Genomewide Pharmacogenetics of Bisphosphonate-Induced
Osteonecrosis of the Jaw: The Role of RBMS3
PAOLA NICOLETTI,aVASSILIKI M. CARTSOS,dPENELOPE K. PALASKA,dYUFENG SHEN,a,b
ARIS FLORATOS,a,bATHANASIOS I. ZAVRASc,e,f
aCenter for Computational Biology and Bioinformatics,bDepartment of Biomedical Informatics, andcHerbert
Irving Comprehensive Cancer Center, Columbia University Medical Center, New York, New York, USA;
dDepartment of Orthodontics, Tufts School of Dental Medicine, Boston, Massachusetts, USA;eDivision of
Oral Epidemiology & Biostatistics, Columbia College of Dental Medicine, New York, New York, USA;
fDepartment of Epidemiology, Mailman School of Public Health, New York, New York, USA
Key Words. Osteonecrosis • Jaw • Bisphosphonates • Pharmacogenetics • Screening • IGFBP7 • ABCC4 •
RBMS3 • Zoledronic acid • Genetic susceptibility • Genomewide association study • ONJ • GWAS
Disclosures: Paola Nicoletti: None; Vassiliki M. Cartsos: None; Penelope K. Palaska: None; Yufeng Shen: None; Aris Floratos: None;
Athanasios I. Zavras: None.
Section Editors: Eduardo Bruera: None; Russell K. Portenoy: Arsenal Medical Inc., Grupo Ferrer, Xenon (C/A); Ameritox, Archimedes
Pharmaceuticals, Boston Scientific, Covidien Mallinckrodt Inc., Endo Pharmaceuticals, Forest Labs, K-Pax Pharmaceuticals, Meda
Pharmaceuticals, Medtronics, Otsuka Pharma, ProStrakan, Purdue Pharma, Salix, St. Jude Medical (RF).
Reviewer “A”: None.
(C/A) Consulting/advisory relationship; (RF) Research funding; (E) Employment; (H) Honoraria received; (OI) Ownership interests; (IP)
Intellectual property rights/inventor/patent holder; (SAB) Scientific advisory board
After completing this course, the reader will be able to:
1. Explain the association between bisphosphonates and osteonecrosis of the jaw.
2. Describe the role of RBMS3 in the risk of BRONJ development.
This article is available for continuing medical education credit at CME.TheOncologist.com.
Bisphosphonate-related osteonecrosis of the jaw (BRONJ) is
association study to search for genetic variants with a large
effect size that increase the risk for BRONJ.
Methods. We ascertained BRONJ cases according to the
Maxillofacial Surgeons. We genotyped cases and a set of
treatment-matched controls using Illumina Human Omni
Express 12v1 chip (733,202 markers). To maximize the
power of the study, we expanded the initial control set by
publicly available sources. Imputation at the whole-ge-
nome level was performed to increase the number of single
sociation were carried out by logistic regression, adjusting
for population structure. We also examined a list of candi-
date genes comprising genes potentially involved in the
pathogenesis of BRONJ and genes related to drug absorp-
tion, distribution, metabolism, and excretion.
Results. Based on principal component analysis, we
initially analyzed 30 white cases and 17 treatment-toler-
ant controls. We subsequently expanded the control set
to include 60 genetically matched controls per case. As-
sociation testing identified a significant marker in the
RBMS3 gene, rs17024608 (p-value < 7 ? 10?8); individ-
uals positive for the SNP were 5.8? more likely to de-
Correspondence: Athanasios I. Zavras, D.M.D., D.M.Sc., M.S., Columbia University Medical Center, 622 W 168th Street, Suite
PH17W-306R, New York, New York 10032, USA. Telephone: 212-342-0425; Fax: 212-342-8558; e-mail: firstname.lastname@example.org.
columbia.eduReceived June 16, 2011; accepted for publication September 21, 2011; first published online in The Oncologist Express
on January 20, 2012. ©AlphaMed Press 1083-7159/2012/$40.00/0 http://dx.doi.org/10.1634/theoncologist.2011-0202
velop BRONJ (odds ratio, 5.8; 95% confidence interval,
3.1–11.1). Candidate gene analysis further identified
SNPs in IGFBP7 and ABCC4 as potentially implicated in
Conclusion. Our findings suggest that genetic suscepti-
bility plays a role in the pathophysiology of BRONJ, with
Bisphosphonates (BPs) are widely prescribed antiosteoclastic
medications. The i.v. administered BPs pamidronate and zole-
dronic acid are used in oncology to control bone metastasis and
hypercalcemia. Oral BPs are used to control or prevent bone loss
currently on oral BPs [1–3]. BPs are synthetic analogs of pyro-
for several years. BPs are especially attracted to, and localize in,
areas of the bone undergoing inflammation or resorption. They
are subsequently phagocytozed and internalized by osteoclasts.
These internalized BPs, in turn, trigger apoptosis (cell death) of
the osteoclasts, thus inhibiting osteoclast-mediated bone resorp-
tion [1, 2]. Osteoclasts seem to be affected both in terms of num-
ber and function. Animal studies have also demonstrated some
of the bone because of reduced vasculature .
BPs, especially zoledronic acid, have been associated with a
American Association of Oral and Maxillofacial Surgeons
(AAOMS), BP-related osteonecrosis of the jaw (BRONJ) is de-
tients under BP treatment and with no prior history of radiation
therapy of the jaws . The nonhealing exposed necrotic lesions
ful, persistent, and resistant to treatment. The incidence of
ing on the type of BP, drug administration route [3, 6], dose and
duration of use, comorbidities, and treated condition [1, 3, 6].
Cancer patients are a group with a higher risk for BRONJ,
whereas, among all BPs on the market, zoledronic acid seems to
be the most frequently implicated drug [1, 2]. BRONJ affects as
oral health have been shown to be predisposing factors for
be involved in BRONJ risk [1, 9, 10]. A genetic test capable of
screening subjects for genetic susceptibility to BRONJ prior to
initiating BP therapy would have great clinical utility, especially
netic genomewide association study to identify highly penetrant
polymorphisms associated with BRONJ across multiple drugs.
We recruited patients who had a definite BRONJ diagnosis. We
looked across the whole genome for susceptibility single nucleo-
tide polymorphisms (SNPs) and copy number variation (CNV)
markers using a dense DNA array with ?733,000 markers. Im-
putation analysis allowed the further expansion of the genome-
wide marker panel to include ?3.5 million SNPs. Candidate
SNPs in the insulin-like growth factor (IGF) gene family (IGF1,
sorption, distribution, metabolism, and excretion of drugs
(ADME genes) were specifically inspected .
This research involved a hospital-based case–control study.
The research protocol was reviewed and approved by the in-
stitutional review boards of the recruiting institutions. All the
enrolled subjects signed a written informed consent form. The
eral Hospital, Brigham & Women’s Hospital, the Harvard
School of Dental Medicine and its affiliated clinics, and Nova
University Dental School in Florida. Initially, we searched
ers. Among the BP users, we identified confirmed BRONJ
cases according to the AAOMS diagnostic criteria and unaf-
fected exposed controls. Cases were considered to have devel-
oped BRONJ if all the following three clinical characteristics
developed ONJ, (b) the exposed, necrotic bone in the maxill-
ofacial region persisted for ?8 weeks, and (c) the patient had
no history of radiation therapy to the jaws. Controls were pa-
tients currently under treatment with a BP who had no signs or
symptoms of BRONJ, verified via clinical examination.
Potential participants were contacted by letter and were in-
vited to participate in the study. Patients (cases) with con-
firmed BRONJ status were offered the alternative to
clinic to be examined to ensure their non-BRONJ status. After
signing the consent form, participants were asked to answer a
questionnaire contained questions on demographic character-
fluence the risk for developing BRONJ.
the Oragene DNA collection kit (DNA Genotek, Kanata, Can-
ada). The saliva kits were mailed in one batch to the subcon-
tracting genotyping facility at SABiosciences (Frederick,
MD). DNA was extracted following the manufacturer’s rec-
ommended protocol. High-throughput genotyping was per-
formed using the Human Omni Express 12v1.0 Beadchip
Pharmacogenetics of Bisphosphonate-Related ONJ
(Illumina, San Diego, CA). The Human Omni Express 12v1.0
Beadchip captures 731,442 markers.
Genotype Quality Control
Raw data were processed with Illumina’s GenomeStudio soft-
ware and the downstream analysis was performed using the
PLINK software . We discarded markers that failed the
allele frequency (MAF) ?1%, (c) a p-value for Hardy–Wein-
berg equilibrium (HWE) ?.0000001 in controls (if applica-
ble). We also confirmed that the call rate per sample was
?95%. We tested for cryptic relatedness by estimating the
identity-by-descent for all possible pairs of individuals.
Additional Population and Drug-Treated Controls
To increase the power of our analyses, we augmented the ini-
tial BRONJ group with publicly available population controls.
(WTCCC) , Illumina iControlDB , and international
All subjects, except the ones from the iControlDB, were geno-
typed using Illumina 1M or 1M-duo chips; the subjects from
the iControlDB were genotyped using the Illumina 550K chip
(Table 1). After applying standard quality control procedures,
the controls were combined with the initial BRONJ group to
produce the “population control group.” The effect of popula-
tion structure was assessed through principal components
analysis (PCA) using the smartPCA program from the
EIGENSTRAT package (version 3.0) . SNPs from known
regions of long-range linkage disequilibrium were removed
before running the PCA . Because the population control
group contained a disproportionally large set of north Euro-
pean subjects, we chose a fixed cases/control ratio of ?1/60,
values of the significant PC axes.
Additionally, in order to test the effect of possible con-
founding factors, which may be related to either BP exposure
or clinical diagnosis, we downloaded a set of treatment-toler-
ant cancer sample data from the phs000210.v1.p1 cohort from
dbGAP . This cohort is composed of 878 breast cancer pa-
tients genotyped by the Illumina 610K chip. We selected 107
subjects who had been BP users by reviewing the patients’
loaded datasets. After selecting the white BP users by PCA,
these controls were combined with the initial BRONJ treatment-
tolerant controls to produce the “treatment-tolerant group.”
2009) with data from the 1000 Genomes Project (112 individ-
all ethnicities) as the reference panels . SNPs with poor
quality were pruned before the imputation to avoid false posi-
tives. We divided the genome in 5000-bp long segments and
used an ethnic mixed panel to improve the quality of the im-
putation for rare variants . We retained imputed genotypes
ference in missingness between cases and controls (?2test, p-
value ?.05), and (c) no significant deviation from HWE (p-
We conducted statistical tests using the PLINK software
. We tested the association of single SNPs using logistic
regression with the PCA eigenvalues as covariates under an
additive model. We set the genomewide significance p-
value threshold to 5 ? 10?8to correct for multiple testing
(Bonferroni correction). When top results were imputed, we
assessed the accuracy of the imputation manually, confirm-
ing that the quality of the signal intensity was within the
range of acceptance for all SNPs in the haplotype generating
the imputed genotype. For the candidate gene analysis, we
reviewed the literature and identified genes possibly in-
volved in the pathogenesis of BRONJ, including the IGF
gene family and genes belonging to vitamin D metabolism.
We also included ADME genes from a list compiled specif-
ically for pharmacogenetic studies . Appropriate Bon-
ferroni correction was applied to the candidate gene
We inferred CNVs from SNP chip data using the PennCNV
software (April 2009 version) . To ensure the accuracy
of CNV calling, we applied stringent sample and CNV fil-
tering procedures. We included all samples that had a log2
Table 1. Composition of control study cohorts
n of controls Ethnic compositionGenotyping platform
European collection (including POPRES,
Breast cancer study cohort
1,971 EuropeansIllumina 1M or 1M-Duo
Illumina 550K chip
Illumina 610 chip
Abbreviations: iSAEC, international Serious Adverse Events Consortium; POPRES, population reference sample; WTCCC,
Wellcome Trust Case Control Consortium.
Nicoletti, Cartsos, Palaska et al.
ratio standard deviation ?0.5, maximum number of total
CNV calls ?50, bioaccumulation factor (BAF) median
?0.55 or ?0.45, BAF drift ?0.01, or waviness factor
?0.05 or ??0.05 (recommended parameters). Addition-
ally, to ensure high-confidence CNVs, we excluded individ-
ual CNVs with a PennCNV-generated confidence score
?10, those with calls based on ?10 SNPs or CNV probes,
and those with a span within 1 Mb from centromeres or telo-
We performed burden and common CNV association
analysis whereby any CNV that was present in at least three
subjects was considered to be common. Associations were
tested with the PLINK software  using a two-tailed per-
muted Fisher’s exact test (105permutations). Duplications
and deletions were analyzed separately . We also inves-
tigated singleton CNVs ?500 kb to find evidence for indi-
vidual predisposition to BRONJ. We adopted a coverage
cutoff excluding all CNVs that had coverage ?20 genetic
markers. Finally, we selected the top 150 genes most fre-
quently involved in CNVs (both duplications and dele-
tions). We used the David software  to perform
enrichment analysis (Fisher exact test) of the Kyoto Ency-
(released December 2010) .
those, 32 were female cases with a mean age of 62.8 years, 15
were female controls with a mean age of 64.8 years, five were
male controls with a mean age of 63.6 years, and 15 were male
of 47) and controls (13 of 20) had received zoledronic acid, with
on zoledronic acid was higher in cases than in controls, but the
significant difference between cases and controls in the mean
number of months on zoledronic acid for the 14 subjects who re-
ported a positive history of osteoporosis. Of the 67 individuals
ment-tolerant controls. In what follows we refer to these 53 sam-
ples as the “BRONJ group.”
Population Structure and Selection of Genetically
We applied PCA to expose the population structure of the
BRONJ group and to find additional genetically matched pop-
Figure 1. Population structure of the BRONJ group. The red circles represent the initial BRONJ group, blue dots represent CEU Hap
Map III, orange dots represent TSI Hap Map III, and gray dots represent the European Collections (international Serious Adverse Events
ern (top), southern (lower center), and eastern (lower right) clusters. The gray cluster on the lower left represents the subjects of Spanish
origin who belong to the POPRES collection.
Abbreviations: BRONJ, bisphosphonate-related osteonecrosis of the jaw; CEU, Utah residents with Northern and Western European
in HapMap III.
Pharmacogenetics of Bisphosphonate-Related ONJ
confirm the self-reported ethnicity of the members of the
HapMap III subjects, which included subjects from 11 popu-
lations . We found six individuals not clustering with the
white HapMap III samples (CEU and TSI). For the remaining
47 white subjects, we attempted to refine ethnicity resolution
WTCCC, and iSAEC collections, representing several Euro-
pean subpopulations. This analysis showed that the white
BRONJ study subjects clustered with individuals of north-
western, southern, and eastern European descent (Fig. 1). To
further increase the number of eastern European controls, we
added 2,978 white samples from the iControlDB dataset. We
controls for each case based on the eigenvalues of the first six
principal components. The case/control ratio was chosen to
maximize the total number of controls while keeping the ratio
comparable among the three major clusters. In addition to the
population control group, we identified publically available
GWAS data on a set of breast cancer patients who had been
select 101 white treatment-tolerant cancer subjects from the
107 drug-exposed controls from the phs000210.v1.p1 cohort
tolerant controls in a treatment-tolerant group. PCA showed
that all the three major ethnicity clusters (northwestern, south-
Figure 2. Quantile-quantile plot for logistic regression on the
population control group, On the x-axis is ?log10 of the expected
p-values of an equally sized set of single nucleotide polymor-
phisms under a uniform distribution. The y-axis is ?log10 of the
observed p-values. Black solid lines denote the uniform null dis-
tribution. The bulk of the values (red dots) closely follows the ex-
pectation under the null model (black line), showing that there is
no systematic artifact of population stratification. The tail end
shows significant deviation from the null model, illustrating that
there are a few observed significant associations.
Table 2. BRONJ genomewide association study: top associated SNPs
SNP Chr PositionAA
gene Function OR (95% CI)
7.47 ? 10?8
1.17 ? 10?7
5.16 ? 10?7
5.85 ? 10?7
3.10 ? 10?6
5.53 ? 10?6
6.24 ? 10?6
7.28 ? 10?6
7.87 ? 10?6
8.17 ? 10?6
9.15 ? 10?6
9.16 ? 10?6
9.94 ? 10?6
We performed a genomewide association study on 30 white cases and 1,743 genetically matched controls with more than
three million markers, applying a logistic regression statistic. The table shows the characteristics of the top associated SNPs.
ap-value from logistic regression.
Abbreviations: AA, ancestral allele; BRONJ, bisphosphonate-related osteonecrosis of the jaw; Chr, chromosome; CI,
confidence interval; ctls, controls; MAF, minor allele frequency; OR, odds ratio; SNP, single nucleotide polymorphism.
Nicoletti, Cartsos, Palaska et al.
Genomewide Association Analysis
The white BRONJ group contained 30 white cases and 17
white treatment-exposed controls. In total, 631,507 SNPs
passed quality control. In order to maximize the power of the
study, we grouped each of the 30 white BRONJ cases with 60
ing in a study sample comprising 30 cases and 1,743 controls
(724 males, 1,049 females). Because not all population con-
trols were genotyped with the same chip, only 287,434 SNPs
were shared by all subjects. We imputed this dataset using ref-
erence panels from HapMap 3 and the 1000 Genomes Project.
In total, 3,542,142 markers passed quality control procedures
specific for the imputation (see Methods). We tested the asso-
ciation of single SNPs using logistic regression with the first
six eigenscores as covariates under an additive model.
rs17024608, located in an intron of RBMS3, was found to be
significantly associated with BRONJ (p-value ? 7.4 ? 10?8);
individuals positive for rs17024608 had a fivefold higher risk
controls had a missing call for this marker; consequently, only
2 summarizes the top findings from the logistic regression on
the imputed data. Figures 2 and 3, respectively, present the
quantile-quantile plot of logistic regression and the Manhattan
plot of the region (? 1 Mbp) surrounding rs17024608.
The treatment-tolerant group contained 118 treatment-
minor allele frequency of rs17024608 between the treatment-
tolerant group and the population controls (Fisher’s exact test,
p-value ? .2) (Table 3). This finding is consistent with the hy-
notype because its association is unlikely to be a result of
confounding factors related to BP exposure or clinical diagno-
SNPs in Candidate Genes
Previous work suggests that inherited genetic variations in the
IGF gene family or in ADME genes may play a role in the
pathophysiology of BRONJ [1, 9, 10]. With regard to the IGF
gene family, we examined 1,083 SNPs located within 20 kb
tative causal genes (hereafter, putative causal gene list). We
also examined a list of 4,564 SNPs compiled for pharmacoge-
Figure3. Manhattan plot of the region surrounding rs17024608 (about ?1 Mb). Each dot represents a single nucleotide polymorphism
(SNP). The x-axis represents the position of the SNP on the chromosome. The y-axis represents ?log10of the logistic regression p-value
rs17024608 is marked in green with the p-value just below the genomewide threshold (dashed line). For this marker, we were able to
impute the genotype for 2% of controls who had a missing value for this marker.
Table 3. MAF of rs17024608 in different
White subgroup (n of samples)MAF
BRONJ cases (30)
Population control group (1743)
White group (dbSNP)
Treatment-tolerant group (118)
Rs17024608 is an intronic SNP located in RBMS3. It was
found to be associated with BRONJ with borderline
genomewide significance (odds ratio, 5.3; p-value ?
7.4 ? 10?8). The table shows the frequency of the allele
at risk in different white subgroups.
aThere was no significant difference in MAF between the
treatment-tolerant and population control groups.
Abbreviations: BRONJ, bisphosphonate-related
osteonecrosis of the jaw; MAF, minor allele frequency.
Pharmacogenetics of Bisphosphonate-Related ONJ
netic studies related to ADME genes (hereafter, the ADME
list) . The same two panels of markers were inspected in
the population control group. No SNP reached significance af-
ter Bonferroni correction. In the putative causal gene list, the
most significantly associated SNP was rs11934877, located in
the intronic region of IGFBP7(odds ratio [OR], 2.9; 95% con-
fidence interval [CI], 1.7–5.2; p-value ? .00022). In the
sociated, with borderline significance after multiple testing
correction (OR, 5.3; 95% CI, 2.4–11.4; p-value ? 2.0 ?
10?5). For the SNPs (or their proxies), there was no difference
in MAF between population and drug-exposed control sub-
jects (Table 4).
CNV Association Analysis
All analyses were performed on the initial 52 white subjects.
Fifty-two individuals (33 cases and 19 controls) passed our
stringent quality control criteria for CNV calling; 431 CNVs
were identified, of which 71 were duplications and 360 were
deletions. Cases and controls did not differ significantly in
their rate of CNV for both deletions and duplications. After
multiple-test correction, none of the common CNVs had a sig-
nificant association. We found two unique oversized (?700
kb) duplications in cases and none in controls. The duplica-
tions were found on chromosome 2 (925,407 bp; starting on
rs4850234 and ending on rs16837705) and chromosome 22
Oversized singleton CNVs, as the ones predicted, might
explain individual predisposition to the phenotype. In particu-
lar, the 730-kb heterozygous duplication covers the SLC7A4
be relevant for the bioavailability of BPs. The most enriched
ing pathway, involving five genes (NOTCH1, PSEN1, NUMB,
NOTCH4, and DVL1) with an enrichment score of six and a
Fisher’s exact p-value of .009, the retinol pathway, involving
five genes (CYP3A7, CYP2C19, ADH6, CYP2A6, CYP2A7)
pathway, involving five genes (CYP3A7, CYP2C19, ADH6,
CYP2A6, CYP2A7) with an enrichment score of 4.6 and a p-
value of .023, and the drug metabolism pathway, involving
four genes (CES2, CYP3A7, CYP2A6, CYP2A7) with an en-
richment score of 1.0 and a p-value of .039.
Osteonecrosis of the jaw is a serious adverse effect of BPs, es-
BRONJ negatively affects patient quality of life . Differ-
ences in BRONJ incidence among ethnic groups and previ-
ously published results from pharmacogenetic studies indicate
that genetic factors might be central in BRONJ predisposition,
besides the known risk factors [7–9]. The goal of our GWAS
was to identify high-penetrance genetic biomarkers associated
with BRONJ. Using genetically matched population controls,
associated with the risk for osteonecrosis, controlling for mul-
tiple comparisons. Furthermore, because there was no statisti-
cal difference in MAF between the treatment-tolerant group
and the general population controls, the association of
rs17024608 with BRONJ is unlikely to be a result of potential
confounding factors related to either BP exposure or clinical
with that previously reported for the white population (MAF,
0.09) in the SNP database dbSNP and is comparable among
European countries. However, the risk allele is less frequent in
the African population. This may partly explain why BRONJ
seems to be more frequent in whites than Africans .
Independent biological evidence suggests that RBMS3
might have a pivotal role in BRONJ etiology. RBMS3 is a
binding protein for Prx1, a homeobox transcriptional factor
that upregulates collagen type I in fibroblasts . Type I col-
bone matrix. Mutations in those genes produce genetic bone
disorders characterized by fragile bones such as osteogenesis
imperfecta . Variations in RBMS3 (rs10510628) and
COL1A (rs1800012) have previously been associated with a
decrease in bone mass and osteoporotic fractures, linking both
etiopathogenic mechanisms assumes that it can be caused by
BP-associated suppressed bone turnover that leads to de-
I synthesis in human gingival fibroblasts and osteoblasts .
could affect bone turnover, enhancing the BP-associated sup-
pressed effect on bone apposition.
Moreover, our study did not identify relevant signal on the
major histocompatibility complex region. Human leukocyte
[34–36]. HLA variants are mainly related to a drug-specific
number of affected cases [34, 35]. Given the absence of such a
signal, we could speculate that this adverse drug reaction
(ADR) is more likely to be a toxic ADR, also corroborated by
the fact that patients exposed to higher cumulative doses of
BPs are at a greater risk for developing BRONJ. Co-occurring
sic toxic effects, enhancing drug bioavailability. Indeed, the
candidate SNP analyses led to interesting signals related to
ABCC4, for which there was no significant difference in MAF
between exposed and nonexposed control populations. The
signal on ABCC4 is particularly intriguing. ABCC4 codes for
multidrug resistance transporter (MRP)4 (ABCC4); these
transporters efflux endogenous and xenobiotic substrates out
of cells, having a protective role, especially in the bone mar-
row, spleen, thymus, and gastrointestinal tract . Inherited
variation in these genes has been associated with the occur-
induced leukopenia/neutropenia) . Currently, there is no
published information on MRP4 and BPs. Moreover, CNVs
may also predispose to the phenotype by disrupting genes be-
Nicoletti, Cartsos, Palaska et al.
longing to drug metabolism pathways (CYP3A7, CYP2A7,
Finally IGFBP7, from the putative causal gene list analy-
especially IGF1 with its tyrosine kinase domain, are growth
factors with potent signal transduction capabilities. IGFs are
molecules with an important role in normal growth and devel-
opment. IGF1-deficient children fail to achieve appropriate
height, and pharmacologic therapies now exist to correct such
ferentiation of bone cells through activation of their receptors,
especially IGF1R whereas IGF-binding proteins, produced by
bone cells, compete with the receptors in binding the ligands
and thus affect the bioavailability of IGF1 and IGF2 [40, 41].
Although the RBMS3 finding is compelling and was tested
against different sets of controls, the reader should note that
more research is needed to validate the finding in an indepen-
dent set of study participants. With evolving observations
about the effects of osteonecrosis in different races beyond
lineages, and in particular in subjects of Chinese Han origin or
Our pharmacogenetic genomewide association analysis re-
vealed that one SNP on RBMS3, rs17024608, is significantly
associated with BRONJ. Variations in RBMS3 and COLA1
a role in bone turnover. The effect of the specific polymor-
phism in the etiology of osteonecrosis is currently unknown. It
is plausible that RBMS3 may be involved in reduced collagen
formation and the disruption of bone turnover, thus increasing
the toxic effect of BPs. Candidate gene analyses further sug-
gested that IGFBP7 and ABCC4 might be implicated in
BRONJ pathophysiology. More studies are needed to validate
and replicate these results as well as to elucidate their func-
The authors thank Drs. Thomas Dodson, Sook Bin Woo,
Salvatore Ruggiero, and Cesar Migliorati for their help in
recruiting study subjects. The authors wish to express their
gratitude to all study participants for volunteering their time
and effort to make this research possible. This research was
supported by the National Institute of Dental and Craniofa-
cial Research, National Institutes of Health (grant
P.M. and V.M.C. contributed equally in this project.
Conception/Design: Athanasios I. Zavras, Vassiliki M. Cartsos
Provision of study material or patients: Athanasios I. Zavras, Vassiliki M.
Cartsos, Pinelopi K. Palaska
Collection and/or assembly of data: Athanasios I. Zavras, Vassiliki M.
Cartsos, Pinelopi K. Palaska
Data analysis and interpretation: Athanasios I. Zavras, Paola Nicoletti,
Vassiliki M. Cartsos, Yufeng Shen, Aris Floratos
Manuscript writing: Athanasios I. Zavras, Paola Nicoletti, Vassiliki M.
Cartsos, Pinelopi K. Palaska, Yufeng Shen, Aris Floratos
Final approval of manuscript: Athanasios I. Zavras
Other: Principal Investigator: Athanasios I. Zavras
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SNP Chr Position
cases OR (95% CI) p-valuea
57635783 IGFBP7 0.3
5.3 (2.4–11.4) 2.0 ? 10?50.037
We inspected lists of SNPs belonging to genes putatively involved in the etiology of BRONJ. The table shows the OR and
p-value of the top associated SNPs and compares MAF between the population (n ? 1,743) and treatment-tolerant controls
(n ? 118).
ap-value from logistic regression.
Abbreviations: BRONJ, bisphosphonate-related osteonecrosis of the jaw; Chr, chromosome; CI, confidence interval; MAF,
minor allele frequency; OR, odds ratio; NA, not available; SNP, single nucleotide polymorphism.
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