Mr. Gary LeonardBDent Sc, FFD RCSI (OSOM), MDent Ch (OS), FFD RCSI (OS)

Specialist Oral Surgeon

58 Northumberland Rd. Ballsbridge, D4 Bon Secours Hospital, Glasnevin,

8 Kingsfurze Terrace, Dublin Rd, Naas, Co. KildareClane General Hospital

leonardoralsurgery@eircom.net

Successful Oral Surgery in everyday practice:

Mr. Gary LeonardBDent Sc, FFD RCSI (OSOM), MDent Ch (OS), FFD RCSI (OS)

Specialist Oral Surgeon

Treatment

Need

In House

Referral

History

Examination

Special tests

Informed consentCapable performance Duty of care

Infective Endocarditis (IE) – Antibiotic Prophylaxis

• Journal of the Irish Dental Association– Vol. 54 (6): Dec 2008• Different recommendations:

– British Society for Antimicrobial Chemotherapy (BSAC) 2006– American Heart Association (AHA) 2007– National Institute for Clinical Excellence (NICE) 2008

• NICE guidelines:– No antibiotic cover for patients previously classified as at risk– Lack of efficacy of antibiotic – Risk of anaphylaxis (15-25 patients per million)– Patient care and professional indemnity issues– No Chief Dental Officer in Ireland– Only adopted by the UK and Austria

Dublin Dental School & Hospital Position Statement

Patients with ‘at risk’ cardiac undergoing certain dental procedures should be covered with antimicrobial prophylaxis with:– 3 grams of oral penicillin or – 600mg of oral clindamycin (if allergy to penicillin exists)– Chlorhexidine mouthwash five minutes before the start of the

procedure– IV regimes for procedures under general anaesthesia

At risk patients:– Prosthetic cardiac valve– Previous infective endocarditis– Cardiac transplant patients who develop cardiac valvulopathy– Certain unrepaired congenital heart diseases or repaired conditions

within the first 6 months

At risk procedures– All dental procedures involving the manipulation of gingival tissues or

the periapical region of teeth or perforation of the oral mucosa.

Spontaneous bone exposure – lingual cortex 5 years of FosamaxMarx et al., 2007

Bisphosphonate Related Osteonecrosis of the Jaws (BRONJ)

• Journal of the Irish Dental Association– Vol. 52 (2): Autumn 2006– Oral bisphosphonates are used in the treatment of osteoporosis; they

stop bone loss and preserve bone density by inhibiting osteoclastic resorption of bone (Fosamax, Actonel, Bonviva, Bonefos)

– Intravenous bisphosphonates are used in oncology to prevent the spread and growth of metastatic osteolytic lesions associated with certain tumours eg breast cancer, prostate cancer and multiple myeloma (Zometa, Aredia)

• Patients may be considered to have BRONJ if:– Current or previous treatment with bisphosphonates– Exposed necrotic bone that has persisted for more than 8 weeks– No history of radiation therapy to the jaws

• American Association of Oral & Maxillofacial Surgeons Position Paper on BRONJ – J Oral Maxillofac Surg 65: 369-376, 2007

Bisphosphonate Related Osteonecrosis of the Jaws (BRONJ)

• Incidence of BRONJ:– IV bisphosphonates

• 0.8% to 12%.– Oral bisphosphonates

• 7 per million according to manufacturer Merck (Fosamax)• Up to 0.34 % after extractions (Australia)

• Risk factors:– Duration of therapy– Other medications eg steroids, chemotherapeutic drugs– Systemic conditions eg diabetes– Local anatomy eg mandible vs maxilla, tori, myelohyoid ridge– Extent of surgery

Alveolar bone exposure resulting form tooth extractions after 5 years of FosamaxMarx et al., 2007

Bisphosphonate Related Osteonecrosis of the Jaws (BRONJ)

• Management strategy for patients taking IV bisphosphonates:– Comprehensive oral assessment prior to drug initiation– Regular dental check-ups & preventive care (denture trauma lingual

flange region)– Non surgical endodontic treatment of teeth that otherwise would be

extracted (American Assoc. Of Endodontists Position Statement 2006)

• Management strategy for patients taking oral bisphosphonates:– Prevention– No alteration* or delay in planned surgery is necessary for individuals

medicated for less than 3 years.– ‘Drug holiday of 3 months’ prior to surgery for individuals medicated

for more than three years or less than three years if taking steroids concomitantly.

– Communicate with GMP if advocating ‘drug holiday’ – Risk of hip fracture in osteoporosis is 1:6.

Bisphosphonate Related Osteonecrosis of the Jaws (BRONJ)

*Alterations in surgery for patients taking oral bisphosphonates Journal of the Irish Dental Association– Vol. 54 (4): August/September 2008

• The vast majority of these patients can be treated in the general dental surgery

• Written informed consent• Loading dose of Amoxicillin 3g orally preoperatively and 500mg tds for five

days• Use a block injection or use local anaesthetic agents without a

vasoconstrictor for infiltrations• Atraumatic surgery with minimum disruption of periosteum and sutures not

too tight• Written post-operative instructions (Chlorhexidine & HSMW)• Follow up to ensure adequate recovery• Soft blow down splints may be of some use to prevent food collection in

socket

Sequestrectrectomy after 6 month drug holiday (CTX 299 pg/ml)Marx et al., 2007

Staging and treatment strategies (BRONJ)

Stage 1: Non infected and asymptomatic exposed necrotic bone

• Chlorhexidine mouthrinse• Quarterly follow-up• Review of indications for continued bisphosphonate therapy

– Discontinuation of IV bisphosphonates has no short-term benefit– Discontinuation of oral bisphosphonate therapy for 6-12 months may

result in gradual improvement with either spontaneous sequestration or resolution following debridement surgery.

Staging and treatment strategies (BRONJ)

Stage 2: Infected and symptomatic exposed/necrotic bone • Antibiotic therapy – Amoxicillin, Metronidazole, Clindamycin,

Lymecycline (Tetralysal 300mg po bd)• Analgesia• Chlorhexidine mouthrinse• Limited superficial debridement only to relieve soft tissue

irritation

Stage 3: With extraoral fistula, osteolysis extending to inferior border

or pathologic fracture• As in stage 2 with extraction of symptomatic teeth in

necrotic bone and surgical debridement/resection• Hyperbaric oxygen (HBO2) not as effective as in

osteoradionecrosis– Freiberger et al., J Oral Maxillofacial Surgery 65: 1321-1327, 2007

Healing of bone exposure without surgery after a 6 month drug holiday

Spontaneous bone exposure after 5 years of Fosamax

After 6 month drug holiday

The anti-coagulated patient:

• Why is the patient anti-coagulated?– Deep vein thrombosis (DVT)– Embolization secondary to myocardial infarction– Atrial fibrillation– Renal dialysis– Heart valve replacements– Cerebral thrombosis– Ischaemic heart disease– Peripheral vascular disease

• What drug interactions are likely with Warfarin?– Metronidazole, Erythromycin, aspirin and some antifungals increase the

risk of bleeding– Carbamazepine (Tegretol) can decrease the effectiveness of Warfarin

Warfarin AspirinAnti-

platelet drugs

• How can I perform surgery safely?Warfarin– Enquire after INR history and obtain new reading 24 hours before

procedure– Warfarin must not be stopped unless under special medical supervision– Simple extraction of 2-3 teeth possible if INR less than 3.5– Regional blocks should be avoided– Atraumatic surgery – Haemostatic material (Surgicel, collagen) & suturing of sockets– Tranexamic acid mouthrinse 5% solution (antifibrinolytic)– Further bleeding – consult haematologist (FFP, Vitamin K, Tranexamic

acid)

Aspirin– 100mg or less – no action required– >100mg and bleeding time >20 mins or aspirin and another anti-

platelet drug – stop aspirin in consultation with physician

Other anti-platelet drugs– Clopidogrel (Plavix), Dipyridamole (Asasantin)

Treatment

Need

History

Examination

Special tests

Radiographic markers of proximity to IAN: Howe & Poynton (1960)

1) Loss of tramlines 2) Narrowing of tramlines3) Alteration in direction of IA canal4) Radiolucent band across root

Risk of damage up to 35% when all four markers present

Pre-operative imaging: IAN and second molar

Pre-operative imaging: IAN and second molar

Pre-operative imaging – mental nerve

Pneumatised antrum with displaced root and OAC:

Oro-antral communication R side with sinus opacity:

Canine teeth- Age- Root curvature

Horizontal Parallax2x PA’s

Vertical Parallax- OPG - Upper Ant Occlusal

Treatment

Need

In House

History

Examination

Special tests

Informed consentCapable performance Duty of care

Informed consent:

Informed consent: Risk of IAN damage

Risk of permanent IAN Damage post removal of 3rd Molars

0.04% 0.9%

0.3%

0.4%

Robert & Pogrel, JOMS 2005

Valmaseda-Castellon, Triple O 2001

Rood, BDJ 1983

Carmichael & McGowan, BJOMS 1982

0.5%

Risk of permanent Lingual nerve damage post removal of 3rd Molars

0% 0.8%

0.3%

Walters, BDJ 1995

Robinson & Smith, BDJ 1983Without lingual nerve protection

Robinson & Smith, BDJ 1996With lingual nerve protection

0.5%

Pogrel & Goldman, JOMS 2004

Coronectomy:

Coronectomy: A Technique to protect the inferior Alveolar Nerve.

Pogrel et al., JOMS 62: 1447-1452, 2004

Coronectomy (intentional partial odontectomy of lower third molars)

O’Riordan, Oral Surg Oral Med Oral Pathol 2004:98:274-80

A randomised controlled clinical trial to compare the incidence of injury

to the IAN as a result of coronectomy and removal of third molars

Renton et al., BJOMS (2005) 43, 7-12.

Pogrel et al., JOMS 62: 1447-1452, 2004

Coronectomy:

Contraindications:• Active infection• Mobility• Horizontally impaction

Outcome:• Permanent IAN paraesthesia (0-1.8%)• Infection (6%)• Migration of remaining root (30%)

Post-operative duty of care:

Pharmacological control of post-operative pain

Level 3 – Opiate analgesia– Tramadol 50-100mg po 6 hourly (Zydol, Tradol)

Level 2 – Addition of a mild opiate– Paracetamol/codeine 500/8mg tablets x 2 po 6 hourly (Solpadeine)– Paracetamol/codeine 500/30mg tablets x 2 po 6 hourly (Solpadol,

Tylex)

Level 1 – Non-opiate analgesia– Paracetamol 500mg x 2 po 6 hourly– Ibuprofen 200mg x 2 po 6 hourly– Difene Retard 75mg tablet x 1 every 12 hours (use with omeprazole

10mg od)

Journal of the Irish Dental Association– Vol. 53 (3): Autumn 2007

Thank You