We would like to thank Dr. Lasser for his comments. His questions beg further discussion and inquiry.
Dr. Lasser raises an intuitive point about the possible impact of gum chewing and the consumption of hard-shelled dry fruit and root edibles (carrots and nuts) on patients taking bisphosphonates. Although it is well-known that bisphosphonate medications reduce bone turnover, there is no scientific evidence that substantiates a correlation between chewing gum or eating hard foods and an increased likelihood of developing osteonecrosis.
Until there is evidence to the contrary, we cannot recommend a curtailment of the dietary intake of patients on oral or intravenous bisphosphonates. This is of particular importance in cancer patients, who already may have a decreased appetite.1 Subsequent removal of caloriedense foods, such as nuts and other hard perishables, would be detrimental to the progression of their treatment.
Because osteonecrosis’ etiology lies in wound healing rather than infection, we do not believe that the prophylactic use of a chlorhexidine mouthrinse would be beneficial to the asymptomatic patient population taking bisphosphonates.
Chlorhexidine’s efficacy in reducing surface bacterial colonization is well-documented. Its use in patients with the condition is directed toward reduction of surface bacterial colonization, in the hope of preventing infection that would compound the problem. However, a modulatory role for chlorhexidine in what is essentially an endogenous process has not been reported. Furthermore, chlorhexidine rinses are relatively expensive and not without adverse effects.2 Therefore, the prophylactic use of chlorhexidine in this patient population seems unwarranted at this time.
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