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xD3 Oral Surgery Ex1 > BRONJ (Strauss) I 174-259 > Flashcards

BRONJ (Strauss) I 174-259 Flashcards

1
Q

What are primarily used and effective in the treatment and management of cancer-related conditions including hypercalcemia of malignancy, skeletal-related events associated with bone metastases in the context of solid tumors such as breast cancer, prostate cancer and lung cancer and management of lytic lesions in the setting of multiple myeloma?

A

IV bisphosphonates

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2
Q

What are approved to treat osteoporosis and are frequently used to treat osteopenia…and less common conditions such as Paget’s disease of bone and osteogenesis imperfect of childhood?

A

Oral bisphosphonates

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3
Q

Is there currently a “cause and effect relationship between bisphosphonate exposure and necrosis of the jaw”?

A

No, but there is an association

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4
Q

If all of the following three characteristics are present, a patient may be considered to have what:

  1. Current or previous treatment with bisphosphonate
  2. Exposed bone in the maxillofacial region that has persisted for more than 8 weeks
  3. No history of radiation therapy to the jaws
A

BRONJ (bisphosphonate-related osteonecrosis of the jaw)

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5
Q

What are some commonly misdiagnosed conditions confused with BRONJ?

A
  1. Alverolar osteitis
  2. Sinusitis
  3. Gingivitis / periodontitis
  4. Caries
  5. Periapical pathology
  6. TMJ disorders
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6
Q

Which bisphosphonate patient is at a lower risk for BRONJ: oral bisphosphonate patient or monthly IV bisphosphonate patient?

A

Monthly bisphosphonate patient

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7
Q

What is considered long-term use of oral bisphosphonates?

A

Greater than 3 years

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8
Q

What are the levels of bisphosphonate potency from most potent to least potent?

A

Zolendrate (most potent) > pamidronate > oral bisphosphonates

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9
Q

What are 3 factors of the bisphosphonate therapy that seem to increase the risk of BRONJ?

A
  1. Potency of the prescribed bisphosphonates
  2. Route of administration (IV more risk than oral
  3. Duration of therapy (longer the therapy, the longer the risk)
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10
Q

What are 4 dentoalveolar surgeries that have been identified as local risk factors for BRONG?

A
  1. Extractions
  2. Dental implant placement
  3. Periapical surgery
  4. Periodontal surgery involving osseous injury
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11
Q

What are 3 anatomic variations that increase the risk for BRONG because they have thin overlying mucosa?

A
  1. Lingual tori
  2. Mylohyoid ridge
  3. Palatal tori
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12
Q

What is the AAOMS recommendation for a patient about to undergo IV bisphosphonate therapy?

A

Patient undergoes dental evaluation and receives necessary treatment prior to IV bisphosphonate therapy

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13
Q

If systemic conditions permit, the clinician may consider discontinuation of oral bisphosphonates for a period of ______ prior to and _____ following elective invasive dental surgery in order to lower the risk of BRONJ?

A

3 months prior and 3 months following

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14
Q

What are the major goals of treatment for patients at risk of developing or who have BRONJ?

A
  1. Prioritzation and support of continued oncologic treatment in patients receiving IV bisphosphonates
  2. Preservation of quality of life through patient education and reassurance, control of pain, control of secondary infection, and prevention of extension of lesion and development of new areas of necrosis
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15
Q

How long should bisphoshponate therapy be delayed, when systemic conditions permit, after an extraction?

A

Until the extraction site has mucosalized (14-21 days) or until there is adequate osseous healing

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16
Q

What is a consideration for a patient at risk of BRONJ who wears a partial or complete denture?

A

Examine for areas of mucosal trauma, especially in the lingual flange area

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17
Q

If a patient is at risk of BRONJ and requires a dental procedure, what should be the goal of the procedure, if at all possible?

A

Avoid procedures that involve direct osseous injury (e.g. do not extract a non-restorable tooth, instead remove the crown and endo treat the remaining roots

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18
Q

What are the 2 potent IV bisphosphonates and what is considered a frequent dosing schedule for those IV bisphosphonates?

A
  1. Zolendronic acid
  2. Pamidronate
    4-12 times a year
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19
Q

Are dental implants indicated for a patient taking Zonedronic acid or Pamidronate on a frequent schedule?

A

No

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20
Q

Though patients taking oral bisphosphonates are at a decreased risk of BRONJ with elective dentoalveolar surgery, what is recommended prior to the surgery?

A

Inform the patient of the small risk of compromised bone healing.
Use bone turnover markers in conjunction with a drug holiday.
The above stuff requires further study.

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21
Q

What duration of treatment with oral bisphosphonates places those patient at an inreasked risk for BRONJ?

A

If treated with oral bisphosphonates greater than 3 yars

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22
Q

Does evidence shoe a difference in risk between those patients taking oral bisphosphonates monthly versus those does weekly?

A

No

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23
Q

What is the modification of dental surgery if the individual who has taken an oral bisphosphonate for less than 3 years and has no clinical risk factors?

A

No alteration or delay is necessary

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24
Q

What is suggested if a patient taking an oral bisphosphonate for less than 3 years is to get a dental implant?

A

Get informed consent that the implant may fail or osteonecrosis may occur if oral bisphosphonate therapy is continued

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25
Q

What is the modification of dental surgery if the individual has taken oral bisphosphonates for less than 3 years but has also taken corticosteroids concomitantly?

A
  1. Require drug holiday by prescribing MD for 3 months prior to surgery
  2. Do not restart oral bisphosphonates until osseous healing occurs
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26
Q

What are the treatment objectives for a patient with an established diagnosis of BRONJ?

A
  1. Eliminate pain
  2. Control infection of the soft and hard tissue
  3. Minimize progression or occurrence of bone necrosis
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27
Q

Why do patients with established BRONJ have less predictable response to surgical therapy?

A

Difficult to get surgical margin of bleeding bone because entire jaw has been exposed to bisphosphonate

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28
Q

Due to poor response to surgical therapy in BRONJ patients, surgical therapy is reserved for those BRONJ patient meeting what criteria?

A

In stage 3 of the disease or if the patient has well-defined sequestrum

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29
Q

Is it alright to remove a symptomatic tooth within already exposed, necrotic bone?

A

Yes. It will not exacerbate the established necrotic process.

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30
Q

What stage is a patient with no clinical evidence of necrotic bone, but present with non-specific symptoms or clinical radiographic findings such as odontalgia with no odontogenic cause, dull aching bone in body of the mandible possibly radiating to TMJ, sinus pain and possible thickening of maxillary sinus wall, and altered neurosensory function?

A

Stage 0

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31
Q

A patient with exposed and necrotic bone who is asymptomatic and having no evidence of infection is what stage of BRONJ?

A

Stage 1

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32
Q

A patient with exposed and necrotic bone with pain, infection, and one or more of the following is what stage of BRONJ?

  1. Exposed necrotic bone extending beyond the region of alveolar bone
  2. Pathologic fracture
  3. Extra-oral fistula
  4. Oral antra/oral nasal communication
  5. Osteolysis extending to inferior border of the mandible or floor of the sinus
A

Stage 3

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33
Q

Symptomatic treatment and control of local factors such as periodontal disease and caries, along with the management of chronic pain and control of infection with antibiotics is the treatment protocol for what stage BRONJ?

A

Stage 0

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34
Q

A patient in what stage of BRONJ benefits from the use of oral antimicrobial rinses such as 0.12% chlorhexadine (no surgical treatment is indicated for a patient in this stage of BRONJ)?

A

Stage 1

35
Q

In what stage of BRONJ does a patient benefit from oral antimicrobial rinses and antibiotic therapy?

A

Stage 2

36
Q

What antibiotic group has been found to be useful in Stage 2 BRONJ antibiotic therapy?

A

Penicillin group

37
Q

What should a stage 2 BRONJ patient be cultured for and why?

A

Presence of actinomyces which will require adjustment of antibiotic therapy

38
Q

In what stage of BRONJ does the patient benefit from debridement, including resection, in combination with antibiotic therapy?

A

Stage 3

39
Q

Regardless of the stage of BRONJ patient, what should be done with mobile segments of bony sequestrum?

A

Remove without exposing uninvolved bone

40
Q

What can be done if systemic conditions permit for an IV bisphosphonate patient with established BRONJ?

A

Long-term discontinuation of IV bisphosphonates

41
Q

What is the time farm for discontinuation of oral bisphosphonates if systemic conditions permit in a patient with established BRONJ?

A

6-12 monhs

42
Q

Does discontinuation of IV bisphosphonates show any short-term benefit in avoiding BRONJ?

A

No

43
Q

What are 4 early subclinical radiographic signs of BRONJ?

A
  1. Sclerosis of lamina dura
  2. Loss of lamina dura
  3. Widened PDL, especially in molars
  4. Furcation involvement
44
Q

What are 3 general features of BRONJ?

A
  1. Exposed alveolar bone spontaneously or post-op
  2. Mobile teeth
  3. Pain not otherwise explained
45
Q

What cells lay down bone in response to stress for required strength and will eventually get caught within their osteoid and become osteocytes?

A

Osteoblasts

46
Q

What is the problem with a dead osteocyte?

A

The bone in that area is not adaptive

47
Q

What is released when an osteoclast resorbs bone and what is the importance?

A

BMP, ILG-1, and ILG-2 are released, which stimulates stem cells to differentiate into osteoblasts to lay down new bone leading to homeostasis

48
Q

What cell does the bisphosphonate destroy and via which pathway?

A

Bisphosphonate destroys the osteoclast as it resorbs the bisphosphonate from the matrix

49
Q

What is the only way bisphosphonate can be removed from bone matrix?

A

Osteoclast resorption which kills the osteoclast

50
Q

What are 3 oral bisphosphonates?

A
  1. Risironate (Actonel)
  2. Alendronate (Fosamax)
  3. Ibandronate (Boniva)
51
Q

What are 2 IV bisphosphonates?

A
  1. Pamidronate (Aredia)

2. Zolendronate (Zometa)

52
Q

What are 2 non-nitrogen bisphosphonates?

A
  1. Etidronate (Didronel)

2. Tiludronate (Skelid)

53
Q

What is the number of doses to get to the toxicc level for IV bisphosphonates (Pamidronate, Zolendronate)?

A

6-9 doses

54
Q

What treatment duration is required to get to toxic levels with oral bisphosphonates (Risindronate, Alendronate, Ibandronate)?

A

Up to 3 years

55
Q

Why are IV bisphosphonates used in cancer therapy?

A

Because cancer cannot resorb bone itself, it recruits osteoclasts via RANKL. Bisphosphonates thereby decrease osteoclast availability and decrease cancer-caused resorption.

56
Q

Which BRONJ is curable and which is manageable?

A

Oral bisphoshponate BRONJ is curable

IV bisphoshponate BRONJ is manageable

57
Q

What is the most common initiating event for BRONJ?

A

Surgical (47%)
Periodontitis active (28%)
Spontaneous (25%)

58
Q

What is the prevalence of BRONJ?

A

3-6%, perhaps up to 10%

59
Q

What bone takes up bisphosphonates the most and depends on osteoclastic bone remodeling more than any other one in the body?

A

Alveolar bone

60
Q

BRONJ first develops at what bone?

A

Alveolar bone

61
Q

What are 3 goals of treatment for IV BRONJ?

A
  1. Reduce pain
  2. Reduce odor
  3. Prevent pathologic fracture
62
Q

What should be done with mobile teeth in an IV bisphosphonate patient?

A

Splint, no extractions

63
Q

What is the treatment for an IV bisphosphonate patient with an orocutaneous fistula?

A

Antibiotics, no extractions

64
Q

Should minor surgery be done on an IV bisphosphonate patient?

A

No. Either no surgery or major surgery.

65
Q

What antibiotic is indicated for IV bisphosphonate with exposed bone?

A

Pen VK 500 mg q.i.d.

Peridex t.i.d.

66
Q

What is an antibiotic alternative if an IV bisphosphonate patient with exposed bone is allergic to penicillin?

A

Levofloxacin 500 mg q.i.d. for 2 weeks

67
Q

Is it probable to have pain-free living with exposed bone?

A

Yes. 87% of patients can achieve such.

68
Q

What are 2 indications for surgical resections in an IV bisphosphonate patient?

A
  1. Disease refractory to conservative masers

2. Pathologic fracture with pain and infection not responsive to antibiotics

69
Q

Is osteoporosis a bone turnover problem or a problem with calcium metabolism?

A

Bone turnover problem

70
Q

Do bisphosphonates grown new bone?

A

No. They only increase bone density.

71
Q

What are 3 questions to ask a patient on oral bisphosphonates?

A
  1. How long on therapy
  2. Is it for bones or osteoporosis
  3. Any cancer or chemotherapy
72
Q

What lab test should be ordered for a patient on oral bisphosphonate therapy to assess risk?

A

Serum CTX (C-terminal cross-linking telopeptide)

73
Q

If a patient is within the first 3 years of oral bisphosphonate therapy, what dental procedures can be done?

A

Any dental procedure

74
Q

What CTX results show that low-risk and elective oral surgery is alright?

A

Greater than 150 pg.mL

75
Q

What CTX result shows a moderate risk for BRONJ and no elective oral surgery?

A

101-150 pg/mL

76
Q

What CTX result shows a high risk for BRONJ and no elective oral surgery?

A

Less than 100 pg/mL

77
Q

What is the spontaneous healing rate for a patient having oral bisphosphonate BRONJ with a drug holiday of how long and a CTX of what?

A

4-6 month drug holiday

CTX greater than 105 pg/mL

78
Q

Will a patient taking bisphosphonates for steroid-induced osteoporosis require a longer or shorter drug holiday to raise the CTX and heal from oral bisphoshponate BRONJ?

A

Longer (1-1.5 years)

79
Q

How many pg/mL increase in CTX should be expected for each month of a drug holiday?

A

26 pg/mL per month

80
Q

What is the desired T-score (bone density measure above or below the mean) and CTX level to treat a patient using oral bisphosphonates?

A

T-score = -2.5

CTX greater than 150 pg/mL

81
Q

What should be done if a patient is taking oral bisphosphonates but requires urgent surgery?

A

Do the surgery after obtaining informed consent of the risks

82
Q

All bisphosphonates containing what element will cause osteonecrosis of the jaw?

A

Nitrogen

83
Q

IV bisphoshponates create what type of osteonecrosis?

A

Irreversible

84
Q

What is a valuable indicator of the oral bisphoshponate patient’s ability to heal?

A

CTX

xD3 Oral Surgery Ex1 (4 decks)

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