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Letter to the editor, RANKL inhibitors

March 19, 2013

Letter to the editor

By: Ken Tankersley, DDS, MD

By now, we all know about the bisphosponates and their potential for osteonecrosis of the jaw. There is a relatively new (approved by the FDA in June 2010) class of medication known as RANKL inhibitors which can be every bit as problematic as the IV Bisphosphonates. The medications are either injected monthly for certain cancer treatments or every six months for osteoporosis.

The RANKL inhibitors are monoclonal antibodies which bind to the osteoclasts and render them nonfunctional. Osteoclast activity is critical to normal bone healing following extractions, implants, surgical endo, and perio surgery. As a result, without normal bone healing it may result in osteonecrosis following oral surgical procedures, and this can be quite devastating to the patient. The patient that I’ve been seeing had had a total of three injections spaced six months apart for post-menopausal osteoporosis. She originally presented with a persistent infection that was not responsive to antibiotics following two mandibular extractions by her dentist. She had significant cheek swelling, left inferior alveolar paresthesia/hypoesthesia, deep jaw pain, purulent discharge from her left mandible intraorally, and clinical/radiographical evidence of a large sequestrum that extended close the inferior border of the mandible. After a couple of conservative debridements of the mobile sequestra and several months of antibiotics, she is starting to stabilize and feel better. She is still at risk for a pathological fracture and is being currently maintained with long term antibiotics and Peridex®. Nonetheless, she had Class III Osteonecrosis of the Jaw. Unfortunately, there is no “cure” and the condition will need to be managed over the duration.

I haven’t seen much on these drugs in the dental literature. An internet search will reveal plenty of warnings of osteonecrosis in association with these meds, but it hadn’t percolated up to my consciousness. I was not personally screening for these agents prior to this patient. Inquire of your patients that carry the diagnosis of osteoporosis or cancer if they are being treated by these medications prior to performing any oral surgery. And if your patients are on these drugs, it may be beneficial to have more frequent recalls to reinforce oral hygiene and catch pathology at an early and manageable stage. The drug is generically known as Denosumab. It goes by the trade names of Prolia® and Xgeva®.