national primary oral health conference...pdl associated with extracted teeth only 11% (3/26) pts...
TRANSCRIPT
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National Primary Oral Health Conference
ORAL BISPHOSPHONATE RELATED OSTEONECROSIS OF THE JAWS
DONLAD M. COHEN DMD, MS, MBA
DIVISION HEAD ORAL & MAXILLOFACIAL PATHOLOGY
UNIVERSITY OF FLORIDA COLLEGE OF DENTISTRY
GAINESVILLE, FLORIDA
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LECTURE OBJECTIVES
Learn diagnostic features of osteochemonecrosis (OCN) including pre-OCN ( Stage 0).
Learn the etiology and pathogenesis and why the jaws are the only target.
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LECTURE OBJECTIVES
The incidents and risk factors of OCN will also be clarified.
Participants will also learn how to treat and prevent it.
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PRE-TEST
70 Y/O FEMALE WITH NON HEALING SOCKET LR 2ND MOLAR AREA(ON ZOMETA)
– A)OSTEOMYELITIS
– B) OSTEOCHEMONECROSIS
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PRE-TEST 80 Y/O female on Fosamax for 10 years.
Extraction done 3 months ago (LL). Safe to do implants??
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PRE-TEST 76 y/o female on Fosamax 4 years, off for
two. Had extraction (LR) 2 yrs ago but never healed. Last year developed ulcerated torus. ?Treatment
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PRE-TEST: EXTRACT #13 & 14 ??
70 y/o female slightly loose PM with significant decay
3900 cGY radiation to nasal cavity and paranasal sinuses 1998 for lymphoma
Long standing (10 year) oral bisphosphonate use.
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BISPHOSPHONATES
Endogenous regulators of bone mineralization (bone resorption inhibitors) which accumulate in hydroxyapatite in mineralized bone
Over 300,000 patients on I.V. form of these drugs
30 Million on oral forms
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STRUCTURE BISPHOSPHONATES
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Generics, Brands
Alendronate Fosamax
Etidronate Didronel
Ibandronate Boniva
Pamidronate Aredia
Risedronate Actonel
Zoledronate Reclast, Zometa
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INDICATIONS
Osteoporosis/osteopenia
Multiple myeloma
Breast/Prostate cancer
Hypercalcemia of malignancy
Cancer related bone lesions/ metastases
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BISPHOSPHONATES(BP)
Reduces skeletal complications & bone pain and improves quality of life
Does not definitely extend life
Oral forms used for metabolic bone diseases (high turnover) i.e. osteoporosis, & Paget’s disease
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BISPHOSPHONATES
Zometa and Aredia i.v. drugs most associated with intraoral bone necrosis
These more powerful i.v. drugs used for cancer patients to prevent metastasis and hypercalcemia of malignancy
I.V. drugs together account for 97% of cases of ONJ
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BISPHOSPHONATES
Weaker, oral drugs used for osteoporosis to prevent fracture.
Tremendous morbidity and costs associated with hip & vertebral fractures especially.
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FRACTURE INCIDENCE AND COST
Lifetime risk of any fracture at age 50 – • 53% for Caucasian women – • 21% for Caucasian men
Fractures are expected to triple in 50 years and costs to rise substantially
Direct cost is at least $17 billion/year
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HIP FRACTURE CONSEQUENCES
200,000 women and 100,000 men every year
Increased morbidity & major reason for nursing home admission
30% of patients do not regain their pre- ambulatory status
15%-20% excess mortality
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FRACTURE REALTIVE RISK REDUCTION
Vertebral fractures 40%-65%
Multiple vertebral fractures 75%-95%
Hip fracture 40%-50%
Spine fracture in patients on glucocorticoids 70%
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ZOMETA & AREDIA
These along with Fosamax are newer generation, extremely potent, nitrogen containing, non-metabolizable pyrophosphates
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NITROGEN CONTAINING BP’S
Stays in bone a long time (12 years)
Necrosis mainly due to anti-osteoclastic effects
With long term build up, anti-angiogenesis effect (decrease VEG-F) may occur also
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NITROGEN CONTAINING BP’S
Powerful inhibitor of osteoclastic activity
Cytotoxic especially to osteoclast precursors and irreversibly inhibits recruitment and activation and shortens life span of osteoclasts
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MECHANISM OF ACTION
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NITROGEN CONTAINING BP’S
Bone resorption essential for bone viability
Without resorption bone accumulates injuries “cracks”
Leads to bony sclerosis ? Avascularity
Bone breaks down if increased functional demands
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ONJ WHY NOW??
Nitrogen containing (more potent, newer generation) are only bisphosphonates that cause ONJ
Continuous dose accumulates in bone
Risk increases proportionally each year
More patients on more potent drugs continuously, = more cases
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BISPHOSPHONATE OSTEOCHEMONECROSIS
Potency of drugs may be similar but absorption is 1% for oral preparations and 50% for i.v.
2.5% of cases seen with oral bisphosphonates (alendronate, ibandronate, risedronate )
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WHY ONLY THE JAWS???
Alveolar bone remodeling depends more on osteoclasis than any other bone.
Remodeling rate of mandible is 10x that of any other bone and alveolus remodels 2-3x faster than the rest of the mandible.
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WHY ONLY THE JAWS???
BP’s localize to areas where osteoclasts are remodeling bone 8 x more than normal bone
i.e. 240X more bisphosphonate in area of periodontal disease (crest of ridge, PDL, area above mandibular canal)
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WHY ONLY THE JAWS???
Local lesions (ulcers, plaque, trauma) increase need for bone remodeling significantly
Infection, perio disease, bacterial lipo-polysaccharides and inflammation increase bone remodeling and concentration of bisphosphonates in bone
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RAT ANIMAL MODEL
Replicates clinical, radiographic and histologic features of BON
Rats given Zometa & Dexamethasone for 1-3 weeks before extractions
Controls healed normally experimental had non-healing ulcers then BON
Sonis S et al. Oral Oncol 2008 Aug18
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MUCOSAL DAMAGE
INJURY- MUCOSITIS
EXTRACTION/TRAUMA
COLONIZATION INFECTION/BIOFILM FORMATION
PATHOGENESIS OF BON
DAMAGED BONE
DELAYED BONE HEALING SOFT TISSUE HEALS
DECREASED OSTEOCLASTIC BONE RESORPTION
MARKEDLY THINNED MUCOSA
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IV PATIENT THIN MUCOSA MULTIPLE PAINFUL AREAS
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DRAMATICALLY THIN MUCOSA BONE EXPOSURE
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THIN MUCOSA WITH BONE EXPOSURE
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THIN MUCOSA WITH BONE EXPOSURE
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PATHOGENESIS OF BON COLONIZED BONE/ ACTINO
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CASE STUDY
80 Y/O female with massive ulcers of maxillary and mandibular gingivae with possible bone exposure. Non-responsive to antibiotics and Peridex and getting worse . Started 2 weeks after dental cleaning. Patient on experimental iv drug for 18 months for osteoporosis- Denosumab (Prolia).
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SOFT TISSUE CHEMONECROSIS VS LYMPHOMA
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DENOSUMAB (PROLIA)
New fully human monoclonal antibody to RANKL (receptor activator of nuclear factor-kB ligand) the dominant promoter of bone resorption.
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MECHANISM OF ACTION OPG AND RANKL
RANKL is produced by osteoblasts in response to pro-resorptive stimuli (PTH,IL-1,TNF)
It binds and activates RANK (receptor activator of nuclear factor Kb) a receptor found on osteoclasts and osteoclast precursors.
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BISPHOSPHONATES
Lesions developed after 2-180 months on meds
Zometa average 9 months, Aredia 14
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BON FROM ORAL BISPHOSPHONATES
UF COD Merck sponsored study 36 confirmed patients with BON
All female and 98% had osteoporosis
One patient had breast cancer
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ORAL BISPHOSPHONATES
Alendronate average 46 (62)months
For oral medications
– earliest 1.5 yr (+ radiation)
– 31/36 3+yrs
– range 18-180 months
– average 5.15 years
Alendronate has a 10 year half life
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DEFINITION: BISPHOSPHONATE INDUCED OSTEOCHEMONECROSIS
Painless(43%) or painful(57%) exposure of avascular bone, mand(51%), max(24%) both(3%)
Pain is indication of infection
Exposure present >/= 6-8 weeks
No response to Tx
No history of radiation
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BISPHOSPHONATE OSTEOCHEMONECROSIS
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CLINICAL MANIFESTATIONS
Exposed bone +/- Pain - 100%
Supra alveolar sclerosis -100%
Bony expansion
Delayed onset of symptoms 3-12 months
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EXPOSED BONE
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EXPOSED BONE TEETH LOST
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SUPRA- ALVEOLAR SCLEROSIS
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BONEY EXPANSION/DELAYED ONSET 8 MONTHS
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BONEY EXPANSION/DELAYED ONSET 8 MONTHS
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TRIGGER BISPHOSPHONATE OSTEOCHEMONECROSIS
1. None- spontaneous bone necrosis: large lobular tori, mylohyoid ridge etc. - 25%(42%)
2. Tooth extraction -38%(54%)
3. Periodontal disease & surgery 100% (if applicable) most common trigger
4. Implants 3.4%(2) and apico <1%
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SPONTANEOUS VS. TRAUMA ??
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SPONTANEOUS???
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TOOTH EXTRACTION
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PERIO SURGERY
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IMPLANTS & OCN
3/19/08 5/27/09
ON ALENDRONATE SINCE 2004
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ORTHODONTICS & OCN
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SERUM-C-TERMINAL TELOPEPTIDE(CTX)
Can predict risk of ORN from bisphosphonates
Specific marker of bone T/O
Octapeptide cleaved from type I collagen by osteoclasts during bone resorption
Marker of osteoclast activity
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SERUM-C-TERMINAL TELOPEPTIDE(CTX)
CTX <100pg/ml = high risk for ORN
CTX 101-150pg/ml = moderate risk
CTX >150 = Low risk
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PREDICTING RISK: CTX VS. X-RAY FEATURES
20 Patients on BP with pre-op CTX value < 150 pg/ml
20/20 extraction site healed completely w/o complications
55 extraction patients on BP with pre-op x-ray findings
29 developed BRON 26 did not
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PREDICTING RISK: CTX VS. X-RAY FEATURES
83% (24/29) with BON had widened PDL associated with extracted teeth
Only 11% (3/26) pts who did not develop BRON had widened PDL
Predicting Risk for Bisphosphonate-Related
Osteonecrosis of the Jaws: CTX Versus Radiographic Features Oral Surg:2010 e-pub ahead of print
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EARLIEST SIGNS
Sclerosis: lamina dura/crest of ridge, alveolar process
Widened PDL
Incipient bifurcation involvement
Pain-pre-ocn
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2005 2006
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ORAL FOSAMAX OSTEOCHEMONECROSIS
Alendronate first introduced 1993
30 million Rx for oral forms of bisphosphonate (190 million in world)
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FOSAMAX(ALENDRONATE) & OSTEOCHEMONECROSIS
Incidence 0.01-0.04%, in Australia
Following extractions, 0.09-0.34%.
Kaiser-Permanente survey 13,946
Prevalence in patients receiving long-term oral bisphosphonate therapy 0.1% (1:1,000).
Lo JC et al J Oral & Maxillofac Surg 68:243-253, 2010
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CO-MORBIDITIES
Other possible associated risk factors
– LT steroid use(22%) (UF 12%)
– Diabetes
– Smoking (UF 15%) & Obesity
– Radiation # 1 potent factor!!
Shorten time to development don’t cause OCN
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LONG TERM STEROIDS AND FOSOMAX
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RADIATION & FOSAMAX
2006 1.5 yrs Alendronate
2010 D/C Alendronate 2006
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RADIATION & ORAL BON
368 ORN patients
Mean radiation dose 7430cGY
2.2% on oral bisphosphonates
Overall incidence ORN 12%
Not on OB (n=360) 10.8%
On OB (n=8) 62.5% p=.001
– Sandow et al UF COD research day
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RADIATION & ORAL BON
Radiation is strongest co-factor for BON not an exclusion factor
Patients with combination oral BP and radiation have highest risk
Also worst outcomes 7/8 patients stable, one resected
No cures
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NEWEST RECOMMENDATIONS
ORAL BP + EXPOSED BONE
If systemic conditions permit, modification or cessation of oral bisphosphonate in consultation with the physician and patient.
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WHY A DRUG HOLIDAY??
Bisphosphonates accumulate about 7% a year, remains in bone indefinitely
Become toxic in jaws after 3-5 years
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WHY A DRUG HOLIDAY??
19% Fracture rate (non-vertebral) if on bisphosphonate for 5 years then off for 5 years
18.9% if on 10 years straight
JAMA Black et al Dec 27,2006;296(24): 2927
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WHY A DRUG HOLIDAY??
For many woman d/c alendronate for up to 5 years does not significantly increase fracture risk
Woman at high risk for vertebral fractures may benefit from continued therapy
JAMA Black et al Dec 27,2006;296(24): 2927
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WHY A DRUG HOLIDAY??
However definite increase occurs in bone remodeling after a few months of cessation of BP therapy
It may not effect fracture rates but it demonstrates improved ability to remodel and heal bone lesions
Kimmel DBB J Dent Res 86(11): 1022-1033, 2007
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WHY A DRUG HOLIDAY??
Intermittent therapy may be wave of future
Zolendronate (Reclast) 5mg IV 1x/yr>>10 mg alendronate/day/yr
Approved by the FDA in August 2007.
A single, large, prospective placebo-controlled study established its efficacy through three years of treatment
Two cases of BON were reported, one each in the treatment and control groups,
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I.V. IBANDRONATE
Oral dose 150 mg q month
1% absorbed = 1.5 mg/month
I.V. 3 mg q 3 months
50% absorbed dose = .5 mg/month
But more effective!
?less BON?
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NEWEST RECOMMENDATIONS
PATIENTS ON ORAL BISPHOSHONATES
Lesions less severe from oral meds (Alendronate)
Respond better to local therapy
More predictable, reversible and amenable to surgery
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TREATMENT
Spontaneous resolution can occur
Discontinuation of oral bisphosphonates for 6-12 months may result in spontaneous sequestration or resolution following debridement
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TREATMENT
Conservative sequestrectomy may help but avoid surgery if patient still on BP!!!
Surgery seems to trigger bad outcomes even in patients on oral bisphosphonates
The effectiveness of hyperbaric oxygen therapy is undetermined but it appears to increase amounts of VEG-F and counters this bisphosphonate effect
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UF ORAL BON OUTCOMES
91 % completely healed
9% stable with continuing disease
0% worse despite intermittent therapy
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UF ORAL BON TREATMENTS
Minimal surgery(sequestration)- 12%
Major surgery(resection)- 6%
Medical management(antibiotics)- 9%
Combination therapy(medical & minor surgery)- 73%
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TREATMENT
For elective surgery (oral BP patients only) discontinue oral bisphosphonate for 3-4 months, do necessary surgery then allow 3-4 more months for healing.
Antibiotic therapy and chlorhexidine rinses may be helpful for prevention.
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POST FOSOMAX HEALING
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POST FOSOMAX HEALING
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BONY SEQUESTRUM
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CONSERVATIVE SEQUESTRECTOMY
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8 MONTHS LATER!!
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POST FOSOMAX HEALING
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POST FOSOMAX HEALING
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1 YEAR OFF FOSAMAX
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Position Paper on Bisphosphonate-Related Osteonecrosis of the Jaws
American Association of Oral and Maxillofacial Surgeons
Position Paper on Bisphosphonate-Related Osteonecrosis of the Jaw—2009 Update
Approved by the Board of Trustees January 2009
Task Force on Bisphosphonate-Related Osteonecrosis of the Jaws: Salvatore L. Ruggiero, DMD, MD, Associate Professor, Division of Oral
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Management Strategies for Patients Treated with Bisphosphonates Prevention of BRON
Therefore, if systemic conditions permit, initiation of bisphosphonate therapy should be delayed until dental health is optimized. This decision must be made in conjunction with the treating physician and oncologist
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PREVENTION AND TREATMENT
Pre-medication dental evaluation BEFORE start bisphosphonate
Extraction avoidance AFTER to prevent or reduce problem
If systemic conditions permit, the clinician may consider discontinuation of oral bisphosphonates for a period of three months prior to and three months following elective invasive dental surgery in order to lower the risk of BRONJ.
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Prevention AFTER Bisphosphonates
Dental evaluation every 4 months
Prophy and Fluoride Trays
Endo and crown abscessed teeth
(Cut off crown at gingival level if it is not restorable)
Splint 1+ and 2+ mobile teeth
Remove abscessed and 3+ mobile teeth
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EXPERT PANEL RECOMMENDATIONS PATIENTS ON ORAL BISPHOSHONATES
Non-surgical Endodontics is preferred to extraction.
Periodontal disease, conservative perio first
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EXPERT PANEL RECOMMENDATIONS PATIENTS ON ORAL BISPHOSHONATES
Conservative surgery if unresolved avoid guided bone regeneration
If extractions necessary conservative approach with primary closure
Immediate pre and post surgery use peridex rinse (gentle) and then rinse 2x/day for two months.
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EXPERT PANEL RECOMMENDATIONS PATIENTS ON ORAL BISPHOSHONATES
Elective dentoalveolar surgery not contraindicated in OBP group
Patients MUST be adequately informed of small risk of compromised bone healing.
Efficacy of systemic marker of bone turnover to assess risk of BON in patients at risk will require further research before it can be considered valid
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EXPERT PANEL RECOMMENDATIONS PATIENTS ON ORAL BISPHOSHONATES
For patients on an oral bisphosphonate for > 3 years +/- steroid medication prescribing provider should be contacted to consider discontinuation of OPB for 3 months prior to oral surgery, if systemic conditions permit.
The bisphosphonate should not be restarted until osseous healing has occurred.
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Staging and Treatment Strategies: At risk category
No exposed/necrotic bone in patients who have been treated with either oral or IV bisphosphonates
No treatment indicated
Patient education
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STAGE 0: PRE-OCN
Specifically, a Stage 0 category was added to include patients with non-specific symptoms, or clinical and radiographic abnormalities that may be due to bisphosphonate exposure.
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STAGE 0: PRE-OCN???
PTS HAVE NON SPECIFIC SYMPTOMS OR SYMPTOMS MIMIC DENTAL DISEASE
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FUNCTIONAL CT SCAN
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STAGE 0:PRE-OCN
PATIENTS HAVE CLINICAL FEATURES THAT MAY BE RELATED TO BP EXPOSURE
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STAGE 0:PRE-OCN
Many cases are silent
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STAGE 0 PRE-OCN???
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Staging and Treatment Strategies: Stage 1
Exposed/necrotic bone in asymptomatic patients who have no evidence of infection
Antibacterial mouth rinse
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Staging and Treatment Strategies: Stage 1
Clinical follow-up on a quarterly basis
Patient education and review of indications for continued bisphosphonate therapy
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Staging and Treatment Strategies: Stage 2
Exposed/ infected bone pain and erythema +/-purulent drainage
Symptomatic treatment broad-spectrum oral antibiotics: penicillin, cephalexin, clindamycin, or fluoroquinolone
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Staging and Treatment Strategies: Stage 2
Most microbes sensitive to penicillin
Quinolones, metronidazole, clindamycin, doxycycline and erythromycin used patients allergic to penicillin.
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Staging and Treatment Strategies: Stage 2
Microbial cultures analyzed for Actinomyces
Antibiotic regimen should be adjusted according to sensitivity.
Refractory cases, require combination antibiotic therapy, long-term antibiotic maintenance, or a course of I.V. antibiotics
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Staging and Treatment Strategies: Stage 2
Treat pain with Pen VK 500mg Q.I.D. and chlorhexidine mouth rinse until pain free and
Add Flagyl 500mg T.I.D. if pain persists
Only superficial debridements to relieve soft tissue irritation
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Staging and Treatment Strategies: Stage 3
Pathologic fracture
Exposed bone with inflammation infection or pain
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Staging and Treatment Strategies: Stage 3
Not responsive to antibiotics due to volume of necrotic bone
Extra oral fistula
Osteolysis extending to inferior border
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Staging and Treatment Strategies: Stage 3
Antibacterial mouth rinse
Antibiotic therapy and pain control
Surgical debridement/resection for longer term palliation of infection and pain
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Staging and Treatment Strategies: Stage 3
Surgical debridement has been variably effective in eradicating the necrotic bone.
Surgical treatment should be delayed if possible.
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Staging and Treatment Strategies: Stage 3
Loose segments of bony sequestrum should be removed without exposing uninvolved bone.
Symptomatic patients with pathologic mandibular fractures may require segmental resection and immediate reconstruction with a reconstruction plate.
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Staging and Treatment Strategies: Stage 3
The extraction of symptomatic teeth within exposed, necrotic bone should be considered since unlikely that the extraction will exacerbate the necrotic process.
Patients with established BRON should avoid elective dentoalveolar surgical procedures
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POST-TEST
70 Y/O FEMALE WITH NON HEALING SOCKET LR 2ND MOLAR AREA(ON ZOMETA)
– A)OSTEOMYELITIS
– B) OSTEOCHEMONECROSIS
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POST-TEST
80 Y/O female on Fosamax for 10 years. Extraction done 3 months ago (LR). Safe to do implants??
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POST-TEST 76 y/o female on Fosamax 4 years, off for
two. Had extraction (LR) 2 yrs ago but never healed. Last year developed ulcerated torus. ?Treatment
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POST TEST: 11 MONTHS LATER TOTAL 35 MONTHS
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POST-TEST 1 YEAR LATER
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POST TEST- EXTRACT #13 & 14 ??
70 y/o female slightly loose PM with significant decay
3900 cGY radiation to nasal cavity and paranasal sinuses 1998 for lymphoma
Long standing (10 year) oral bisphosphonate use.
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2 MONTHS POST SIMPLE EXTRACTION #13, 14
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CONCLUSION
Add radiographic features to criteria for BON.
Add additional Stage 0 category also called pre-osteochemonecrosis
Patients have radiographic and/or clinical signs (pain) of BON before bone exposure occurs.
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CONCLUSION
There is an increased risk of complications in surgery patients actively on a bisphosphonate
Radiation is a co-morbidity for BON not an exclusion factor
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CONCLUSION
In Shands database 5/8 patients with both developed BON
Bisphosphonates should be used with caution in these patients.