Osteonecrosis of the jaw (ONJ) is a major health problem arising from the use of bisphosphonates when treating bone metastatic carcinomas of the breast and prostate. Denosumab is a newer agent that is used as an alternative to bisphosphonates when those agents are contraindicated or cannot be tolerated.
Denosumab inhibits the receptor activator of nuclear factor kappa-B ligand (RANKL) of osteoclasts, which increases bone mass and prevents bone resorption activities. Denosumab has shown strong activity in preventing bone incidences in metastatic bone disease and osteoporosis.
Denosumab is approved by the Therapeutic Goods Administration to be administered at 120mg monthly to control bone metastases in metastatic breast and prostate cancers; and at 60mg yearly to treat osteoporosis.
Denosumab is assumed to cause an increase in the incidence of ONJ similar to bisphosphonates. However, the clinical evidence required to ascertain the extent of this risk has been lacking. A report by Professor O’Halloran from the University of Western Australia in the Australian Dental Journal, describes two cases that had been treated by oncologists for bony metastatic cancers while undergoing dental interventions. These patients developed ONJ while being treated with denosumab.
This report supports the emerging evidence that denosumab may present a risk of causing ONJ similar to that of bisphosphonates.
Patients should be warned to complete all planned dental interventions prior to commencing denosumab treatment.
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- O’Halloran M, Boyd NM, Smith A. Denosumab and osteonecrosis of the jaws – the pharmacology, pathogenesis and a report of two cases. Aust Dent J 2014; Aug 16. In Press.