Bisphosphonate-related osteonecrosis of the jaw in cancer patients and hyperbaric oxygen therapy.

Dear Sir: In the March issue of JOP. Journal of the Pancreas, Smith et al. provide the first report of bisphosphonate-related osteonecrosis of the jaw (BRONJ) in a patient with pancreatic adenocarcinoma [1]. As to the greater recognition of the relationship between the use of bisphosphonates and oral osteonecrosis, new cases with different malignancies have been diagnosed as suffering from BRONJ. The case presented by Smith et al. reminds us to be alert against this serious complication of bisphosphonates. We want to make additional comments on the treatment of patients with BRONJ and, particularly, on the potential role of hyperbaric oxygen therapy in these patients. Bisphosphonates are potent inhibitors of osteoclastic bone resorption and one of the most frequently prescribed drugs. They are widely used in the treatment of osteoporosis, skeletal lesions of multiple myeloma and bone metastasis of solid tumors. After the paper by Marx et al. which described the first cases of BRONJ, awareness increased in the medical community [2]. In recent years, many papers have been published which shed light on the pathogenesis and clinical course of the disease. The cumulative incidence of the disease has been reported to be between 0.8 to 12% in patients using intravenous bisphosphonates [3]. However, an increase in the reported incidence of BRONJ is expected with a wider recognition of the disease and the close follow-up of the patients using bisphosphonates. Given the widespread use of bisphosphonates in clinical practice, even a very low incidence of oral osteonecrosis in bisphosphonate users should be considered a public emergency. According to the diagnostic criteria defined by the American Association of Oral and Maxillofacial Surgeons, BRONJ is diagnosed in patients with a history of current or previous treatment with a bisphosphonate, with an exposed bone in the maxillofacial region which has continued for more than eight weeks, and with no history of radiation therapy to the jaw [3]. There is no definitive treatment for BRONJ at this time. The management of BRONJ remains an important clinical challenge in cancer patients and requires a multidisciplinary approach involving dentists, medical oncologists, oral and maxillofacial surgeons and others, if necessary [4]. Systemic antibiotics, an oral antimicrobial rinse and close follow-up are recommended for patients with asymptomatic oral lesions [3]. Since bisphosphonates remain in the bone for very long periods and some patients cannot survive without bisphosphonates, cessation of bisphosphonate treatment is not carried out in every patient. …