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Hey all, just thought I'd share an interesting case with you all.
Recently I consulted my patient who we treatment planned for elective extraction #32 (only 3rd in the mouth) due to prosthetic reasons. After some discussion with the oral surgery department, we came to the conclusion that it would be risky to perform the procedure and subsequently informed the patient.
Why?
She was taking Actonel, a bisphosphonate-derivitave medication. Turns out that there is a tremendous amount of published research indicating the relative risk of osteonecrosis while taking oral and IV bisphosphonates. Recent studies (Marx JOMFS Nov 05) show a risk of close to 37.8% of developing osteonecrosis after performing extractions on patients taking bisphosphonates. Marx's study also shows risks with the following: advanced periodontitis 28.6%, periodontal surgery 11.2%, dental implants 3.4% and root canal surgery 0.8%
This is a comment from the drug maker:
"Novartis Pharmaceuticals Corporation has notified dental health professionals of the risk of osteonecrosis of the jaw (ONJ) and the use of the bisphosphonates, pamidronate, and zoledronic acid. This warning has not be issued for risedronate.
Previously, Novartis and the Food and Drug Administration (FDA) had notified healthcare providers of a serious adverse event related to the use of bisphosphonates. Osteonecrosis of the jaw has been reported in patients with cancer who were receiving chemotherapy, corticosteroids, and chronic bisphosphonate therapy. The bisphosphonates involved were pamidronate and zoledronic acid. To date, there are no reported associations between risedronate and osteonecrosis of the jaw. Dental exams and preventative dentistry should be performed prior to placing patients with risk factors (chemotherapy, corticosteroids, poor oral hygiene) on chronic bisphosphonate therapy. Invasive dental procedures should be avoided during treatment. Product labelings for pamidronate (Aredia®) and zoledronic acid (Zometa®) have been updated. Recently, 63 cases of osteonecrosis associated with the use of bisphosphonates were published (Ruggiero, 2004). In a retrospective review, 56 of the patients received intravenous bisphosphonates for at least one year and 7 patients were on chronic oral therapy. The presenting symptom was a nonhealing extraction socket or an exposed jawbone. These lesions did not show evidence of metastatic disease and required removal of involved bone in most cases.
Bisphosphonates are widely used in the management of metastatic bone disease to treat hypercalcemia associated with malignancies and to treat osteoporosis. In the report by Ruggiero et al, the cluster of patients observed to have necrotic lesions in the jaw shared only one common clinical feature, all received chronic bisphosphonate therapy. The necrosis detected was typical of osteoradionecrosis. It was suggested that because of the trend in the use of chronic bisphosphonate therapy, the observation of an associated risk of osteonecrosis of the jaw should alert practitioners to monitor for this previously unrecognized potential complication."
Hopefully this makes sense, if not, there is a plethora of information being published out there. Keep an eye on those patients of yours who are taking bisphosphonates.
-Mike
Recently I consulted my patient who we treatment planned for elective extraction #32 (only 3rd in the mouth) due to prosthetic reasons. After some discussion with the oral surgery department, we came to the conclusion that it would be risky to perform the procedure and subsequently informed the patient.
Why?
She was taking Actonel, a bisphosphonate-derivitave medication. Turns out that there is a tremendous amount of published research indicating the relative risk of osteonecrosis while taking oral and IV bisphosphonates. Recent studies (Marx JOMFS Nov 05) show a risk of close to 37.8% of developing osteonecrosis after performing extractions on patients taking bisphosphonates. Marx's study also shows risks with the following: advanced periodontitis 28.6%, periodontal surgery 11.2%, dental implants 3.4% and root canal surgery 0.8%
This is a comment from the drug maker:
"Novartis Pharmaceuticals Corporation has notified dental health professionals of the risk of osteonecrosis of the jaw (ONJ) and the use of the bisphosphonates, pamidronate, and zoledronic acid. This warning has not be issued for risedronate.
Previously, Novartis and the Food and Drug Administration (FDA) had notified healthcare providers of a serious adverse event related to the use of bisphosphonates. Osteonecrosis of the jaw has been reported in patients with cancer who were receiving chemotherapy, corticosteroids, and chronic bisphosphonate therapy. The bisphosphonates involved were pamidronate and zoledronic acid. To date, there are no reported associations between risedronate and osteonecrosis of the jaw. Dental exams and preventative dentistry should be performed prior to placing patients with risk factors (chemotherapy, corticosteroids, poor oral hygiene) on chronic bisphosphonate therapy. Invasive dental procedures should be avoided during treatment. Product labelings for pamidronate (Aredia®) and zoledronic acid (Zometa®) have been updated. Recently, 63 cases of osteonecrosis associated with the use of bisphosphonates were published (Ruggiero, 2004). In a retrospective review, 56 of the patients received intravenous bisphosphonates for at least one year and 7 patients were on chronic oral therapy. The presenting symptom was a nonhealing extraction socket or an exposed jawbone. These lesions did not show evidence of metastatic disease and required removal of involved bone in most cases.
Bisphosphonates are widely used in the management of metastatic bone disease to treat hypercalcemia associated with malignancies and to treat osteoporosis. In the report by Ruggiero et al, the cluster of patients observed to have necrotic lesions in the jaw shared only one common clinical feature, all received chronic bisphosphonate therapy. The necrosis detected was typical of osteoradionecrosis. It was suggested that because of the trend in the use of chronic bisphosphonate therapy, the observation of an associated risk of osteonecrosis of the jaw should alert practitioners to monitor for this previously unrecognized potential complication."
Hopefully this makes sense, if not, there is a plethora of information being published out there. Keep an eye on those patients of yours who are taking bisphosphonates.
-Mike
