Symptomatic osteonecrosis in childhood leukemia survivors: prevalence, risk factors and impact on quality of life in adulthood.

Corticosteroid can induce osteonecrosis in children with leukemia. Few studies have been designed to assess the influence of a wide range of cumulative steroid dose on this side effect. Prevalence, risk factors of symptomatic osteonecrosis and its impact on adults' Quality of Life were assessed in 943 patients enrolled in the French "Leucémies de l'Enfant et de l'Adolescent" (LEA) cohort of childhood leukemia survivors. During each medical visit, data on previous osteonecrosis diagnosis were retrospectively collected. Patients without a history but with suggestive symptoms were investigated with magnetic resonance imaging. The total steroid dose in equivalent of prednisone was calculated for each patient and its effect on osteonecrosis occurrence was studied in multivariate models. Cumulative incidence was 1.4% after chemotherapy alone versus 6.8% after transplantation (P<0.001). A higher cumulative steroid dose, age over ten years at diagnosis, and treatment with transplantation significantly increased the risk of osteonecrosis. A higher post-transplant steroid dose and age over ten years at time of transplantation were significant factors in the transplanted group. With patients grouped according to steroid dose quartile, cumulative incidence of osteonecrosis reached 3.8% in the chemotherapy group for a dose beyond 5835 mg/m(2) and 23.8% after transplantation for a post-transplant dose higher than 2055 mg/m(2). Mean physical composite score of Quality of Life was 44.3 in patients with osteonecrosis versus 54.8% in patients without (P<0.001). We conclude that total and post-transplant cumulative steroid dose may predict the risk of osteonecrosis, a rare late effect with a strong negative impact on physical domains of Quality of Life.

A survey of consultant members of the British Association of Oral and Maxillofacial Surgeons regarding bisphosphonate-induced osteonecrosis of the jaws.

The aims of this survey of consultants in the British Association of Oral and Maxillofacial Surgeons were threefold. Firstly, to estimate the number of patients screened for oral health before starting intravenous bisphosphonate medication, secondly, to indicate the use of antibiotics in patients on bisphosphonates who need routine extraction of a lower first molar tooth, and finally to estimate the number of new and currently managed cases of bisphosphonate-induced osteonecrosis of the jaw (BONJ) in the last year, and approximately how many of those currently being managed had healed. A questionnaire was mailed to 322 consultants working at 154 hospitals in the summer of 2008. There were responses from 184 consultants (57%) and from 111 hospitals (72%). Screening patients before starting intravenous bisphosphonates was uncommon (15%). Almost all consultants would prescribe antibiotics for molar extraction and in about two-thirds this was both before and after extraction. Relatively few would stop bisphosphonates. Nearly two-thirds of consultants had seen new cases of BONJ from intravenous treatment in the last year, and a quarter had seen three or more. A similar proportion had patients on intravenous bisphosphonates under review for BONJ, and it was estimated that in a fifth of patients the lesion had healed. This survey indicates current practice among oral and maxillofacial surgeons in the UK. A national project for the registration of new patients will provide a stronger evidence base with respect to incidence, risk factors, and management of BONJ.