Placing Implants in Patients taking Humira?

This is a tough call since the MD is not on board. What I would do is find out what the medical condition is and why the physician feels this way. My part would be to explain the risks and benefits to the dental procedure and come to a consensus with the MD about how to proceed. I have had patients on this med with implants and I like to coordinate the treatment. Giving the physician the dental aspect will help him decide. Also it may be possible due to the patient's medical condition they may not be a candidate for implants long term. If the implant placement goes South it would be best to have a coordinated treatment since honestly it is best for the patient.

According to an article i read. Osteonecrosis in humaria pt is 0.11 percent. 75 percent females effected. Majority pts were tx for rheumatoid arthritis and methotraxate in combination with humaria increase the risk. The alarming part is that majority of cases are reported in pts who started humaria only in last 6 months. So unlike bisphosphonates use of drug overtime has no correlation with likelyhood of osteonecrosis.

What was the purpose of the x-ray?

http://www.ehealthme.com/print/ds18377395 As requested by CRS

Thanks Dr. Manzoor for sharing that study. I'm not surprised. I have posted a case of severe post-op infection in a lower right wisdom molar extraction site last year on this site. That lady was on ACTEMRA and had a surgical extraction in Florida before moving back to Toronto 8 days later. When she showed up at my practice, it was almost Ludwig's angina. The infection was profound, difficult to treat and with severe trismus and fever, was very difficult to overcome. She had been switched to ACTEMRA from methotrexate only 3 months before. It took me three different antibiotics, physically draining the pus using a wide bore syringe and multiple appointments before she started the healing process. These drugs are classified politely as "biological response modifiers", but are potent immune suppressors, blocking TN alpha production seriously. Good for their RA symptoms, but any moderate infection can be lethal. Unlike bizphosphonates, bone biology is not affected (as far as I know), so doing a bony surgery under antibiotic prophylaxis, clean incisions and profuse irrigation of bone during osteotomy with saline, post-op CHX 0.12% rinse, regular check ups, etc. should help. Best way is if a 4 week holiday from the drug can be obtained with her MD's consent. Good Luck and Happy Healing!

I think you got real lucky, the patient would have benefitted with hospitalization, an infectious disease consult and iv antibiotics. A Ludwigs is notable for the absence of pus, more of a cellulitis with airway compromise.

J Craniomaxillofac Surg. 2013 Jun;41(4):e65-9. doi: 10.1016/j.jcms.2012.10.014. Epub 2012 Dec 21. Denosumab osteonecrosis of the mandible: a new entity? A case report. Pichardo SE, Kuypers SC, van Merkesteyn JP. Author information Abstract In the treatment of osteoporosis, M. Kahler and bone metastases from prostate and breast cancer bisphosphonates play a major role. Not all patients respond well to bisphosphonate treatment. Since a few years adverse effects of these drugs have been reported. A new drug, denosumab, a fully human monoclonal antibody to RANKL, has recently been developed. This case reports a 74-year-old male patient with a medical history of diabetes mellitus, angina pectoris, coronary bypasses, hypertension, and prostate cancer with multiple metastases to lymph nodes, bone and lungs. The prostate cancer was treated according to the protocol. But he was never treated with bisphosphonates. Instead he was included in a phase III randomized double blind multicenter trial, testing the efficacy of denosumab compared to zoledronic acid in the treatment of bone metastases of hormone resistant prostate cancer. Only 7 months after start of denosumab infectious symptoms developed, followed by infestation of the mandible. Despite surgical treatment fistula and exposed bone remained. This case illustrates that use of denosumab can lead to a type of osteonecrosis resembling bisphosphonate related osteonecrosis of the jaws. Here is what I found on this topic it is just a case report. Personally I have a lot of experience in the treatment of BIONJ caused ether by orally administrated or intravenously administrated BP but with ORN caused by denosumab unfortunately I do not have. Maybe because where I work before the treatment was started with these types of drugs the patients are referred to oral and maxillofacial surgeon to exclude all possible infective sites in the mouth so the patients are at low risk to develop any dental related inflammatory pathology. You haven't stated the reason why these patient is taking denosumab. If the general condition does not allow the treating doctor to stop denosumab maybe these is not even an appropriate candidate for implant treatment- indications and contraindications for implant treatment. My advice is to get in touch with the treating doctor and find out what is his expectation for the general condition of the patient to improve. If the chances for improvement are small than it is contraindication to perform any implant treatment. If the condition is expected to improve than you should wait and after discontinuation of the denosumab do the implant surgery. Keep in mind dental implant surgery is not emergency procedure. Good luck. Dime Sapundziev

Dear Dime, is there a way to contact you off the blog, website email? In my area there are very few resources for the BIONJ management. I was recently asked to testify in a case and I need more information by someone more experienced. It would be very helpful and appreciated. I never thought I would have to manage this condition when first heard of it. Your references are great and appreciated, I was trained in the Marx protocol and I hope there are more options.