Table 5. Drugs and Biologics Used in Oncology and Reported to Be Associated With ONJ continued...
Management of ONJ
Confirmed ONJ with exposed bone in the oral cavity should initially be managed conservatively with local debridement and removal of sharp margins of bone; this reduces the risk of trauma to soft tissue, including the tongue. Systemic antibiotics should be administered when active infection with purulent secretion, swelling and inflammation of the surrounding soft tissues, and pain are present. Initial therapy can be implemented with a single antibiotic, but there is no agreement regarding drug of first choice. Options include the following:
- Amoxicillin, 500 mg 4 times a day for at least 14 days.
- Metronidazole, 250 mg 3 times a day for at least 14 days.
- Clindamycin, 300 mg 4 times a day for at least 14 days.
- Amoxicillin and clavulanic acid, 500 mg 4 times a day for at least 14 days.
In addition, topical oral therapy can be implemented via 0.12% chlorhexidine mouth rinses or tetracycline rinses (62.5 mg/oz) twice a day. The need for oral hygiene with meticulous brushing and flossing after meals should be emphasized.[4,10,11,13,24,25]
The patient should be reevaluated in 2 weeks. Systemic antibiotics can be discontinued when clinical signs and symptoms improve. The local measures should be maintained, however, as part of the routine oral hygiene procedures consisting of brushing and flossing.
In ONJ cases refractory to therapy, patients may need to be maintained on long-term antibiotic therapy. With these patients, a combination of different antibiotic agents such as penicillin and metronidazole can be considered. Another possibility is to use clindamycin or the combination of amoxicillin and clavulanic acid in place of amoxicillin. When the infectious process extends to more critical areas of the head and neck, the patient may need hospitalization and intravenous antibiotic therapy, culminating in the need for extensive surgical resection of the affected areas.
Reports suggest that ONJ can be successfully managed by surgical resection and primary wound closure, especially in cases refractory to conservative therapy.[26,27,28] The use of radical surgery is increasing, and it appears that the initial paradigm that surgery should not be done in ONJ cases is no longer true. However, patients must be advised that surgery may result in treatment failure and that not all cases are treated successfully. With surgery as a treatment option, clinicians are now performing bone biopsies to confirm ONJ diagnoses. In cancer patients, there is always a possibility of metastatic disease to the jawbones mimicking ONJ; the final diagnosis should be confirmed by histopathological examination. The use of surgical lasers has also been suggested as an alternative for ONJ patients who do not respond to conservative management.