Bisphosphonat-assoziierte Kiefernekrose. Literaturübersicht und Analyse des Patientengutes eines Hauses der Maximalversorgung am Beispiel der Klinik für Mund-, Kiefer- und Gesichtschirurgie - Plastische Operationen - am Helios Klinikum Erfurt

In 2003 for the first time correlation was reported between the therapy of bisphosphonates and osteonecrosis of the jaw. Since that time the bisphosphonate related osteonecrosis of the jaw (BRONJ) has become a serious and widely known problem in the daily clinical routine, especially in the therapy of patients with malignancies and intravenous application of aminobisphosphonates. The intention of this evaluation was to analyze the data of patients with BRONJ, to compare these information with data published in the literature and finally to identify all influencing factors. In 62 cases the different underlying diseases, applied bisphosphonates, comorbidities, comedication and other influencing factors, as primary BRONJ disease and following affections of BRONJ, loose of dentures and prosthetics and other potentially promoting criteria could be described. Variable primary symptoms, different diagnostic methods (histological and radiological), therapies and the classification of the stages of the BRONJ according to the outcome were analysed. Most of the patients were affected by a malignant disease and received intravenous aminobisphosphonates. In accordance with other studies published in the literature one of the most important risk factors for the development of a BRONJ seems to be a previous surgical treatment of the oral cavity, especially a previous tooth extraction. Further predispositions for the progress of a BRONJ are marginal or apical periodontitis, artificial dentition like prostheses and insufficient oral hygiene. Further studies should explore whether BRONJ is caused by the antiangiogenetic effect of the BP or the different impacts of the drug remain bone. Histological and radiological diagnosis such as primary clinical symptoms are unspecific. In most cases the diagnosis could be proven following the clinical appearance. Apart from that an accurate medical history is necessary to establish a correlation. Patients with bisphosphonate medication can be separated into a high risk, medium risk and low risk group. Associated with a high risk are patients with an intravenous bisphosphonate application and bone metastases or myeloma. The medium risk group is characterized by intravenous bisphosphonate application due to a therapy induced osteoporosis. The low risk group compromisis patients with a bisphosphonate medication due to osteoporosis. It seems noteworthy that BRONJ is seen predominant in patients with an intravenous therapy with Pamidronate or Zoledronate lasting more than twelve months and a malignant disease with metastases. According to the results of both the present and a multitude of published studies it is unanimously agreed that the development of BRONJ is related to an interaction of many different risk factors. In most cases BRONJ is located in the lower jaw. As data show there is still need for action regarding prophylaxis, prevention and treatment of this disease pattern. Preferably a gentle and complete removal of the necrotic bone in association with conservative treatment will effect the best results. Especially for patients treated with BP and a malignant disease it should be evaluated whether it can be useful to change to a drug associated with a lower risk for BRONJ. In addition it should be clarified whether it is reasonable to interrupt the BP medication in patients with an apparent BRONJ. Up to discussion is also how often BP really should be applied with regard to half life of this drug lasting for months and even years. Interdisciplinary communication should aim at advancing and developing a corporate, long- term and well coordinated care of the affected patients. All fields should conduct causal research in matters of BRONJ because only an exact knowledge of this disease may lead to a successful and efficient therapy.