Patient on Aledronic acid and Methotrexate: Risks of complications?

Discuss with her physician why she is on these meds, duration of treatment and prognosis. Then have him clear he for your recommended dental treatment. There are numerous BRONJ resources inline of course I'm partial to the Marx protocol and AAOMS protocols since oral surgeons usually manage this and are your backup.Most of the protocols copy this. Adequate patient information and consent. The Bisphosphinates are an unpredictable animal, I've seen problems ten years down the line and have also had successful implants placed in these patients. The drugs have a very long half life and we just don't know how to predict who and how severely the bone will be affected. Don't put confidence in a test or an article read in a ADA journal. Osteointegration is especially unpredictable in these patients so don't promise something you are not sure of. Combining this issue with Methotrexate adds another potential problem which her MD and a literature search will help. Remember, dental implants are elective and the risk benefit ratio need always be considered. Theses are my recommendations, and your welcome!

I personally would not do it for a few reasons. As stated above, Fosamax and other oral bisphosphonates can be very unpredictable when it comes to primary stabilization and long term stabilization of implants. Secondly, Methotrexate is a medication which is usually used in severe cases of certain disease processes and can cause patients to bleed and also eventually become immunocompromised. You must find out why she is on both of these drugs from her physician. Many times implants are not very successful in immunocompromised patients. Thirdly, you are talking about the upper second molar area for your implants. This area has the least amount of dense bone and is really an elective place to put an implant. Most do well with replacements to the first molar area. That is why I would probably leave well enough alone.

It is well documented in most resources that orally administered bizphosphonates are usually OK for minor oral surgery, with precautions and proper informed consent. The complications are reported mostly from iv administered bizphosphonates, and BRONJ being the most severe and debilitating. I understand that you have mentioned maxillary posterior region deliberately as it has good perfusion, and soft trabecular bone, lot of osteoblasts/cytes. Last month, I placed a crown on an implant I had placed about 4 months ago in the maxillary premolar area in a 67 y o lady who took a 4 week holiday from her ACTONEL[Risedronate Sodium] with her physician's consent, and started her meds back a month after her Stage I surgery. She did fine, and healed well and the crown is doing well too. I have no experience with Methotrexate myself though I understand it is mostly given in advanced auto-immune diseases like Rheumatoid Arthritis (besides chemotherapy for cancers) to suppress the body's immune response. It can seriously affect healing in dense bone. A few months ago, we saw a bad case of infection in a lower wisdom molar exo performed by a surgeon in Florida and the patient flew back here to Toronto, Canada after about a week. Soon, she had severe trismus, pus draining from socket, fever, pain,etc. Classic dry socket. Non-smoker and very careful type of person. I cleaned it out as best I could with her trismus, and had her on high Clinda+metronidazole orally for three days, but nothing worked. It quickly spread to sub-mandibular space and even her parotid space (scary) and then we had her admitted to a nearby ER where they put her on iv Clindamycin (Penicillin algy) and drained it from inside mouth for a day and then released her once she stabilized. This lady is about 51, a long term arthritis patient and was taking the new medication, called ACTEMRA for the last few months. I am not aware if the OMFS in Florida took any special precautions for this or not. I did detailed research but nowhere is it mentioned in their side-effects that dental surgeries to be avoided while on it. We even called their 1-800 number and reported this event. I am just their general dentist, but was able to chart the whole month-long ordeal as she finally got better. I would be very very careful doing bony surgeries in patients taking this category of drugs. I hope the incidents I have described helps you to make an informed decision. Good Luck!

WHY? WHY EVEN CONSIDER THE PROPOSED PROCEDURE? AN IMPLANT IN THE MAXILLARY SECOND MOLAR AREA IN A COMPROMISED AND UNHEALTHY PATIENT. PROVE THAT THIS IS OF SUBSTANTIAL BENEFIT TO THE PATIENT. Measure the "risk vs. the reward". RNM,DMD

i 've had 3 cases of bronj in my office 2 with fosamax and 1 with prolia and my question is How bad does this pt want an implant in an upper 2nd molar?? is it worth the risk ??

I've had troubles both with osseointegration and early bone loss in the few patiënts on MTX that I did. I don't do them anymore. Combine this with fosamax and your bone has no healing capacity at all!

The current issue of JOMI has its main Themtic review on this topic which is a very worthwhile read . I agree WHY bother with a second molar case when there could be issues . Having said that current research ( Jomi November ) show that Bisphosphonates can improve oseo-integration and just how small the risk of BRONJ in fact are . Having worked and placed on many patients with full AIDS in the early 90s we have been suprised by the long term results in these immuno-compromised patients . But in our letigious world is worth it , especially for a 2 nd molar . Peter