Guidelines for management of pxs relating to bisphosphonates

Question 1

ONJ

Answer 1

Osteonecrosis of the jaws
Potential complication of bisphosphonate therapy
Area of exposed/ necrotic bone in
maxfax region that did not heal within 8 weeks after identification by
HCP, in px who was receiving/ had been exposed to
bisphosphonate & had not had radiation therapy to craniofacial
region

Question 2

Incidence of bisphosphonate-associated ONJ

Answer 2

1-10% (pxs with malignancy)
ONJ with bisphosphonate therapy for osteoporosis or Paget’s disease 0.001-0.01%
Incidence increases with > duration of therapy

Question 3

High dose IV bisphosphonates for malignancy: prior to commencing therapy

Answer 3

Educate px with regards to need for good OH,
regular care and likely complications of future extractions
When clinically appropriate to delay the start of bisphosphonate
therapy, it is advisable to arrange extraction of all teeth of poor long
term prognosis and make dentally fit

Question 4

High dose IV bisphosphonates for malignancy: during/ after treatment

Answer 4

6-12 monthly dental check-ups
Continue perio maintenance & any restorative work required as usual
Elective dentoalveolar procedures not recommended (e.g. implant placement, tori reduction, extraction of asymptomatic teeth)
Avoid extractions/ surgery involving bone if possible Symptomatic teeth
that would otherwise require extraction should receive non-surgical
endodontic/ perio therapy and left in place.
Indications for extraction are mobile teeth at risk of aspiration, and
symptomatic teeth within an area of exposed or necrotic bone

Question 5

High dose IV bisphosphonates for malignancy: guidance for extraction

Answer 5

Inform px’s specialist of proposed extractions & consider
discussing “drug holiday” with interruption of bisphosphonate until
complete healing of extraction/ surgical site is achieved
Warn px risk of ONJ.
Treat any concomitant oral infection
Pre-op scale and polish
Use of prophylactic antibiotics depends on clinician’s level of
concern relative to individual px’s risk of infection
Pre and post-op Corsodyl mouth wash
Remove any bony protuberances, loose bone fragments or granulation
tissue from socket
Removed tissue should be submitted to oral & maxfax pathology
for histopathological examination
Suture sockets to ensure > mucosal coverage.
Review until surgical site has healed satisfactorily

Question 6

Bisphosphonates for Osteoporosis / Paget’s disease: before commencing treatment

Answer 6

Educate px with regards to the need for good OH,
regular care and possibility of complications of future extractions
Dental assessment not necessary before commencing treatment
Pxs should register with GDP
Elective surgery not contra-indicated, but conservative measures
preferable if bisphosphonate therapy exceeds 3 years

Question 7

Bisphosphonates for Osteoporosis / Paget’s disease: guidance for extractions

Answer 7

Warn px risk of ONJ
Review until surgical site has healed satisfactorily
Pxs regarded as high risk for ONJ/ have previously had ONJ, refer to above guidance

Question 8

Management of osteonecrosis

Answer 8

If healing not complete at 8 weeks, diagnosis of bisphosponate related necrosis of jaws may be made
Manage pain effectively
Ensure documentation of name of bisphosphonate, dose, duration &
route
Minimal surface debridement to reduce sharp or rough bone
surfaces
Obtain culture and sensitivity from bone fragments removed
Submit tissue for histopathological examination
Prescribe appropriate antimicrobials if there is evidence of infection
Consider use of removable appliance to cover and protect exposed bone
In severe cases, stopping/ interrupting bisphosphonate therapy may
be required, following liaison with px’s specialist