Early surgical approach preferable to medical therapy for bisphosphonate-related osteonecrosis of the jaws.

The recently published practical guidelines for the management of osteonecrosis of the jaws (ONJ) in patients receiving bisphosphonate (BP) therapy reported that medical therapy associated with antimicrobial rinses could be suggested for patients with stage II ONJ (exposed necrotic bone associated with pain and infection), whereas surgical treatment should be reserved for those with stage III ONJ (exposed necrotic bone associated with pain and infection and pathological fracture, extraoral fistula, or osteolysis extending to the inferior border).1 In addition, some authors have recommended medical therapy instead of surgical treatment for established BP-associated ONJ. [2] and [3] Wide-spectrum antibiotic treatment (eg, amoxicillin 2g/day in combination with metronidazole 500 mg/twice a day for 15 days3) is of great value in the immediate management of the infectious process. In our experience, it is possible to observe a resolution of the symptoms for a period usually not exceeding 4 weeks. After that, a new cycle of antibiotic treatment becomes necessary when symptoms return. Interestingly, subsequent recurrences are progressively worse, and the symptom-free period becomes increasingly shorter, with the result that almost antibiotic treatment becomes necessary. Many cancer patients who undergo chemotherapy and are debilitated by the malignancy cannot bear the side effects of prolonged (and sometimes permanent) therapeutic antibiotic schemes.4 In addition, many of these patients demonstrate an uncontrolled progression of BP-related ONJ, characterized by such severe complications as pathological bone fracture and maxillary sinus and orbital involvement.