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[BISPHOSPHONATES ASSOCIATED OSTEONECROSIS OF THE JAWS] Oral Surgery
B i s p h o s p h o n a t e s a s s o c i a t e d o s t e o n e c r o s i s o f t h e J a w s
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This script is combination between Record , 2009 script & the book . We notify you
that's sometimes we write in different way than the doctor spoke and we use the last
year script and the book to get the best similar information. Hope you Enjoy our work.
- Today we're going to talk about osteochemonecrosis and
osteoradionecrosis which mean the effect of chemotherapy or radiotherapy
to bone that may cause necrosis.
Now there are group of drugs called Bisphosphonates , They are potent
inhibitors of osteoclastic activity (thus inhibit bone resorption ), Used in
two forms either IV or oral.
You have to be aware of the condition that may it be on bisphosphonates
either IV or the oral preparation for example any patient who has cancer
and he has bony metastasis is suspected to be on bisphosphonates.
Any patients who has multiple myeloma , Paget's disease , breast cancer
& prostate cancer those cancers they have three Dimensions to
metastasis in to bone .
Usually they are on IV bisphosphonates as pamidronate , Zolendronate
(note : both these 2 drugs are only available as IV preparation) and
others preparation .
[BISPHOSPHONATES ASSOCIATED OSTEONECROSIS OF THE JAWS] Oral Surgery
B i s p h o s p h o n a t e s a s s o c i a t e d o s t e o n e c r o s i s o f t h e J a w s
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-The patients who have osteoporosis they are taken oral bisphosphonates
and this is a risk factor to cause osteochemonecrosis that's why it's very
common in the exams (international exams) to ask that : patient who
present to you who osteoporotic and he seeking dental implants many
they may think the answer is the quality of bone and something like this
but the answer is the problem that they may be on bisphosphonates. So
we have to take care and follow the guidelines.
So again we have oral preparation and IV preparation .
Patients receiving bisphosphonates intravenously
clearly are more susceptible to Bisphosphonates
associated osteonecrosis of the Jaws (BOJ) than
are those receiving the drug orally.
-Newly they are giving to osteoporotic patients IV preparation only one
dose annually but you have to put in your mind the bisphosphonates
either IV or oral because the guidelines depends on the way that the
patient take medication either oral or IV .
IV preparation related to : cancer , malignancy , bone metastasis , multiple myeloma & Paget's disease .
Oral preparation related to : osteoporosis.
This point is very impotant that the effect last for IV preparation (specially even the patient took decades
IV) 1 year ago or 2 years ago or 20 years ago the effect . decadesand the risk of osteochemonecrosis last for
[BISPHOSPHONATES ASSOCIATED OSTEONECROSIS OF THE JAWS] Oral Surgery
B i s p h o s p h o n a t e s a s s o c i a t e d o s t e o n e c r o s i s o f t h e J a w s
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-It's a new oral complication seen in patients who have not had any
radiation treatment, and the methods used to treat osteoradionecrosis
do not seem to be effective for the treatment of these lesions what
patients with these lesions have in common is that they are taking a
bisphosphonate medication, usually as an adjunct to chemotherapy for
malignant disease.
- Bisphosphonates associated
osteonecrosis of the Jaws (BOJ) is a
condition of chronically exposed
necrotic bone, painful and often
primarily or secondarily infected
- Exposure either spontaneously or
secondarily to an invasive dental
procedure ( Extraction is the most
common cause of bone exposure )
- Patients complain of halitosis and have
difficulty eating and speaking.
- Clinically, the lesions appear as oral
mucosal ulcerations that expose the
underlying bone and frequently are
extremely painful, The lesions are
persistent and do not respond to
conventional treatment modalities such
as debridement, antibiotic therapy, or
HBO therapy .
What is Bisphosphonates Associated Osteonecrosis of The Bone ?
[BISPHOSPHONATES ASSOCIATED OSTEONECROSIS OF THE JAWS] Oral Surgery
B i s p h o s p h o n a t e s a s s o c i a t e d o s t e o n e c r o s i s o f t h e J a w s
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Affects the jaws (Mandible > Maxilla).
The most common clinical presentation associated with BOJ is an
ulcer with exposed bone in a patient who has had a dental
extraction. (non healing socket with exposed bone).
In the early stages of oral BOJ no radiographic manifestations
can be seen (Similar to osteoradionecrosis).
Patients may be asymptomatic but may have severe pain
because of the necrotic bone becoming infected secondarily
after it iafter it is exposed to the oral environment.
The most common dental comorbidity in these patients
reportedly is clinically and radiographically apparent
periodoperiodontitis.
Other local factors associated with BOJ are infected teeth,
dental abscesses, previous endodontic treatments, and tori.
Area of exposed bone it has to be for more than 8 weeks
[BISPHOSPHONATES ASSOCIATED OSTEONECROSIS OF THE JAWS] Oral Surgery
B i s p h o s p h o n a t e s a s s o c i a t e d o s t e o n e c r o s i s o f t h e J a w s
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Similar to the management of patients who will receive radiation
treatment, the dentist should see all patients before intravenous
bisphosphonate therapy begins.
Although a small percentage of patients receiving bisphosphonates have
BON spontaneously, the majority of affected patients experience this
complication following routine dentoalveolar surgery (i. e . , extraction,
Dental implant placement, or apical surgery) Therefore, teeth with a
poor prognosis should be removed before bisphosphonat administration
or as early as possible.
A progressive case of bisphosphonate-
related osteonecrosis of the
mandible. At initial presentation,
areas of bone exposure occurred
along the anterior teeth.
This two photographs are related
to mylohyoid ridges .It's a very
common presentation because it's a
sharp bone ridge and due to trauma
and non healing capacity it will be
expose.(in this case, it's bilateral)
[BISPHOSPHONATES ASSOCIATED OSTEONECROSIS OF THE JAWS] Oral Surgery
B i s p h o s p h o n a t e s a s s o c i a t e d o s t e o n e c r o s i s o f t h e J a w s
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Stage one :
-Exposed bone , asymptomatic & no infection.
Stage two :
-Exposed bone , pain & clinical evidence of infection
(local infection at the sight of the bone exposure).
Stage three :
- More serious and severe form … when we find that there is a oroantral
fistula, a skin lesion, a pathological fracture, or open into the maxillary
sinus so it is not localized (it's going outside the oral cavity).
Stages of Bisphosphonates Osteonecrosis of The Jaws
Because of the infection not because of the exposed bone we will have painful exposed bone .
Stage one
Stage Two
This X-ray is showing pathologic
fracture at the left side of
mandible. (this x-ray for different
patient than one above).
[BISPHOSPHONATES ASSOCIATED OSTEONECROSIS OF THE JAWS] Oral Surgery
B i s p h o s p h o n a t e s a s s o c i a t e d o s t e o n e c r o s i s o f t h e J a w s
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Most importantly How to prevent bisphosphonates osteonecrosis of
the jaws ?
Insure dental health before
starting the therapy
how
By extraction of all teeth that have poor prognosis to prevent any
dentoalveolar surgery that may be needed later on.
Invasive procedure 4 to 6 weeks before therapy to insure that the site
is healed completely. this is the duration that is required for complete
healing. So if we have any invasive procedure we have to do it in 4 to 6
weeks before starting the therapy .
Avoidance of extraction and Surgical
treatment during the therapy before 4
to 6 weeks, if we have any surgery we
have to do it before 4 to 6 weeks in
addition to dental care .
Now we will continue with Ahmed Al-Salahi
[BISPHOSPHONATES ASSOCIATED OSTEONECROSIS OF THE JAWS] Oral Surgery
B i s p h o s p h o n a t e s a s s o c i a t e d o s t e o n e c r o s i s o f t h e J a w s
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-If the patient has osteonecrosis of the jaws due to bisphosohonate, the
management usually by oral maxillofacial Surgeon. until now no
therapeutic modality prove to be successful, actually the English dr's
they said we have to be conservative and just removing minimal amount
which is detached from the tissues, the Americans are aggressive they
are removing more bone, they are trying to do reconstruction , but
actually through many cases that I saw, I go with conservative approach
because usually this drug affect the hole jaw even if you saw small
amount of exposed bone but all the jaw has been affected. usually
during the surgery our indication of how much we remove, we remove
the exposed bone until we reach bleeding bone but usually in these
cases we don't find bleeding bone which is the healthy bone that's why
I am with the conservative approach which is minimal debridement.
- So the idea for this patient to live with his exposed bone but
comfortably Without infections without any problems
So practically we are more conservative , only we are doing minimal
debridement if there are obvious signs of infection we are giving
antibiotics.
-We give antibiotic if the patient has signs of infection, because many
people thinks that BOJ is an infection which is not .If it's painful, it
means that it has an infection but otherwise it's not an infection. So
antibiotic indicated in case of infection overlays the BOJ.
[BISPHOSPHONATES ASSOCIATED OSTEONECROSIS OF THE JAWS] Oral Surgery
B i s p h o s p h o n a t e s a s s o c i a t e d o s t e o n e c r o s i s o f t h e J a w s
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-If there is obvious signs of infections we give antibiotics (antibiotics not
because there is exposed bone)
-No one knows or expect what could happen if it proceeds or not.
Bisphosohonate is a group of drugs used for treatment of
either patients have cancer or osteoporotic patients. the IV
preparation for cancer patients and the oral preparation for
osteoporotic patients , the risk of osteonecrosis increased with
IV preparation , it's only affect the maxilla & mandible and
usually presents as non healing socket which is painless for
more than 8 weeks. the patient has no history of radio-therapy,
the management is problematic and they are no definite
guidelines for the management of BOJ.
Progression
conclusion
[BISPHOSPHONATES ASSOCIATED OSTEONECROSIS OF THE JAWS] Oral Surgery
B i s p h o s p h o n a t e s a s s o c i a t e d o s t e o n e c r o s i s o f t h e J a w s
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- ORN is a condition of non vital bone in a site which receives
radiation. its related to radiotherapy, radio therapy has an
effect on the bone which makes it hypocellular, hypovascular
and hypoxic (3 H) , those are the three histological features
which make the healing capacity of the bone is less and that's
why it cause osteonecrosis.
- Risk factors of ORN, radiation therapy dose is more tha 60 gray
(1 gray = 100 Centigray)
Osteoradionecrosis is not caused by a dose of 48 or less
-The R-therapy has to be to max. or Mand. in order to get
necrosis in the jaws not like OCN, for example if the
patient have a cancer and he took bisphosohonate
chemotherapy, he might have necrosis in the jaws this is
important difference.
- ORN might happen due to injuries which is the most Common, due to extraction or it can happen spontaneously.
Osteoradionecrosis ( ORN )
[BISPHOSPHONATES ASSOCIATED OSTEONECROSIS OF THE JAWS] Oral Surgery
B i s p h o s p h o n a t e s a s s o c i a t e d o s t e o n e c r o s i s o f t h e J a w s
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Extract teeth 2 weeks before R-therapy (ideal method).
Regular preventive dental care to avoid extraction during
R-therapy.
Extraction the teeth that needs to be extracted during R- therapy, I
would wait until muocositis "side effect of R- therapy'' is subsided
and then extract the teeth, usually 4 to 6 months after the starting of
R-therapy.
Usually ORN is greater beyond 18 months after finishing the therapy so
Mucositis resolves within 4 months (1st safest period) and then after the
mucositis is gone up to 18 months (2nd safest period).
Even if the patient comes in the safe period you don’t do an extraction as
a GP (general physician) to protect yourself and the patient, So the
treatment is done by a OMF surgeon
-It is commoner in Mand. than max. same as OCN
[BISPHOSPHONATES ASSOCIATED OSTEONECROSIS OF THE JAWS] Oral Surgery
B i s p h o s p h o n a t e s a s s o c i a t e d o s t e o n e c r o s i s o f t h e J a w s
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-Although it is not an infectious process but to prevent infection: we give
systemic antibiotics not like OCN that we give antibiotics only if there is
an infection.
-There is a difference between someone who presented with osteoradionecrosis and
someone who wants to do a procedure.
-Our problem here with the hypoxic stage , oxygen doesn’t reach to the
sac.
-So there is a treatment modality called hyperbaric oxygen … (hyperbaric
oxygen: a pressurized oxygen where you are placing a patient in a
chamber that has 100% & 2.3 atoms. pressure of oxygen so they make
multiple dives into this chamber) 20-30 dives before the procedure and 10
after to maximize the oxygenation of the tissues
so it is a suggested treatment modality ,so we ask the patient to do it
before the extraction and after and follow up is needed.
-Its problematic as in OCN
We give AB if there is a pain or infection
remember
Hyperbaric Oxygen Therapy:
Remember:
In OCN management we give AB if there is a pain or infection only.
In ORN Management same as OCN we give AB if there is a pain or
infection.
In ORN prevention we give AB.
[BISPHOSPHONATES ASSOCIATED OSTEONECROSIS OF THE JAWS] Oral Surgery
B i s p h o s p h o n a t e s a s s o c i a t e d o s t e o n e c r o s i s o f t h e J a w s
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Remove sequestra: which is the pieces of dead bone.
A difference between ORN and OCN if I have bone less than 1 cm by
irrigation and removal of the sequestrum it tends to heal in ORN but not
in OCN
Hyperbaric oxygen therapy ( HBO Therapy ) improve the oxygenation to
the site.
Surgical intervention in cases that there is no response, I have to remove
to reach a healthy bone which is unlikely to be found , unless a specific
site is radiated for example the angle and the anterior mandible is
healthy.
The End
Dedicated to the kind friends :
Anas Abu Ghazalah , Yusif Sadik , Ibrahim Amer , Mutasem Dom & Wael Al Harbi
Last but not least our amazing group (Group 1 ).