Sunday O.

Hersh, Elliot V.

English

ScholarlyCommons@Penn

University of Pennsylvania ScholarlyCommons Departmental Papers (Dental) Penn Dental Medicine 5-18-2016 Impact of Communication Between Physicians and Dentists on the Incidence of Jaw Osteonecrosis Caused by Bone Anti-Resorptives Sunday O. Akintoye University of Pennsylvania Elliot V. Hersh University of Pennsylvania Follow this and additional works at: https://repository.upenn.edu/dental_papers  Part of the Dentistry Commons Recommended Citation Akintoye, S. O., & Hersh, E. V. (2016). Impact of Communication Between Physicians and Dentists on the Incidence of Jaw Osteonecrosis Caused by Bone Anti-Resorptives. Current Medical Research and Opinion, 32 (8), 1455-1456. http://dx.doi.org/10.1080/03007995.2016.1185401 This paper is posted at ScholarlyCommons. https://repository.upenn.edu/dental_papers/74 For more information, please contact repository@pobox.upenn.edu. Impact of Communication Between Physicians and Dentists on the Incidence of Jaw Osteonecrosis Caused by Bone Anti-Resorptives Abstract Dental management of osteoporosis patients on anti-resorptive therapy can be challenging for both the dentist and physician because of the risk of osteonecrosis of the jaw (ONJ). This editorial reflects on the paper written by Tagushi et al that expressed a relative lack of communication between health care providers when treating osteoporosis patients. Osteoporosis-related bone fractures can be debilitating and occasionally lethal, but management with anti-resorptives is vital while cognizant of the complication of ONJ that can also negatively impact patient’s quality of life. Keywords Osteoporosis, anti-resorptive therapies, osteonecrosis of the jaw, bisphosphonates, communication between physicians and dentists Disciplines Dentistry This journal article is available at ScholarlyCommons: https://repository.upenn.edu/dental_papers/74 Impact of communication between physicians and dentists on the incidence of jaw osteonecrosis caused by bone anti-resorptivesSunday O. Akintoye1 and Elliot V. Hersh21Department of Oral Medicine, School of Dental Medicine, University of Pennsylvania, Philadelphia PA2Department of Oral and Maxillofacial Surgery and Pharmacology, School of Dental Medicine, University of Pennsylvania, Philadelphia PAAbstractDental management of osteoporosis patients on anti-resorptive therapy can be challenging for both the dentist and physician because of the risk of osteonecrosis of the jaw (ONJ). This editorial reflects on the paper written by Tagushi et al that expressed a relative lack of communication between health care providers when treating osteoporosis patients. Osteoporosis-related bone fractures can be debilitating and occasionally lethal, but management with anti-resorptives is vital while cognizant of the complication of ONJ that can also negatively impact patient’s quality of life.KeywordsOsteoporosis; anti-resorptive therapies; osteonecrosis of the jaw; bisphosphonates; communication between physicians and dentistsA common African proverb states that ‘when two elephants fight, it is the grass that suffers’. Which 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, patient’s 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 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 Address for correspondence: Dr. Sunday O. Akintoye, 1Department of Oral Medicine, School of Dental Medicine, University of Pennsylvania, 240 South 40th Street, Philadelphia PA, 19104-6030 USA. Declaration of financial/other relationships:The Authors have no relevant financial relationships to disclose.HHS Public AccessAuthor manuscriptCurr Med Res Opin. Author manuscript; available in PMC 2018 February 09.Published in final edited form as:Curr Med Res Opin. 2016 August ; 32(8): 1455–1456. doi:10.1080/03007995.2016.1185401.Author ManuscriptAuthor ManuscriptAuthor ManuscriptAuthor Manuscriptcomplication of ONJ. Anti-resorptives are highly efficacious and have been used successful in the management of osteoporosis and skeletal events of cancer metastasis2, 3. They also provide many drug options to choose from as well as different dosing regimens. Unfortunately ONJ is a major complication of anti-resorptives4–6. It is recalcitrant and unpredictable, which has alarmed the medical community to prescribe anti-resorptives with caution. There is still no clear understanding of ONJ pathophysiology, and management regimens are still confusing at best7, 8The increasing incidence of osteoporosis due to the aging population combined with the reliance on anti-resorptive therapies means a balance must be struck to improve osteoporosis while limiting the occurrence of ONJ so 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 administration of anti-resorptive drugs further heighten 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 ONJ10–12 but this theory has not been clearly proven. Notwithstanding, some dental healthcare providers as reported by Tagushi et al often request physicians to withdraw anti-resorptive therapy before major dental procedures13. Unfortunately, this approach increases the chances of causing adverse events of osteoporosis including skeletal fractures that will further jeopardize the health of the patient.The paper by Tagushi et al highlight 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 adverse events of osteoporosis 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 stated 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, Tagushi et al concluded that these results supported their earlier data and strengthens the assertion that cooperation between physicians and dentists treating patients with osteoporosis is vital to prevention of both osteoporosis related Akintoye and Hersh Page 2Curr Med Res Opin. Author manuscript; available in PMC 2018 February 09.Author ManuscriptAuthor ManuscriptAuthor ManuscriptAuthor Manuscriptfractures 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 academies15, 16, a 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 communications open among healthcare providers when managing patients with osteoporosis.AcknowledgmentsTransparencyDeclaration 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).References1. NIH. The Surgeon General’s Report on Bone Health and Osteoporosis: What It Means to You. Bethesda MD: National Institutes of Health; 2012. NIH Publication No. 12-78272. Weinerman S, Usera GL. Antiresorptive Therapies for Osteoporosis. Oral Maxillofac Surg Clin North Am. 2015 Nov; 27(4):555–60. [PubMed: 26412797] 3. Rizzoli R, Burlet N, Cahall D, Delmas PD, Eriksen EF, Felsenberg D, et al. Osteonecrosis of the jaw and bisphosphonate treatment for osteoporosis. Bone. 2008 May; 42(5):841–7. [PubMed: 18314405] 4. Aghaloo T, Hazboun R, Tetradis S. Pathophysiology of Osteonecrosis of the Jaws. Oral Maxillofac Surg Clin North Am. 2015 Nov; 27(4):489–96. [PubMed: 26412796] 5. Khan A, Morrison A, Cheung A, Hashem W, Compston J. Osteonecrosis of the jaw (ONJ): diagnosis and management in 2015. Osteoporos Int. 2016 Mar; 27(3):853–9. [PubMed: 26493811] 6. Akintoye SO, Hersh EV. Risks for jaw osteonecrosis drastically increases after 2 years of bisphosphonate therapy. The journal of evidence-based dental practice. 2012 Jun; 12(2):116–8. [PubMed: 22726797] 7. Sarin J, DeRossi SS, Akintoye SO. Updates on bisphosphonates and potential pathobiology of bisphosphonate-induced jaw osteonecrosis. Oral diseases. 2008 Apr; 14(3):277–85. [PubMed: 18336375] 8. Omolehinwa TT, Akintoye SO. Chemical and Radiation-Associated Jaw Lesions. Dental clinics of North America. 2016 Jan; 60(1):265–77. [PubMed: 26614957] 9. Center for Disease Control. , editor. CDC. National Oral Health Surveillance System-Complete Tooth Loss. 2010. June 15, 200910. Kim YH, Lee HK, Song SI, Lee JK. Drug holiday as a prognostic factor of medication-related osteonecrosis of the jaw. J Korean Assoc Oral Maxillofac Surg. 2014 Oct; 40(5):206–10. [PubMed: 25368832] 11. Damm DD, Jones DM. Bisphosphonate-related osteonecrosis of the jaws: a potential alternative to drug holidays. Gen Dent. 2013 Aug; 61(5):33–8.12. Yang L, Boyd K, Kaste SC, Kamdem Kamdem L, Rahija RJ, Relling MV. A mouse model for glucocorticoid-induced osteonecrosis: effect of a steroid holiday. J Orthop Res. 2009 Feb; 27(2):169–75. [PubMed: 18683891] Akintoye and Hersh Page 3Curr Med Res Opin. Author manuscript; available in PMC 2018 February 09.Author ManuscriptAuthor ManuscriptAuthor ManuscriptAuthor Manuscript13. Taguchi A, Shiraki M, Sugimoto T, Ohta H, Soen S, Japan Osteoporosis S. Lack of cooperation between physicians and dentists during osteoporosis treatment may increase fractures and osteonecrosis of the jaw. Curr Med Res Opin. 2016 Mar.23:1–29.14. Shiraki M, Kuroda T, Miyakawa N, Fujinawa N, Tanzawa K, Ishizuka A, et al. Design of a pragmatic approach to evaluate the effectiveness of concurrent treatment for the prevention of osteoporotic fractures: rationale, aims and organization of a Japanese Osteoporosis Intervention Trial (JOINT) initiated by the Research Group of Adequate Treatment of Osteoporosis (A-TOP). J Bone Miner Metab. 2011 Jan; 29(1):37–43. [PubMed: 20461422] 15. Ruggiero SL, Dodson TB, Assael LA, Landesberg R, Marx RE, Mehrotra B. American Association of Oral and Maxillofacial Surgeons position paper on bisphosphonate-related osteonecrosis of the jaws–2009 update. J Oral Maxillofac Surg. 2009 May; 67(5 Suppl):2–12.16. Khosla S, Burr D, Cauley J, Dempster DW, Ebeling PR, Felsenberg D, et al. Bisphosphonate-associated osteonecrosis of the jaw: report of a task force of the American Society for Bone and Mineral Research. J Bone Miner Res. 2007 Oct; 22(10):1479–91. [PubMed: 17663640] Akintoye and Hersh Page 4Curr Med Res Opin. Author manuscript; available in PMC 2018 February 09.Author ManuscriptAuthor ManuscriptAuthor ManuscriptAuthor Manuscript

Impact of Communication Between Physicians and Dentists on the Incidence of Jaw Osteonecrosis Caused by Bone Anti-Resorptives

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Impact of Communication Between Physicians and Dentists on the Incidence of Jaw Osteonecrosis Caused by Bone Anti-Resorptives

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