Readers of Healthplusair their views
Dear Sir - A recent editorial in the Irish Medical Journal (IMJ) was quoted in Tuesday's July 8th 2008 Healthplusby Dr Muiris Houston, entitled "Specialists play down risk of jaw condition". Consultant rheumatologists in Galway and Dublin suggest that the American Dental Association (ADA) is incorrect when recommending dental evaluation prior to the commencement of oral bisphosphonate treatment.
There is no disagreement that this class of drugs is of great benefit to the public and has been used for more than 30 years with great clinical success. It is frequently used in the treatment of the common condition osteoporosis; it is also deemed to be the "standard of care" in the treatment of certain cancers by the American Society of Clinical Oncology. The condition known as Bisphosphonate-Related Osteonecrosis of the Jaw (BRONJ) is a well-documented side effect of this drug class when used intravenously.
The risk of developing BRONJ is considerably lower when this drug is used orally. Nevertheless, this small risk merits caution prior to commencing bisphosphonate treatment if we are to keep our patients' dental and oral health interests at heart. As the onus of treating patients with this painful and persistent condition falls on oral medicine and oral maxillofacial departments to manage, we feel we need to offer a response and hopefully develop a considered, balanced view.
BRONJ may occur spontaneously following bisphosphonate administration. Yet, more frequently it is precipitated by invasive dental procedures such as tooth extraction. Trauma to the oral mucosa and ill-fitting dentures may also give rise to the condition. In order to eliminate these risk factors and reduce the potential of inducing BRONJ the ADA have recommended patients are referred for a pre-treatment check-up with their dentist.
This evaluation will allow the dentist to assess the patient's current dental health, thereby eliminating infections and preventing the need for invasive procedures in the future. It also affords the opportunity to encourage routine dental care and good oral health. It may serve to educate the patient as to the risk of BRONJ, however small. Ultimately the cost of a dental check-up is modest when compared to the consequences of developing BRONJ even at the low levels of risk. In summary the dismissal of a pre-treatment evaluation seems ill-founded and contrary to the multidisciplinary, holistic vision of patient health care.
Dr Gillian Smith, Prof Stephen Flint, Prof Leo Stassen
Dublin Dental School Hospital
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