SDCEP Bisphosphonates guidelines

Question 1

What is the MOA of bisphosphonates ?

Answer 1

• hinder the formation, recruitment and function of osteoclasts

Question 3

What is the most common use of bisphosphonates?

Answer 3

Osteoporosis

Question 4

How are bisphosphonate drugs used in the management of malignant or non-malignant conditions ?

Answer 4

they can delay the onset of treatment (e.g. chemo) complications such as bone fractures and bone pain

Question 5

Why is the jaw at risk of otseonecrosis when taking bisphosphonates ?

Answer 5

this is because bisphosphonates accumulates at sites of high bone turnover. Here, they reduce bone turn over and blood supply leading to the death of the bone (osteonecrosis)

Question 6

Give examples of non-malignant conditions that can be treated with bisphosphonates

Answer 6

• osteoporosis
• pagets disease
• fibrous dysplasia
• osteogenesis imperfecta
• primary hyperparathyroidism
• cystic fibrosis

Question 7

Give examples of malignant conditions that can be treated with bisphosphonates

Answer 7

• myeloma
• prostate cancer
• breast cancer
• hypercalcaemia of metastasis
• bone metstatic lesions

Question 8

What is the postulated reason for the lack of a true incidence of BONJ?

Answer 8

too few cases are reported

Question 9

It is possible to develop BONJ spontaneously (in the absence of trauma or injury?). True or false

Answer 9

true

Question 10

The duration of the effect of bisphosphonates may extend beyond the duration of the treatment. Why is this?

Answer 10

This is because bisphosphonates stay in the skeletal system/base for years

Half life of 10 years

Question 11

Current evidence supports assessing the risk of the development of BONJ on …

Answer 11

the condition which the bisphosphonate was prescribed for

high risk… for malignant conditions

low risk… for non-malignant conditions

Question 12

What should prescribers and dispensers of bisphosphonates advise patients?

Answer 12

• that the medication they have been given is associated with a very small risk of BONJ
• to make an appointment with a dentist A.S.A.P. to ensure they are dentally fit
• to inform their dentist of their bisphosphonate use
  *

Question 13

What signs and symptoms should a patient at risk of developing BONJ look out for?

Answer 13

• feeling of numbness, heaviness or unusual sensation in the jaw
• pain in jaw and bad taste
• swelling of jaw
• loose teeth
• exposed bone

Question 14

What patients are at low risk of developing BONJ?

Answer 14

• patients about to start bisphoshonate therapy for any condition
• patient taking bisphosphonate to manage or prevent osteoporosis (without higher risk factors)

Question 15

What is the guidance for dentists for the management of patients with low risk of developing BONJ ?

Answer 15

• perform extractions/oral surgery/procedures that may impact bone in primary care as atraumatically as possoible; avoid raising flaps and achieve good haemostasis
• review healing at 4 weeks after carrying out any invasive treatment
• if surgery sites failr to heal within 4-6 weeks refer to OS/OMFS specialist

Question 16

What patients are considered to be at high risk of developing BONJ?

Answer 16

• previous diagnosis of BONJ
• on bisphosphonates to manage a malignant condition
• on bisphosphonates to manage systemic non-malignant conditions (pagets disease)
• under care of specialist for rare medical condition such as osteogenesis imperfecta
• concurrent use of corticosteroids and immunosuppressants
• coagulopathy, chemotherapu or radiotherapy

Question 17

What is the guidance for dentists regarding the management of patients with high risk of developing BONJ?

Answer 17

Seek advice from an OS/OMFS specialist (preferrably by letter) about whether treatment can be carried out in primary care for extraction, oral surgery or procedure which may impact bone or whether to refer

Question 18

What is the primary indication for alendronic acid?

Answer 18

osteoporosis

Question 19

What is the primary indication of risedronate sodium?

Answer 19

• osteoporosis
• pagets disease

Question 20

What is the primary indication for zoledronic acid?

Answer 20

• Pagets disease
• skeletal events associated with bone metastases
• hypercalemia

Question 21

What is the primary indication of etidronate disodium?

Answer 21

• osteoporosis
• pagets disease

Question 22

What is the primary indication for tiludronic acid?

Answer 22

pagets disease

Question 23

What is the primary indication for ibandronic acid?

Answer 23

• osteoporosis
• bone metastasis
• hypercalcaemia

Question 24

What is the primary indication for pamidronate disodium ?

Answer 24

• pagets disease
• bone pain
• skeletal events associated with bone metastases
• hypercalcaemia

Question 25

What is the primary indication for sodium clodronate?

Answer 25

• bone pain
• skeletal events associated with bone metastases
• hypercalcaemia

Question 26

What are the most commonly prescribed bisphosnonates?

Answer 26

• alendronic acid
• risedronate sodium
• zoledronic acid

Question 27

There is no evidence supporting the use of antibiotic or topical antiseptic prophylaxis in reducing the risk of BONJ. True or false

Answer 27

True

Question 28

You should not bother allocating a patient that has completed bisphosphonate therapy into a risk group. True or false

Answer 28

False

They should still be allocated into a risk group

Question 29

Before the commencement of bisphoshonate therapy, what dental care should be received by a patient?

Answer 29

• care that will reduce mucosal trauma/help avoid subsequent extraction or oral surgery e.g.
• remedial dental work
• reduction of periodontal/dental infection
• adjuse or replace ill fitting dentures to minimise mucosal trauma

Question 30

What preventive advice should be given to patients prescribed bisphosphonates?

Answer 30

• maintain good OH
• healthy diet; reduce sugary snacks and drinks
• stop smoking
• limit alcohol intake
• regular dental checks
• report following symptoms: loose teeth, pain, swelling A.S.A.P.