Underlying Mechanisms and Therapeutic Strategies for Bisphosphonate-Related Osteonecrosis of the Jaw (BRONJ)

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  • Endo Yasuo
    Division of Oral and Maxillofacial Surgery, Graduate School of Dentistry, Tohoku University
  • Kumamoto Hiroyuki
    Division of Oral Pathology, Graduate School of Dentistry, Tohoku University
  • Nakamura Masanori
    Department of Oral Anatomy and Developmental Biology, School of Dentistry, Showa University
  • Sugawara Shunji
    Division of Oral Molecular Regulation, Graduate School of Dentistry, Tohoku University
  • Takano-Yamamoto Teruko
    Division of Orthodontics and Dentofacial Orthopedics, Graduate School of Dentistry, Tohoku University
  • Sasaki Keiichi
    Division of Advanced Prosthetic Dentistry, Graduate School of Dentistry, Tohoku University
  • Takahashi Tetsu
    Division of Oral and Maxillofacial Surgery, Graduate School of Dentistry, Tohoku University

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  • Underlying mechanisms and therapeutic strategies for bisphosphonate-related osteonecrosis of the jaw (BRONJ) (review)

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<p>Bisphosphonates (BPs), with a non-hydrolysable P-C-P structure, are cytotoxic analogues of pyrophosphate, bind strongly to bone, are taken into osteoclasts during bone-resorption and exhibit long-acting anti-bone-resorptive effects. Among the BPs, nitrogen-containing BPs (N-BPs) have far stronger anti-bone-resorptive effects than non-N-BPs. In addition to their pyrogenic and digestive-organ-injuring side effects, BP-related osteonecrosis of jaws (BRONJ), mostly caused by N-BPs, has been a serious concern since 2003. The mechanism underlying BRONJ has proved difficult to unravel, and there are no solid strategies for treating and/or preventing BRONJ. Our mouse experiments have yielded the following results. (a) N-BPs, but not non-N-BPs, exhibit direct inflammatory and/or necrotic effects on soft tissues. (b) These effects are augmented by lipopolysaccharide, a bacterial-cell-wall component. (c) N-BPs are transported into cells via phosphate transporters. (d) The non-N-BPs etidronate (Eti) and clodronate (Clo) competitively inhibit this transportation (potencies, Clo>Eti) and reduce and/or prevent the N-BP-induced inflammation and/or necrosis. (e) Eti, but not Clo, can expel N-BPs that have accumulated within bones. (f) Eti and Clo each have an analgesic effect (potencies, Clo>Eti) via inhibition of phosphate transporters involved in pain transmission. From these findings, we propose that phosphate-transporter-mediated and inflammation/infection-promoted mechanisms underlie BRONJ. To treat and/or prevent BRONJ, we propose (i) Eti as a substitution drug for N-BPs and (ii) Clo as a combination drug with N-BPs while retaining their anti-bone-resorptive effects. Our clinical trials support this role for Eti (we cannot perform such trials using Clo because Clo is not clinically approved in Japan).</p>

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