Stable oral health can be a critical preventive measure against drug-induced osteonecrosis of the jaws.
The more complex a system, the more difficult it is to trace the root cause of a mistake. I woke up this morning to my lawn man calling me on my cell phone and wanting me to open the gate so that he could mow my lawn. I jumped out of bed, threw on my gym clothes and ran out the front door.
Fozzy, my standard poodle pup, ran alongside me and I quickly realized her electronic collar wasn’t working. She headed for the road just as fast as she does when I replenish her food bowl. A non-working collar meant one of two things: either her collar wasn’t charged properly or I’d have to replace the entire collar, which is a much more expensive option. I quickly read the operating manual for the electronic system and got lost in the maze of endless pages of instructions. I started to feel the tension rising, mainly because I have a cascade of home gadgets to maintain and I’m frequently pushed for time and sometimes panic when something goes wrong.
Many of us feel the same concerns when our physician prescribes a new medication and we begin to worry about drug safety, effectiveness and interactions, especially if this new medication is one of many we need to manage. Some patients immediately Google the new drug and get lost in the maze of adverse side effects reported. Some common reasons expressed by patients for not taking a new medication are cost, misunderstanding of need, fear of unwanted side effects and mistrust of the prescribing doctor. Every pharma company has a group in its regulatory division dedicated to tracking adverse events and most companies are very diligent in reporting these side effects internally and to the FDA.7
Just like gadgets, medications can go horribly wrong, despite the best intentions of the providers who prescribe them or the companies who research, develop and market them. I remember the time period when Merck Pharmaceuticals took the blockbuster drug Vioxx off the market. Merck aggressively marketed this painkiller for arthritis pain and most people who took it didn’t need it.1 Those who took it were at greater risk of heart attack or stroke. When new drugs get approved by the FDA, there are often unresolved safety issues and the FDA has been reluctant to encourage post-marketing safety studies.1 Under the Donald Trump administration, the FDA is under pressure to approve drugs faster than before, even though one-third of new drugs have safety issues after FDA approval.2
Evolution of drugs that cause osteonecrosis of the jaws
I’ve been writing about drug-induced osteonecrosis of the jaws (DIONJ) for about 10 years. I’ve learned a lot about bone physiology and chemical injury by drugs approved by the FDA that cause this severe adverse drug reaction.3-5 When I first began learning about DIONJ, only bisphosphonates (oral and IV) were implicated in DIONJ pathogenesis. Besides bisphosphonates, the offending drugs have expanded to include:
When only bisphosphonates were implicated in the pathogenesis of DIONJ, some common names given to the DIONJ diagnosis were bisphosphonate-induced osteonecrosis, bisphosphonate-related osteonecrosis, bisphosphonate-associated osteonecrosis and anti-resorptive-related osteonecrosis. To further complicate matters, the American Association of Oral and Maxillofacial Surgeons favors the term Medication Related Osteonecrosis of the Jaw (MRONJ) while the American Medical Association prefers DIONJ and has adopted a site specific ICD-10 code of M87.10.8,9
In reading the 2018 updated position paper on DIONJ by Marx and Tursun, University of Miami, division of oral and maxillofacial surgery, several important points were made:
DIONJ isn’t a tsunami, but it isn’t an innocent trickle or a manufactured alarm either. Instead, it continues to cause very painful injuries to a small percentage of susceptible and innocent individuals. Prescribing physicians may not be well-versed on the pathogenesis of medications causing DIONJ and risk factors, especially the importance of stable oral health as an important preventive measure besides the drugs themselves. Dental hygienists are in a unique position to educate patients about DIONJ and how to reduce or prevent initiating events.
Marx, RE, Tursun R. University of Miami Division of Oral and Maxillofacial Surgery Position Paper on Drug Induced Osteonecrosis of the Jaws. April 23, 2018.