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Review
Introduction
Orofacial conditions with similar presentations to ONJ
1. Osteoradionecrosis 2. Conditions affecting bone turnover
Management of ONJ
1. Prevention 2. Treatment
BISPHOSPHONATES(BPS)
BPs are drugs used to suppress bone turnover, primarily through effects on osteoclasts. Nitrogen-Containing Bisphosphonates (NBPs) More Potent Less Potent Zoledronic acid , Pamidronate Alendronate , Risedronate Intravenously used Prevent skeletal related events (SREs) associated with malignancy Severe forms of osteogenesis imperfecta Orally used Osteoporosis Pagets disease of bone
Oversuppresing turnover
Compromising jaw healing both to Injury (e.g. tooth extraction) Normal microdamage from occlusion
PATHOPHYSIOLOGY
may be multifactorial
Oversuppression of bone turnover Oversuppression of angiogenesis Altered functioning of oral mucosal cells Microbial flora Anti-inflammatory effect Genetic predisposition.
6.79.1%
Introduction Orofacial conditions with similar presentations to ONJ 1. Osteoradionecrosis 2. Conditions affecting bone turnover Bisphosphonates in different clinical settings
1. Implants 2. Periodontics 3. Orthodontics 4. Endodontics
Management of ONJ
1. Prevention 2. Treatment
OSTEORADIONECROSIS (ORN)
ORN is caused by radiotherapy to the orofacial structures creating hypoxic, hypocellular and hypovascular tissue.
Both ONJ and ORN 1. Necrosis of jaw bones 2. Susceptible to secondary infection.
Hyperbaric oxygen therapy (HBO) For ORN: beneficial For ONJ inconclusive
Phossy Jaw
Individuals exposed to white (yellow) phosphorous in match stick production White phosphorous is converted to a compound similar to modern NBPs.
Management of ONJ
IMPLANTS
Implants in 50, 115, 101, 61 and 11 subjects with an oral BP exposure hx found no cases of ONJ
A recent South Australian study ,2009 Receiving oral BPs implant failure risk
0.88%
Topical BP Application
In animal models May enhance osseointegration of dental implants For humans Toxic effects on the oral mucosa ONJ risk
PERIODONTICS
Periodontal Disease
A precipitant of ONJ
May necessitate invasive periodontal procedures or dental extraction, and hence increase the risk of ONJ
Topical BPs in ortho. tx for rats 1. inhibiting undesirable movement of anchor teeth 2. inhibiting post-tx relapse For humans ? caution in light of ONJ risk
Caution is advised with 1. Miniscrew skeletal anchorage devices 2. Mucosal trauma from retainers 3. Orthognathic surgery 4. Tooth extraction Discontinue BPs prior to ortho. tx ? require further investigation
ENDODONTICS
Endodontic tx. is the preferred treatment over extraction to minimize ONJ risk. If ext. direct closure of the socket by suturing antibiotic prophylaxis considered
PREVENTION
ONJ is often refractory to tx BPs: terminal half-life of approximately 10 years.
Before BP therapy
A comprehensive oral evaluation Invasive dental procedures and subsequent healing are best completed
Under BP therapy
Biannual f/u to ensure oral health
Pt using NBPs for malignancy management should be under the care of a dental specialist and the oncology team.
Guidelines for Cessation of Routine Oral and IV BPs prior to Invasive Dental Procedures
IV BPs Best ceased at least 1M , and not recommenced until healing is achieved
Beta-CTX-1
TREATMENT
Conservative approach If there is evidence of infection chlorhexidine 0.12% rinse and systemic antibiotics
The ASBMR guidelines
No empirical evidence to cease BP therapy on ONJ development. Ceasing BP therapy for 3M on ONJ development
MFA,2009
Recommencement of BPs is best delayed until ONJ resolution, with either oral non-NBPs or a reduced frequency of IV NBPs, clinical condition permitting.
CONCLUSIONS
1. 2. BPs have revolutionized osteoporosis tx and confer considerable anti-fracture benefits that outweigh the small risk of ONJ. In the context of substantial uncertainty, the implications of bisphosphonate use in the dental clinical setting are still being determined. Invasive dental procedures are certainly to be avoided wherever possible in patients with a hx of BP use, especially IV BPs for cancer. Cessation of oral and IV BPs is advised, both prior to invasive dental procedures and on development of ONJ. Limited surgical debridement together with systemic and local antibiotics is the favoured management of ONJ, however, healing is not assured. More controlled clinical studies are recommended to justify the use of serum beta-CTX-1 in assessing ONJ risk.
3. 4. 5.
6.