Minimise risks
A current hot topic in general dentistry and, in particular, any type of surgical dentistry, including simple extractions, is in the management and care of patients who are undergoing therapy with a group of drugs called bisphosphonates.
Bisphosphonates are a drug group that can be immensely beneficial to patients with osteoporosis and many other serious medical problems. However, it has become apparent that certain dental treatments, including extractions, implant surgery and any form of dento-alveolar surgery, can be more risky in these patients where a type of osteonecrosis may ensue.
Bisphosphonate osteonecrosis of the jaw, or BON as it is commonly known, is a severe osteonecrosis that is painful, debilitating and virtually untreatable. Dentists must know and understand how to minimise these risks.
As someone who has seen a case of BON and heard about many others, including seeing photographs, from colleagues in their work in maxillo-facial units, believe me, it is something that I hope all my colleagues in practice never have to deal with.
The problem is that many of our medical colleagues, especially general practitioners, are not fully aware of the issue and, to make matters worse, bisphosphonates are being much more commonly prescribed.
For example, in my referral practice, I do not go more than a week or two without seeing a female patient, referred for implants, who is on alendronic acid, and, literally millions of women in the United States are on ‘Fosamax’.
When I do speak with a patient’s medical practitioner about this, they are usually very interested and grateful that I have alerted them to the issue and ask me for further information.
The Association of Dental Implantology (ADI) recently commissioned a white paper from Professor Jon Suzuki in the United States for distribution to our members and publication on the ADI website. Below is the guidance found within our paper.
Guidance
•Patients on intravenous (IV) bisphosphonates are at the highest risk of developing bisphosphonate – associated osteonecrosis (BON), particularly if they have been receiving IV treatment for more than six months. Elective dental implant treatment cannot be recommended for these patients. If treatment is required, this should be undertaken in a hospital environment with intravenous antibiotic therapy and full aseptic technique being considered as appropriate.
• Patients on IV bisphosphonates for less than six months should be at low risk of developing problems in relation to non-surgical periodontal and restorative care. However, surgical treatment, e.g. extractions, should only be undertaken if absolutely necessary and should be approached cautiously and conservatively. If possible, a single intervention should be undertaken and an interval of two months left to verify acceptable healing before considering further surgical intervention.
• Patients on oral bisphosphonates treatment for three years or less probably have only a slightly increased risk of developing BON. As such, elective dental therapies including extractions and dental implants are not contraindicated. The patient should, however, be informed of the risk and appropriate consent obtained.
• Patients on oral bisphosphonates treatment for more than three years are at an increased risk of developing BON and this risk may increase with the duration of bisphosphonates therapy and other co-factors such as smoking. Therefore, surgical treatment, e.g. extractions, should be approached extremely cautiously and conservatively. If possible, a single intervention should be undertaken and an interval of two months left to verify acceptable healing before considering further surgical intervention.
• All patients on bisphosphonates treatment should rinse for one minute using a chlorohexidine aqueous solution 0.2% prior to dental treatment and to continue rinsing twice daily for 14 days after treatment.
• All patients on bisphosphonates treatment should be prescribed systemic antibiotics for one to two days prior to any dental procedures which involve trauma to bone, e.g. extractions, implant placement and periodontal surgery.
• All patients on bisphosphonates treatment should be encouraged to attend for regular dental assessment and maintenance. The importance of ensuring a high standard of oral hygiene and good diet should be emphasised to reduce the need for possible future dental surgical intervention. Patients who smoke should also be encouraged to cease.
Final thoughts
Some patients receive IV bisphosphonates as infrequently as twice yearly and often forget to reveal this in their routine medical history questionnaire. Dental practitioners should be aware of this factor and be very careful when verbally confirming the medical status of the patient.
Further, there is no evidence in the literature that ceasing drug therapy or taking a ‘drug holiday’ reduces the risks of BON, due to the extremely long half-life of these drugs.
Therefore, the education of our patients, together with their medical practitioners, is of paramount importance. In many cases, courses of dental treatment, including extractions, implant treatment and periodontal surgery, can be carried out prior to the commencement of drug therapy, or before the critical time of taking the drugs has elapsed.
Dental fx is based in Bearsden Glasgow and was founded by Dr Stephen Jacobs in 2006. Although dealing in all aspects of dentistry, Stephen has a special interest in implants and has been placing implants for over twenty years.
Dental fx is a teaching centre for dentists and nurses interested in learning more about dental implants and to this end Stephen runs a number of courses throughout the year.
Please contact us for more information regarding the courses by emailing our course co-ordinator ator visit our web site http://www.dentalfx.co.uk
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