Survey of members of myeloma UK on biphosphonates‐associated jaw osteonecrosis

Bisphosphonate jaw necrosis (BON) is defined as exposed, avascular, non-healing bone in either the mandible or maxilla in association with current or previous i.v. or oral bisphosphonate therapy (Marx et al, 2005). The onset of BON has been linked to trauma, such as dental extractions, but it can also occur spontaneously. The American Association of Oral and Maxillofacial Surgeons (American Association of Oral and Maxillofacial Surgeons, 2006) estimated the incidence of necrosis related to i.v. bisphosphonates to be 0·8–12%. The management of BON tends to be symptomatic relief, and cure is difficult to achieve, hence the onus is on prevention (Barker & Rogers, 2006). Guidelines have been established by an expert multidisciplinary panel in the USA. (Damato et al, 2005; Advisory Task Force on Bisphosphonate-Related Ostenonecrosis of the Jaws, American Association of Oral and Maxillofacial Surgeons, 2007). Before initiating i.v. bisphosphonate therapy, all patients should undergo a routine clinical examination to detect potential dental infections. Teeth with a poor prognosis should be extracted and tissue allowed to heal prior to commencement of therapy. Whilst on i.v. bisphosphonate therapy patients should have regular hard and soft tissue oral assessments, ensuring maintenance of excellent oral hygiene and avoidance of any invasive dental procedures. Minimal information has been published regarding the current practices of dental assessment and the incidence of BON in the UK. Therefore, this questionnaire aimed to survey clinicians treating myeloma patients with i.v. bisphosphonates regarding the aspects of dental care and cases of BON. It was hoped that the survey results would help clinicians compare their current practice to UK colleagues and also inform the wider medical team as to any possible changes in the provision of dental assessment that might be deemed appropriate. A postal survey of 648 healthcare professionals (myeloma UK database) in the UK was conducted between Spring (initial posting) and Autumn (reminder) 2006. They were asked about (i) their experience of treating myeloma using i.v. bisphosphonates during 2004 and 2005 (none, 1–4, 5–10, 11–20, >20 patients), (ii) dental considerations before starting therapy and at outpatient follow-up and (iii) cases of i.v. bisphosphonate-induced jaw necrosis they had seen, including when necrosis occurred and whether bisphosphonate treatment was stopped temporarily. Sixty-three per cent (177/280) of consultants and 35% (116/335) of non-consultants responded; 33 were excluded (21 irrelevant to current practice, six retired and six blank). Some of the non-responders may also have been unsuitable for this survey. The speciality background was haematology (280), medical oncology (2), transfusion medicine (2), palliative care (2), clinical oncology (1) and unknown (6). Treatment experience in 2004/2005 varied considerably, ranging from none treated (24 patients), 1–4 (67), 5–10 (108), 11–20 (57) to more than 20 (31) treated, unknown for six. Results given are for 263 responders who treated patients in 2004 or 2005. Consultant and non-consultants had similar results (not shown). Those with greatest treatment experience (>20 patients in 2004 or 2005) were more likely to warn patients about potential dental complications, whilst 17% (43) never warned patients (Table I). Only 10% (26/261) always asked patients to see their dentists before starting treatment, whilst 54% (140) never did. Low risk of necrosis (44%, 115) and delays to treatment (35%, 91) were the two main reasons given for not always referring patients for dental assessment. Only 38% (96/252) had information sheets for patients. Those with most treatment experience were more likely to ask about oral symptoms and health during outpatient follow-up consultations. Bisphosphonate-induced jaw necrosis had been seen in the previous 2 years by one-third (32%, 81/257) of responders overall and by nearly two-thirds of those with most treatment experience (Table II). These 81 respondents had seen 138 necrosis cases. The two most common reasons they gave for what might have caused jaw necrosis were ‘spontaneous’ (54%, 43/79) and ‘dental extraction’ (42%, 33/79). Spontaneity increased as a reason with treatment experience. One-quarter (26%, 20/77) indicated that they had seen necrosis occurring within 1 year after treatment and 85% (65/77) within 3 years. In 96% (76/79) of necrosis cases, the bisphosphonate treatment was stopped temporarily. This was the first national survey in the UK that asked a body of clinicians treating myeloma about their practice relating to dental assessment prior to commencing i.v. bisphosphonates. It is recognized that there are limitations associated with postal surveys hence the findings must be viewed with some caution. However, the results gave an indication of current practice and certainly demonstrated a range in views and service provision. As most cases of BON are incurable, prevention is imperative (Ruggiero et al, 2004; Marx et al, 2005; Barker & Rogers, 2006). Despite recent literature, it is surprising that nearly one-fifth of patients were not warned about dental complications of bisphosphonate treatment. Most clinicians did not ask patients to see their own dentist prior to starting treatment. It seems that the main barriers to advising dental assessment were potential delays in treatment and the perceived low risk of BON. In addition to raising awareness of BON, perhaps one key requirement is to ensure that there is the availability of, and access to, a timely dental check-up. This should ideally be in the primary sector or community dental service but provision might be necessary through the cancer network. It is vital that care pathways are put in place which ensures that patients have access to an oral examination and preventative information. Most clinicians did not have a patient information sheet and the majority of those did use material produced by the pharmaceutical industry. Less than half of responders always or sometimes asked their patients about oral symptoms at consultations in spite of the spontaneous occurrence of BON following trivial denture trauma, not just following tooth extraction. Bisphosphonate treatment was stopped in the vast majority of patients who developed BON. The merit of this is not substantiated given the long half-life of this drug. Close collaboration with the medical oncologist and Maxillofacial Surgery Departments is essential in patients suspected of having BON. In conclusion, it would appear that there is scope for improving patient access to dental assessment and raising awareness of the importance of dental health prior to and during i.v. bisphosphonates treatment.