Jaw Osteonecrosis a Risk Factor in Bisphosphonate Therapy

Jaw Osteonecrosis a Risk Factor in Bisphosphonate therapy- What a Dentist Needs to know ?

About 80 million people in the US alone take bisphosphonates for cancer, osteoperosis, etc. These drugs seem to be prescribed almost routinely for women over age 60 if there is any suspicion of osteoporosis. It is clear that patients who have received IV bisphosphonates are at high risk for osteonecrosis in the mandible and maxilla.

What is not clear is the situation for patients who have taken bisphosphonates via the oral route. Not as much data has been collected on oral bisphosphonates and osteonecrosis and dental implant failure. However, the evidence for is mounting daily that orally administered forms of bisphosphonates may lead to osteonecrosis. What does this imply for dental implant placement in these cases and for our routine clinical management?

For patients on i.v. bisphosphonate therapy
It is important for dentists to be aware that while on treatment, invasive dental procedures should be avoided in patients receiving i.v. bisphosphonates, if possible. Dentists need to exercise their professional judgment, perhaps after consultation with the patient’s physician, in deciding whether invasive treatment is needed under the particular clinical situations.

Guideline on osteoporosis treatment notes:

o Prior to treatment with a bisphosphonate a dental examination with appropriate preventative dentistry should be considered.
o While taking a bisphosphonate invasive dental procedures should be avoided if possible.
o If someone develops osteonecrosis of the jaw while taking a bisphosphonate dental surgery may exacerbate the condition.
o If an invasive dental procedure cannot be avoided there are no data to suggest whether discontinuing bisphosphonate treatment reduces the risk of osteonecrosis of the jaw.

NOTE: An increased awareness of the potential risk of Osteo Nectrosis of Jaw in patients receiving bisphosphonate therapy is needed. Close coordination between the treating physician and oral surgeon and/or a dental specialist is strongly recommended in making treatment decisions.

Resources

ADA: A-Z Topics: Osteonecrosis of the Jaw: http://www.ada.org/prof/resources/topics/osteonecrosis.asp

ADA Council on Scientific Affairs. Expert Panel Recommendations: Dental Management of Patients on Oral Bisphosphonate Therapy. June 2006. [PDF, 159K]

Migliorati CA, Casiglia J, Epstein J, Jacobsen PL, Siegel MA, Woo SB. Managing the care of patients with bisphosphonate-associated osteonecrosis: an American Academy of Oral Medicine position paper. Abstract.
J Am Dent Assoc. 2005 Dec;136(12):1658-68. Review. Erratum in: J Am Dent Assoc. 2006 Jan;137(1):26.
PMID: 16383047

Osteonecrosis a Risk Factor ? http://www.clinicalanswers.nhs.uk/index.cfm?question=5335

Guidelines for prevention

Value of masticatory exercise in Hyperdivergent patients

Objective: This retrospective study was designed to evaluate the morphologic effects of masticatory muscle exercise as an adjunctive therapy for hyperdivergent patients treated with fixed orthodontic appliances.

Materials and Methods: Three samples of 50 subjects were selected, including one sample treated with orthodontics combined with exercise, one sample treated with orthodontics only, and an untreated control sample. Subjects were matched on the basis of age, sex, mandibular plane angle (MPA), treatment duration, and treatment rendered. Patients in the treated exercise sample were instructed to clench their teeth together as hard as possible for 15 seconds and to repeat this process at least four times for a total of one minute; this one-minute exercise was to be performed as often as possible throughout the day. Morphologic data was derived from pre- and posttreatment lateral cephalograms.

Results: Exercise with orthodontics produced significant (P < .05) increases in overbite compared to orthodontics alone. However, changes in vertical facial morphology were not significantly different between the two treated samples. Relative to untreated controls, both treated samples showed significantly greater increases in the MPA (S-N to Go-Me), Y-axis, and the lower to total facial height ratio; the treated samples also showed significantly less true forward mandibular rotation than the untreated controls.

Conclusion: Short-term clenching exercises performed daily are insufficient as an adjunct to traditional orthodontic treatment for correcting or controlling the vertical dimension.

KEY WORDS: Hyperdivergence, Cephalometrics, Exercise, Fixed orthodontic treatment

To read the full text of this publication click HERE

Best pain killer after Wisdom Tooth extraction

The commonly used and inexpensive analgesic acetaminophen (Tylenol or paracetamol) is an effective pain reliever after surgical removal of lower wisdom teeth, according to a new systematic review of 21 studies. The most effective dose appears to be 1,000 milligrams taken at six-hour intervals, the review concludes.

"Acetaminophen has been around a long time. It has a good safety record and is widely available without prescription. Our findings suggest it is a good choice for dental pain," said review co-author Kiaran Weil.

The review appears in the latest issue of The Cochrane Library, a publication of The Cochrane Collaboration, an international organization that evaluates medical research. Systematic reviews draw evidence-based conclusions about medical practice after considering both the content and quality of existing medical trials on a topic.

Researchers from the University of Manchester School of Dentistry in England and the University of Amsterdam in the Netherlands analyzed the studies.

The review examined data from 1,968 patients enrolled in studies that compared the effectiveness of acetaminophen versus placebo to decrease pain after surgical extraction of the third molars, or lower wisdom teeth. The review included patients who received local anesthesia, intravenous sedation or general anesthesia; however, it excluded patients who took pain relievers at the time of surgery.

All patients reported moderate to severe pain just after surgery. Researchers tallied the number of patients who reported 50 percent pain relief at four and six hours after surgery.

Patients who received any dose of acetaminophen after surgery were at least three times more likely to report 50 percent pain relief than patients who took a placebo. However, patients given the higher dose of 1,000 milligrams were four to five times more likely to report that their pain was cut in half. Study participants who took less than 1,000 milligrams were about twice as likely to report 50 percent pain relief.

Patients treated with acetaminophen reported a similar number of side effects as patients who received a placebo. However, researchers monitored patients taking acetaminophen, and Weil cautions that side effects are less likely to occur under controlled circumstances.

The maximum recommended dose of acetaminophen is 4,000 milligrams per day for adults.

Acetaminophen can cause liver toxicity when an individual exceeds the maximum daily dose. Heavy drinkers, malnourished patients and people with AIDS or anorexia nervosa also have an increased risk for liver toxicity.

While the review shows acetaminophen is effective for pain relief, oral surgeon Morton Rosenberg said many dentists prescribe analgesics plus narcotic pain relievers after surgical removal of wisdom teeth.

"This is a procedure where the dentist is working on bone and cutting oral tissue. These are some of the strongest stimuli for pain that we know of," said Rosenberg, professor of oral and maxillofacial surgery at Tufts University School of Dental Medicine in Boston.

In his practice, Rosenberg treats pain after wisdom tooth removal on a case-by-case basis.

"It varies so much from patient to patient that it is hard to generalize. I do often give a prescription for something like Tylenol with codeine and advise the patient to fill the prescription if needed," he said. Many patients expect to receive something stronger than an over-the-counter medication, he added.

Future reviews of studies will compare acetaminophen directly to other pain relievers such as ibuprofen.

To read an excellent paper on Analgesics in Dentistry CLICK HERE

Oral Health and Systemic Health are deeply connected

Friends

Healthmantra has brought you updates for past 10 years and now we are creating this blog so that you can always check it for updates and also post your comments.

Oral cavity is a natural incubator with optimal growth environment making it ideal for most types of microbes to inhabit. About 400 species of bacteria can be found in oral cavity all of which are not harmful.

Two major diseases caries and periodontitis are of microbial origin. If not treated both these ailments have potential to transmit the oral flora/ inflammatory products to the blood stream to all parts of body.

The periodontium, comprised of the gingiva, bone and other supporting tissues that anchor the teeth, plays a vital role in the interplay between oral health and systemic disease. Infection in these tissues, primarily by gram-negative anaerobic bacteria, can initiate a series of inflammatory and immunologic changes leading to the destruction of connective tissue and bone. Long considered a localized infection, periodontal diseases are now linked to a variety of conditions with systemic implications. There is a global campaign ( Assisted by Oral Care Giant Colgate) to educate all about the importance of good oral care and its impact on general health.

It is essential for each one of us to understand the importance of this key issue in our profession and take responsibility to educate public and medical specialists. This will lead to better oral and general health for our population and motivate patients for regular dental check ups.

This issue is vital for our profession, let us pool our resources and ensure that each and every citizen of this country is educated in this aspect.

To learn more you can go to these resources:

www.healthmantra.com/blog/

Healthmantra the leading online resource on health

http://www.whocollab.od.mah.se/expl/systemic.html

WHO resource

http://www.ada.org/prof/resources/topics/oralsystemic.asp

http://jada.ada.org/cgi/content/full/134/suppl_1/59S

JADA

http://www.cdc.gov/OralHealth/conferences/periodontal_infections.htm

CDC USA

http://www.colgate.com/app/Colgate/US/OC/Information/InteractiveGuides/SmileSaver.cvsp

Colgate smile saver tool for your patients

http://155.37.7.13/infantoralhealth/infantoralhealth2002/index.html