bisphos protocol

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Dental Extractions and Bisphosohonates

An algorithm is presented with the aim of supporting the optimal management of patients inthis recently defined and rapidly expanding group.

The diagrammatic guidance should be understood in conjunction with the explanatory notes.

A suggested reading list of supporting refereed publications is cited.

The authors welcome constructive criticism and comments with the aim of furtheringdevelopment of a safe, effective protocol.

Nick Malden BDS, FDSDept. Oral Surgery

Edinburgh Dental InstituteLauriston Place

EdinburghEH3 9YW

[email protected]

Charalampos Beltes DDS, MSc.Dept. Oral Surgery

Edinburgh Dental InstituteLauriston Place

EdinburghEH3 9YW

December 2007

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mailto:[email protected]:[email protected]


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Algorithm: Extractions in Bisphosphonate patients

(to be read in conjunction with explanatory notes)

Alendronate / Risedronate / Ibandronate Ibandronate / Pamidronate / Zoledronate

2

Extraction indicatedCan extractions

be avoided ?

Consider reducing risk

factors for BONJ

Monitor

Otherrisk factors for BONJ ?

NoReduce risk

factors?

Informedconsent

(Lower risk & severity of

BONJ)

Risks accepted Risks accepted

Proceedwith extractions

including adjunctive therapy

Proceedwith simplified

extraction protocol

Informed Consent

moderate risk

Monitoras per Low riskReviewweekly

(If debris in socket irrigate withsaline or chlorhexidine only)

Healing noted at 3 - 4 weeksIs bone exposed

at 6 - 8 weeks?

No Yes

Referto

specialist

Routine review to report if

symptoms develop

Yes

No

Yes

Medium / Unknown RiskLow Risk High Risk

Yes

Yes

No

Risks accepted

No

Starttreatment

for BONJ

NJM & ChB 2007

Seek

advice

Informed consent

(High risk & severity of

BONJ)


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EXPLANATORY NOTES

Bisphosphonates And ExtractionsThe 5 named bisphosphonate drugs are those that have been most commonly associated with bonenecrosis of the jaws. Alendronic acid (sodium alendronate), risedronate sodium, ibandronic acid, disodiumpamidronate and zoledronic acid.

Low Or High Risk?These drugs have been associated with a variable risk of development of bisphosphonate associated

osteonecrosis of the jaws (BONJ). However increasingly the more toxic IV drugs are being used at lowerdosages to treat osteoporosis. It is likely that the tailored doses of IV drugs will have the same reduced risksfor BONJ as the oral preparations Ref 1.

Options For Avoiding ExtractionEndodontics preferable to extractions Ref 2. Non surgical endodontic re treatment. Crown amputation leavingendodontically treated roots. The aim being to reduce potential sources of infection and relieve painfulsymptoms as well as reducing invasiveness of procedure Ref 3.

Other Risk FactorsLocal risk factors mandibular molar extraction, poor oral hygiene, periodontal disease, denture trauma.General risk factors extended use of bisphosphonates > 3 years Ref 1, smoking, concurrent corticosteroiduse, general debilitation Ref 3, extreme of age, (over 60 Ref 4).

Reduction Of Risk FactorsApart from extreme of age all other risk factors can potentially be removed or their effects reduced.Discontinuation of bisphosphonates should also be given consideration in many cases Ref 5. Whenbisphosphonates are being used to protect the skeleton against the osteoporotic affects of corticosteroids,the maximum benefit of bisphosphonates is achieved if given during the first year of steroid administration.If reduction or discontinuation of the corticosteroids is planned, as part of the patients general management,then delaying the extraction could be considered. Discontinuation of the bisphosphonate for at least a 3month period prior to surgery has also been proposed Ref 5.

Informed ConsentA recent study has attempted to estimate the frequency of BONJ in those taking bisphosphonates with andwithout the extraction of teeth Ref 6. A risk of spontaneous occurring BONJ is present for all patients receiving

bisphosphonates. An extraction can increase the risk of BONJ by a factor of up to 7. An extraction in theosteoporosis group has been estimated to be associated with a frequency of BONJ as high as andsometimes > 1:1,000 (Australian figures) but severe destructive BONJ has rarely been reported in this group.In those receiving the more toxic drugs, usually given intravenously, the frequency of BONJ has beenestimated to be in the region of 1:50 to 1:7 (Pagets disease), and 1:15 to 1:11 (for malignancy cases) andthese are more likely to be examples of severe BONJ.

Adjunctive TherapiesThese include the use of antibiotic prophylaxis. Bony remodelling with minimal soft tissue surgery.Use of soft tissue flaps to provide periosteal coverage of bone. Bisphosphonate drug holidays Ref 5+7.

Simplified Extraction ProtocolImprove oral hygiene where appropriate. Preoperative chlorhexidine mouth rinsing, straight forward

extraction technique and post operative chlorhexidine mouth rinsing until healing observed Ref 2. Reduceobvious sharp socket wall margins and inter radicular bone if protruding post operatively. Avoid liftingperiosteum from bony margins.

Seeking AdviceIt would be expected that a number of points of contact providing guidance for the management of thesepatients would be available at a regional level and also through the internet. It would be expected that Oraland Maxillofacial Surgery units would have a knowledge of the prevention and management of BONJ, butquite often hospital dental services and salaried dental services and other specialists may well be able togive advice.

Disclaimer.Although the advice and information contained in this guideline is believed to be true and accurate at the

time of production the authors can accept no responsibility or liability for any errors, omissions or detrimentaleffects that might be considered resultant from applying these guidelines.

N J Malden/Ch Beltes Dec 2007


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REFERENCES

Ref 1 Khosla S, Burr D, Cauley J et al. Bisphosphonate Associated Osteonecrosis of theJaw: Report of a Task Force of the American Society for Bone and MineralResearch. J Bore.Min.Res. 2007;22:1479-89.

Ref 2 A.D.A. Expert panel Recommendations, Dental Management of patients receivingOral bisphosphonate therapy. JADA, 2006;137:1144-50

Ref 3 Marx R E, Sawatari Y, Fortin M, Broumand V, Bisphosphonate-induced ExposedBone (Osteonecrosis/Osteopetrosis) of the Jaws: Risk Factors, Recognition,Prevention and Treatment. JOMFS 2005;63:1567-75.

Ref 4 Pazianas M, Miller P, Blumentals WA, et al, A review of the literature onOsteonecrosis of the Jaw in patients with Osteoporosis Treated with OralBisphosphonates: Prevalence, Risk Factor and Clinical CharacteristicsClin Th 2007;29:1548-58.

Ref 5 AAOMS Task Force Position Paper. Bisphosphonate-related Osteonecrosis of theJaws. JOMFS 2007;65:369-76

Ref 6 Mavrokokki T, Cheng A, Stein B, Goss A, Nature and Frequency of Bisphosphate-Associated Osteonecrosis of the Jaws in Australia. JOMFS 2007;65:415-23.

Ref 7 Zahrowski J.J. Comment on the American Association of Oral & MaxillofacialSurgeons. Statement on Bisphosphonates. 2007;65: 1440-41

N J Malden/Ch Beltes Dec 2007

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