Oral surgery L1 Bone biology Bisphosphonates and other drugs

Question 1

Q1: bone turnover/ remodelling is regulated by which hormones?

Answer 1

Parathyroid hormone,

calcitriol,

calcitonin,

sex hormones,

growth hormone,

thyroid hormone,

and cortisol.

Question 2

Q2: what are the 5 phases in remodelling bone?

Answer 2

1. Activation,
2. Osteoclast recruitment and resorption,
3. Reversal,
4. Osteoblast recruitment and bone formation,
5. Termination

Question 3

Q3: genetic abnormality of the bone such as osteogenesis imperfecta is a defect of the formation of what?

Answer 3

Collagen

Question 4

Q4: genetic abnormality of the bone such as osteopetrosis, is a result of either bone absorption or resorption?

Answer 4

osteoclastic bone resorption

Question 5

Q5: what bone condition is experienced in women post menopause:

Answer 5

osteoporosis

Question 6

Q6: what is osteogenesis imperfecta?

Answer 6

Also known as brittle bone disease, it results in bones that break easily. The severity may be mild to severe.

Question 7

Q7: what is osteopetrosis?

Answer 7

Known as marble disease, where the bones become harden, becoming denser.

Question 8

Q8: what are the long term implications of using glucocorticoid steroids?

Answer 8

Induced osteoporosis

Question 9

Q9: what happens to the alveolar bone, following extraction?

Answer 9

There is physiological osteoclastic bone resorption.

Question 10

Q10: the remodelling process takes 6 months post extraction, what relevance does this have to provision and design of bridges?

Answer 10

If a design of a bridge has been made, upon the next visit the bridge may not fit accordingly, due to the remodelling, may result in a new bridge being made.

Question 11

Q11: the remodelling process takes 6 months post extraction, what relevance does this have to the need for immediate dentures?

Answer 11

Immediate dentures will be given if needed post extraction, however this denture is expected to get lose over the 6 months. Once the resorption has become static, permanent dentures can be made.

Question 12

Q12: the remodelling process takes 6 months post extraction, what relevance does this have to dental implants?

Answer 12

With dental implants it is important that they placed immediately or a few weeks after extraction. The success of dental implants is depended on the availability of alveolar bone. The longer you wait to get an implant in, the greater the resorption occurs.

Question 13

Q13: as resorption occurs in both mandible and maxilla. The greater the resorption will present with more cortical or trabecular bone?

Answer 13

Left with cortical bone.

Question 14

Q14: what are the four classification of drugs that affect bone remodelling?

Answer 14

1. Bisphosphonates,
2. Denosumab and anti-angiogenic drugs,
3. Steroids,
4. NSAID’s

Question 15

Q15: what are Bisphosphonates?

Answer 15

Bisphosphonates are a group drugs that work by slowing bone loss, they do this by inhibiting osteoclastic function.

Question 16

Q16: what are the two classes of bisphosphonates?

Answer 16

Non-nitrogen containing and nitrogen containing

Question 17

Q17: what is the most common reason for patients being on bisphosphonates?

Answer 17

Osteoporosis.

Question 18

Q18: the oral application of bisphosphonates is taken orally how many times?

Answer 18

Is taken orally once per week. It is important when taking it, you must be sat upright.

Question 19

Q19: other than the management of osteoporosis, what other reasons would you take bisphosphonates?

Answer 19

For the management of any malignant cancers, that are directly disrupting the bone, such as breast cancer and multiple myeloma.

Question 20

Q20: a patient classified as low risk is currently doing what in reference to bisphosphonates?

Answer 20

To be classified as low risk a patient has not yet started taking bisphosphonates, or is taking bisphosphonates for the prevention or management of osteoporosis.

Question 21

Q21: a patient taking bisphosphonates intravenously is taking it to manage what condition?

Answer 21

Most likely a malignant condition.

Question 22

Q22: what does MRONJ stand for?

Answer 22

Medically related osteonecrosis of the jaw

Question 23

Q23: how would you manage a patient who is low risk at developing MRONJ, who requires an extraction?

Answer 23

If unavoidable then atraumatic extraction, avoid raising flaps and achieve good haemostasis. Review patient in 4 weeks. If no healing is present in 4-6 weeks, refer to oral/maxillofacial surgeon.

Question 24

Q24: for a patient to fall in the criteria of having MRONJ they must have all three characteristics, what are they?

Answer 24

1. Current or previous treatment with bisphosphonates, antiangiogenic drugs or RANKL inhibitors,
2. Exposed bone in the maxillofacial region or bone that can be probed that has persisted for more than 8 weeks,
3. No history of radiation therapy to the jaws.

Question 25

Q25: if a bone is visible in a white creamy colour and there is no bleeding from the bone, what does that indicate?

Answer 25

The bone is dead.

Question 26

Q26: there is no definitive guidelines in to managing an established lesion of MRONJ, however if the exposed bone is not attached and moving what would you be expected to do?

Answer 26

If possible remove the small loose bone.

Question 27

Q27: if a bone can move what is it called?

Answer 27

Sequestrum

Question 28

Q28: Denosumab is injected subcutaneously and its osteoclast function is inhibited within how long? And osteoclast function returns after how long?

Answer 28

Osteoclast function inhibited within 6 hours and returns 6 months later.