Female patient on oral bisphosphonates: comments on this case?

First things first how long has the patient been on Bisphosp ? There is a protocol to follow regarding exposure time and drug holiday. The teeth need to go first this might even be the start of Bronj they look pretty bad. That said, this should be a ct guided locator case in such an atrophic mandible. I'm going to give some valuable advice, as an OMS I have seen these Bisphosp cases so south on simple extractions by general dds it is not pretty and patients do eventually figure it out and do sue. I wise dds would refer this to an oral surgeon with experience in this, not a case to fly alone on. Good luck and thanks for the post.

Also with those large feeder blood vessels in the socket bases with all that granulation tissue it will be very vascular, read , bloody mess when the teeth are removed. Please don't beat this lady up!

CRS is correct. You should refer the patient out to an oral surgeon who is experienced in treating this type of patients. Interestingly, you can see the changes in the bone architecture on the first 3 images. Don't lose your sleep over this patient!

This is a case I would refer for the extractions. Implants, that will have to be determined by the CTx test and how she responds to the extractions. She may be best managed in an academic setting.

Makes sense to remove the teeth first and see how patient responds to the surgery. I agree that oral bisphosphanates are not the risk that IV meds are but still need to exercise caution. In regards to the restorative treatment, bisphosphanates aside, in no way should this mandible be bone grafted. When placing implants for overdenture attachments, make sure there is enough interarch space for the attachments and adequate denture base thickness to avoid fracture. The mandible doesn't need to be any taller. In fact, when the teeth are removed, get primary closure then place implants after healing. The mandible is plenty thick and tall for implants at it's current configuration.

I have no doubt that CRS is an excellent oral surgeon, but I would love to know what magic treatment he will do to stop bisphosphonate osteonecrosis that an experienced GP dentist can't do. Before any teeth are removed in this case it is essential to reduce as far as possible the infection present in the mouth prior to any extractions. This means that, yes, scaling of teeth and periodontal treatment should be commenced, something I would think an OMS hasn't done for zonks. The use of ozonated water during ultrasonic scaling has been shown to dramatically reduce the bacterial load, together with the use of intra oral ozone gas for sterilization of the pockets prior to removal. Following extraction of the teeth, use of ozone gas in the sockets after extraction, also helps eliminate bacteria and speeds socket healing. Certainly antibiotic cover should also be considered. There are a number of intraoral ozone units available now and these I believe should be an essential armamentarium in every practice, GP or specialist. I have placed quite a few implants in patients who are on bisphosphonates and if you follow a meticulous and atraumatic, as far as possible, surgical protocol, then the chance of osteonecrosis is very small. Needless to say the patient should be adequately informed of the risks involved and a thorough risk/benefit analysis should be done prior to any elective surgery. I don't believe removal of these teeth is elective surgery, however placement of implants to retain a denture is elective and careful consideration of the consequences should always be done before elective treatment.

Dr. Berne, has a very good point. This patient should be cleaned up before any extractions. The locals in my town, think I am crazy when I mandate a cleaning, before removal of teeth. Unfortunately, after that suggestion," I have to shift gears" and suggest no one other than an OMFS with lots of experience treating "bronj", be the one to help work this up. You are not going to be able to gain vertical bone past the buccal and lingual walls, unless you are very lucky. You really need to be ready to treat the worse case scenario. I have 20 active "bronj" cases, some have resolved with one surgery and some are unresolved after 4. Are you seriously grafting, so you can place your implants over the incisive canal? Do you know what the first step of a nerve lateralization procedure is ? Incise the incisive branch of the trigeminal nerve. We are still engaging the inferior most cortex, when possible, just as we engage the slightly more dense floor of the sinus, when we place implants in the posterior maxilla. I'm afraid you are asking for it, with this one. Bvinci

CRS, Thank you for your comments and I am fully aware of the process of bisphonate induced osteonecrosis, but you still haven't shared with us what you as a specialist would do to prevent osteonecrosis from occurring in this instance. You clearly didn't understand what I was saying with the use of ozone .I wasn't advocating ozone for treatment of osteonecrosis but to help disinfect the area before removal of the teeth.Having said that, I believe there may also be a role for ozone in treatment of osteonecrosis. It is generally accepted that removal of active infection is a priority in these cases, and in this regard ozone is second to none. I am surprised as an OMS you are unaware of the use of ozone. Ozone is not only one of the most potent disinfectants available but it has been shown to speed surgical healing, something that is of major importance in these at risk cases. If you disagree with disinfecting the site prior to surgery as I advocated, please would you advise what your special protocol is and how your protocol prevents osteonecrosis in cases such as these, remembering the surgery is not elective-the teeth are clearly in a sea of infection and have to be removed. Also would you kindly advise why your treatment protocol can't be readily used by GP dentists for simple removal of hopeless teeth as in this case?

Ozone, is also in the experimental stage for management of soft tissue injuries and maybe even facial rejuvenation . I was asked to invest in a product similar to this 7-8 Years ago and have yet to see it being used in wound care??? Do you know if it is carried in any other form? Bvinci

Dear Dr Berne, look closely at these teeth, if you can root plane without exfoliating them great. I would use a systemic antibiotic prior to treatment, however I would follow the protocols advocated by AAOMS and Marx and not experiment with ozone or any other modalities. You may get burned for what? Again anything that the surgeon does ,does not cause the BRONJ but aggravates it. Take note of Bvinci's post the treatment is palliative. The Bisphosp half a very long half life, this patient needs viable osteoclasts. Once any infection is removed the necrotic bone has an unpredictable course. As a practioner who understands BRONJ I'm surprised that you don't the protocol it is readily available and I gave two sources. I don't understand your tone it seems attacking perhaps just over enthusiastic over your ozone.And yes like Dr.Bvinci I have sent cases for preop clean up I comprehend the need for infection control.There is some very sage advice being given by experienced doctors in these posts whitch is consistent. I quite frankly don't understand your attitude so I politely and professionally won't go there. To answer your question about the GP following this protocol, if the bone after extraction does develop BRONJ you will need to refer to an experienced OMS, at that time you may open yourself to a failure to refer issue and be held to the standard of an OMS.It is not a wise move to assume that responsibility and expose yourself to that liability.Eventually you will end up in court.As OMS we are here to help not shame.All the best CRS

i would treat this pt in my office in the following manner 1- ctx lab test if results are in the 200's i' would place pt on a 3 months drug holiday anyways and then ext degranulate , hemostasis ( be rady for non life threatning bleeding if you know how to controll it) 2- alveoloplasty and primary clousure 3- antibiotics 3 days prior and for 10 days, wait 3 months and cbct to plan for implants usually 3 or 4 for a oring or locator overdenture NOT 2 ... ORAL BIPHOS ONLY not IV ....

I agree with rsdds's plan.On occasion I used a 9 month drug holiday. Remember to include detailed documentation of how this patient's physician will be discontinuing, or replacing her osteoporosis medications.Since bisphosphonates have a long half life it is possible that she may not be placed back on this medication at all. This step will clarify if implants are an option.

The ctx test has no validity! Bvinci

I'm not certain we aren't looking at early stage "bronj", right now. The ct scan raises some concerns with me. Bv

I'm surprised none of you have mentioned the American Dental Association paper on ARONJ - "Managing the Care of Patients Receiving Antiresorptive Therapy for Treatment and Prevention of Osteoporosis". It's easily available on the internet. It gives all the up to date information on ARONJ and it's avoidance. This lady is presumably on a standard regime of alendronic acid 70mg weekly. Unless she's been on it for a very long time, her ARONJ risk is very small. Clearly you need to follow the recommended protocol - chlorhexidine mouthwash, consider antibiotic prophylaxis (probably not necessary for these extractions), consider a drug holiday, etc - it's all in the ADA paper. I'm also surprised at how many of you have urged referral to an oral surgeon for these extractions. The teeth are flapping in the breeze and if you don't get a shift on they will have fallen out spontaneously. Too many oral surgeons chasing too little work in the USA methinks. With regard to the specifics I suggest the main message is "Keep it simple". No need for preliminary CTX, which is of dubious prognostic value in any case, oral ozone etc. I would also go carefully with pre-extraction scaling 'cos you'll probably flick the teeth out with the scaler, and thus lose your fee for the extractions! As for root planing - Come on chaps lets get back to Planet Earth shall we!! What is more root planing could stir the bugs up even more, and encourage ARONJ. Just a pair of forceps is all that is necessary. Once you have tweaked the teeth out avoid poking about down (aka curetting) the sockets and whatever else you do avoid shoving Alvogyl, BioOss or any other crap down the holes. Just a couple of stitches, if necessary, to coapt the gum margins as neatly as possible. Avoid immediate implant placement. Once the sockets have healed a couple of locators on 2 implants should be adequate - again with all the recommended prophylactic precautions . My only concerns are: (a) the bone looks very dense and there is a risk of overheating. If your implant system supplies single use disposable drills I would strongly recommend them. b) Those nasty vessels. You should be able to avoid them by careful implant placement. If you hit oil it can be messy. The best thing to do is complete the drilling and plug the hole with an implant a.s.a.p. Good luck. I always enjoy the diverse, and sometimes frankly weird, advice on this site.

The suggestion about a 3 month drug holiday is excellent advice if you can wait 3 moths. In this case treatment is not optional-it has to be done as soon as possible. Waiting for 3 months is much more likely to cause problems than solve them. So we don't have a choice in this case, just as thousands of GP dentists every day don't have a choice when someone on bisphosphonates comes into their rooms with an abscess or in acute pain. The treatment has to be done there and then and they don't have the luxury of referring to an OMS who may see them in 1 or 2 weeks, if they are lucky. The GP dentist needs to be familiar with the protocols for treatment of these patients to minimize risk of osteonecrosis.

Please explain why this has to be done today and the patient doesn't have the option of being referred. If you create a pathologic fracture are you going to plate it, because the standard of care management of the edentulous mandible fracture is trans facial rigid fixation. Were you not the one that suggested cleaning them up first? I'll say it a second time, while I have placed implants in patients that have been on meds for osteoporosis, this patient is probably not the right candidate. If this patients develops a ludwigs infection, are you going to treat that as well. You apparently do not like OMFS's and that is a shame. Maybe you don't feel like your patients deserve the best care possible. If your wife, daughter or mother had an impending "bronj" infection, would you send them to a doctor that has treated several of these, or one that has seen a few? Bvinci

By the way, our standard policy is; if the patient is hurting, has a serious infection or has a malignancy, we will see them in 24 hours or less. Maybe Oral surgeons in our town are better than most or maybe you have rubbed everyone of them in such a fashion, that they aren't interested in being on your team. I would hope they could look past any personal issues and maintain a professional mentality. Bvinci

My understanding is that just about every post-menopausal woman in the US is on a bisphosphonate. It's taken over from HRT as over-treatment of the month. I don't quite see why this lady is so much more at risk of ARONJ than all the other squillions out there. Or am I missing something?

This ongoing discussion re Bronj and Bisphosphonates and patient management in these cases has been extremely informative. However, the incidental back-and-forth ego driven sarcastic remarks started out a bit boring to me and are rapidly approaching the level of plain and simple child like ego posturing. Perhaps I am just too simple-minded, but the way that I see it, I think we can all agree that this patient is not the run of the mill ordinary patient who we see in our practices everyday. If we can all agree on this, then why is it so hard for all of us to see the wisdom if not the necessity of referring her to someone who has both more formal training as well as clinical experience in managing such situations. In cases such as this, I think the mind set needs to be anticipation of the "worst case scenario". If we approach this patient with this mindset, then what general dentist in his right mind would feel comfortable embarking on any treatment?? Thank you. DrT

I'll take $1000 for screwing on the abutments and $1800 for taking impressions and delivering the denture. A OMFS or whoever can stay up all night worrying about the rest.

Even denture abrasion with patients on BP can wind up being a significant issue.

In an extraction where the site is ungrafted the bone lining the socket becomes necrotic and this dead done is undermined by osteoclasts and pushed into the socket and out the orifice. My thinking is that because this process is inhibited by bisphosphonates the body cannot get rid of the necrotic bone and the necrosis continues into bronj. In theory if the extraction site is grafted with a material that maintains the socket wall this should prevent bronj. Also in theory if bronj is established and surgery is done to remove the necrotic bone and the vital bone is then grafted with the appropriate graft material the site should heal. If Baker k. Vinci or any other oral surgeon that has refractory bronj cases that have not resolved with routine methods I would be happy to send the graft material at no charge. Greg Steiner Steiner Laboratories

Greg, I appreciate the generous gesture. While I am pretty certain that you are being sincere and one day I may take you up on the offer, but every case I am treating with the exception of 1 or 2, was treated somewhere else,one of the more recent ones was two years status post diagnosis and just before some ENT performed a maxillectomy, we cured them with one surgery. Some of our acedemics were grafting BMP in these refractory cases, but efficacy could not be proven. My first two " bronj " cases were 10 years ago in multiple myeloma patients and they were possibly the easiest cures I have had. The reason the early "standard of care treatment", was to do nothing, in my opinion, was because the longer the case "sits" untreated, apears to be the easier "fix",quite possibly because the amount of necrosis reaches a steady state and the more vascular bone, with normal functioning osteoclast, tends to take over. I have no scientific data to support this opinion, but I don't operate on rats or place bone grafts in muscular pockets. Until I see some proof that our first goal in the management of " bronj ", is something other than resolution of disease and mucosal closure, I will not be grafting these cases during first phase or refractory treatment. Thanks, Bvinci