Dental Extractions and Bisphosohonates An algorithm is presented with the aim of supporting the optimal management of patients in this

recently defined and rapidly expanding group. The diagrammatic guidance should be understood in conjunction with the explanatory notes. A suggested reading list of supporting refereed publications is cited. The authors welcome constructive criticism and comments with the aim of furthering development of a safe, effective protocol. Nick Malden BDS, FDS Dept. Oral Surgery Edinburgh Dental Institute Lauriston Place Edinburgh EH3 9YW nick.malden@lpct.scot.nhs.uk

Charalampos Beltes DDS, MSc. Dept. Oral Surgery Edinburgh Dental Institute Lauriston Place Edinburgh EH3 9YW

December 2007

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Algorithm: Extractions in Bisphosphonate patients (to be read in conjunction with explanatory notes) Low Risk Alendronate / Risedronate / Ibandronate Medium / Unknown Risk High Risk Ibandronate / Pamidronate / Zoledronate Extraction indicated Monitor Yes Can extractions be avoided ? Other risk factors for BONJ ? Yes No No Yes Reduce risk factors? No Consider reducing risk factors for BONJ Informed consent (Lower risk & severity of BONJ) Informed Consent moderate risk Informed consent (High risk & severity of BONJ) Risks accepted Risks accepted Risks accepted Proceed with simplified extraction protocol Seek advice Proceed with extractions including adjunctive therapy Review weekly (If debris in socket irrigate with saline or chlorhexidine only) Monitor as per Low risk Healing noted at 3 .4 weeks No Refer to specialist Is bone exposed at 6 .8 weeks? Yes No Yes Routine review to report if symptoms develop 2 NJM & ChB 2007 Start treatment for BONJ .

Use of soft tissue flaps to provide periosteal coverage of bone. General risk factors – extended use of bisphosphonates > 3 years Ref 1. Discontinuation of bisphosphonates should also be given consideration in many cases Ref 5. N J Malden/Ch Beltes Dec 2007 . The aim being to reduce potential sources of infection and relieve painful symptoms as well as reducing invasiveness of procedure Ref 3. disodium pamidronate and zoledronic acid. poor oral hygiene. the frequency of BONJ has been estimated to be in the region of 1:50 to 1:7 (Paget’s disease). Crown amputation leaving endodontically treated roots. Low Or High Risk? These drugs have been associated with a variable risk of development of bisphosphonate associated osteonecrosis of the jaws (BONJ). denture trauma. An extraction can increase the risk of BONJ by a factor of up to 7. straight forward extraction technique and post operative chlorhexidine mouth rinsing until healing observed Ref 2. If reduction or discontinuation of the corticosteroids is planned. as part of the patients general management. and 1:15 to 1:11 (for malignancy cases) and these are more likely to be examples of severe BONJ. Simplified Extraction Protocol Improve oral hygiene where appropriate. then delaying the extraction could be considered. usually given intravenously. Reduction Of Risk Factors Apart from extreme of age all other risk factors can potentially be removed or their effects reduced. periodontal disease. Alendronic acid (sodium alendronate). general debilitation Ref 3. Avoid lifting periosteum from bony margins. smoking. Non surgical endodontic re treatment. Seeking Advice It would be expected that a number of points of contact providing guidance for the management of these patients would be available at a regional level and also through the internet. (over 60 Ref 4). omissions or detrimental effects that might be considered resultant from applying these guidelines. Preoperative chlorhexidine mouth rinsing. Options For Avoiding Extraction Endodontics preferable to extractions Ref 2. It would be expected that Oral and Maxillofacial Surgery units would have a knowledge of the prevention and management of BONJ. ibandronic acid. Informed Consent A recent study has attempted to estimate the frequency of BONJ in those taking bisphosphonates with and without the extraction of teeth Ref 6. Other Risk Factors Local risk factors – mandibular molar extraction. When bisphosphonates are being used to protect the skeleton against the osteoporotic affects of corticosteroids. the maximum benefit of bisphosphonates is achieved if given during the first year of steroid administration. Although the advice and information contained in this guideline is believed to be true and accurate at the time of production the authors can accept no responsibility or liability for any errors. However increasingly the more toxic IV drugs are being used at lower dosages to treat osteoporosis. Bony remodelling with minimal soft tissue surgery.EXPLANATORY NOTES Bisphosphonates And Extractions The 5 named bisphosphonate drugs are those that have been most commonly associated with bone necrosis of the jaws. Disclaimer. Bisphosphonate drug holidays Ref 5+7. An extraction in the osteoporosis group has been estimated to be associated with a frequency of BONJ as high as and sometimes > 1:1. but quite often hospital dental services and salaried dental services and other specialists may well be able to give advice.000 (Australian figures) but severe destructive BONJ has rarely been reported in this group. Adjunctive Therapies These include the use of antibiotic prophylaxis. In those receiving the more toxic drugs. It is likely that the tailored doses of IV drugs will have the same reduced risks for BONJ as the oral preparations Ref 1. Reduce obvious sharp socket wall margins and inter radicular bone if protruding post operatively. concurrent corticosteroid use. A risk of spontaneous occurring BONJ is present for all patients receiving bisphosphonates. Discontinuation of the bisphosphonate for at least a 3 month period prior to surgery has also been proposed Ref 5. risedronate sodium. extreme of age.

65:369-76 Mavrokokki T. JOMFS 2007. Dental Management of patients receiving Oral bisphosphonate therapy.63:1567-75.65: 1440-41 Ref 2 Ref 3 Ref 4 Ref 5 Ref 6 Ref 7 N J Malden/Ch Beltes Dec 2007 4 . Miller P.J.Res. Blumentals WA. 2006. Recognition.22:1479-89.29:1548-58.4 REFERENCES Ref 1 Khosla S. Bisphosphonate-induced Exposed Bone (Osteonecrosis/Osteopetrosis) of the Jaws: Risk Factors. Pazianas M. Goss A. 2007. Nature and Frequency of BisphosphateAssociated Osteonecrosis of the Jaws in Australia. Bisphosphonate-related Osteonecrosis of the Jaws. Fortin M. A.137:1144-50 Marx R E. Sawatari Y. JOMFS 2007. Zahrowski J. J Bore. Bisphosphonate Associated Osteonecrosis of the Jaw: Report of a Task Force of the American Society for Bone and Mineral Research. Cauley J et al. AAOMS Task Force Position Paper.Min. A review of the literature on Osteonecrosis of the Jaw in patients with Osteoporosis Treated with Oral Bisphosphonates: Prevalence. Prevention and Treatment. Statement on Bisphosphonates. Expert panel Recommendations. JADA. Comment on the American Association of Oral & Maxillofacial Surgeons. et al.D.A. JOMFS 2005. Burr D. 2007. Risk Factor and Clinical Characteristics Clin Th 2007. Broumand V.65:415-23. Cheng A. Stein B.