bone remodeling allows what?
for our bones to repair from daily micro-trauma
what are some common reasons of compromised wound healing?
- medications
- radiotherapy (XRT)
- infection
- systemic disease
disease associated with bone healing problems
- drug (medication) related osteonecrosis (MRONJ) of the jaws
- osteo-radio-necrosis (ORN)
- osteomyelitis
drugs associated with MRONJ
- bisphosphonates
- anti-resorptive agents
- anti-angiogenic medications
example of anti-resorptive agents
- denosumab (Prolia, Xgeva)
example of anti-angiogenic medications
- tyrosine kinase inhibitors
- monoclonal antibodies targeting VEGF
- Sunitinib
what are bisphosphonates (BP)?
synthetic analogs of inorganic pyrophosphate
how does bisphosphonates (BP) work?
- high affinity for Ca2+
- inhibition of osteoclasts
- may inhibit capillary neo-angiogenesis
indications for ORAL bisphosphonates (BP)
- osteoporosis
- osteopenia
- Paget’s disease
- osteogenesis imperfecta
indicatiosn for IV bisphosphonates (BP)
- bone metastases associated with solid tumors
- hypercalcemia of malignancy
- multiple myeloma
diagnosis of MRONJ
- current or previous tx with bisphosphonates (BP)
- exposed bone in the maxillofacial region that has persisted for more than EIGHT weeks
- no history of radiation therapy to the jaws
commonly prescribed ORAL bisphosphonates (BP)
- Fosamax (alendronate)
2. Actonel (risedronate)
commonly prescribed IV bisphosphonates (BP)
- Aredia (pamidronate)
- Zometa (zolendronate)
- Reclast (zolendronate)
commonly prescribed ORAL AND IV bisphosphonates (BP)
Boniva (inandronate)
how does Denosumab (Prolia, Xgeva) work?
stops the osteoclasts
how does anti-angiogenic agents work?
stop the blood supply in certain areas
what can happen when anti-angiogenic agents stop the formation of new vessels?
affects healing of soft tissues and patient can et necrosis
why necrosis in the jaws?
- increased bone turnover in the jaws
2. thin overlying oral mucosa due to jaw anatomy
remodeling rate of jaw is how many times more than long bones?
10x
according to AAOMS position paper, how do you manage a patient about to begin IV therapy?
- delay therapy, if systemic conditions permit
- optimize oral health prior to initiating therapy
- allow adequate osseous healing and wait until the surgery sites become mucosalized
how long does it take for surgery sites to become mucosalized?
14-21 days
according to AAOMS position paper, how do you manage an asymptomatic patient receiving IV therapy?
- maintain oral hygiene
2. avoid osseous injury
T/F: according to AAOMS position paper, managing an asymptomatic patient taking oral bisphosphonates (BP) is still lacking sound recommendations
true
according to AAOMS position paper, how do you manage an asymptomatic patient taking oral bisphosphonates (BP) for <4 years?
proceed with planned tx
according to AAOMS position paper, how do you manage an asymptomatic patient taking oral bisphosphonates (BP) for <4 years and risk factor (steroid/anti-angiogenic meds)?
stop BP therapy 2 months prior to tx
according to AAOMS position paper, how do you manage an asymptomatic patient taking oral bisphosphonates (BP) >4 years?
drug holiday for 2 months
according to AAOMS position paper, when you should resume tx on asymptomatic patient taking oral bisphosphonates (BP)?
when osseous healing has finished in ~14-21 days
T/F: while there have been limited studies on drug holidays for tx of MRONJ, currently there have yet to be studies to confirm drug holidays are effective in prevention of MRONJ without increasing the skeletally related risks of low bone mass
true
drug holidays should be a medical decision based primarily on what?
medical decision based primarily upon the risk for skeletally related events (e.g. fractures)
clinical stage 1 of MRONJ
- exposed/necrotic bone
- asymptomatic
- no infection
tx of clinical stage 1 of MRONJ
oral antimicrobial rinses (e.g. Peridex)
clinical stage 2 of MRONJ
- exposed/necrotic bone
- pain
- infection
tx of clinical stage 2 of MRONJ
- oral antimicrobial rinses
2. antibiotic therapy
clinical stage 3 of MRONJ
- exposed/necrotic bone
- pain
- infection
- one or more of the following…
a. fracture
b. extra-oral fistula
c. oro-nasal communication d. osteolysis
tx of clinical stage 3 of MRONJ
- surgical debridement of resection
2. antibiotic therapy
how to manage patient who is about to start IV bisphosphonates (BP)?
get healthy before
how to manage patient who is receiving IV bisphosphonates (BP)?
avoid osseous surgery if possible
how to manage patient who is taking oral bisphosphonates (BP)?
informed consent/medical consult if considering drug holiday
how to manage patient who has established MRONJ?
consult and refer
T/F: you should take thorough medical hx before performing extraction
true
osteo-radio-necrosis (ORN)
a condition in which irradiated bone becomes exposed through a wound in the overlying skin and/pr mucosa and persist without healing for 3 to 6 months
3 H’s theory of pathogenesis
- hypoxia
- hypovascularity
- hypocellularity
stage 1 osteo-radio-necrosis (ORN)
superficial involvement, only cortical bone exposed
tx for stage 1 osteo-radio-necrosis (ORN)
chlorhexidine mouthwash
stage 2 osteo-radio-necrosis (ORN)
localized involvement with involvement of cortical and medullary bone
tx for stage 2 osteo-radio-necrosis (ORN)
- local debridement with or without HBO (hyperbaric oxygen)
2. chlorhexidine mouthwash
stage 3 osteo-radio-necrosis (ORN)
diffuse involvement including inferior border
tx for stage 3 osteo-radio-necrosis (ORN)
surgical resection and reconstruction
stage 3 osteo-radio-necrosis (ORN) is usually associated with what?
pathologic fracture and possible osteo-cutaneous fistula
what does hyperbaric oxygen (HBO) therapy stimulate?
- collagen synthesis
- angiogenesis
- epithelialization
osteomyelitis
inflammatory process of the bone marrow that involves cancellous and cortical bone with a tendency of progression
pathogenesis of osteomyelitis
- bacterial infection
- inflammation/edema of bone marrow
- compression of blood vessels in the bone marrow
- ischemia
- necrosis (osteomyelitis)
T/F: osteomyelitis occurs more often in the maxilla than the mandible
false, mandible > maxilla
why does osteomyelitis occur more often in the mandible vs the maxilla?
maxilla has a lot of blood supply compared to mandible
predisposing factors of osteomyelitis
- immune-compromised patients
- diabetes mellitus
- alcoholism (malnutrition)
- myeloproliferative disease: leukemia, sickle cell
- chemotherapy
- fractures and odontogenic infections in immune-compromised patients
- osteopetrosis (Albers-Schonberg disease)
radiographic findings of osteomyelitis
- “moth-eaten” appearance
2. radio-opacities which are due to sequestras
sequestra
islands of necrotic non-resorbed bone
signs and symptoms of osteomyelitis
- pain
- swelling
- fever, malaise, trismus
- parasthesia/anesthesia
- tenderness of involved area
- exposed bone
- osteo-cutaneous fistula with purulent discharge
medical management of patients with osteomyelitis
- abx (long term)
2. hospitalization may be required for IV abx
what is the abx of choice to tx patients with osteomyelitis
clindamycin
how long are patients with mild cases of osteomyelitis
hospitalized for in order to get IV abx?
4 weeks
how long are patients with severe cases of osteomyelitis
hospitalized for in order to get IV abx?
up to 6 weeks
surgical management of patients with osteomyelitis
debridement/marginal resection/segmental resection (depend on involvement to remove dead bone)
how can you tell if bone is healthy?
if it’s bleeding
how long does dry socket last for?
not longer than 1 week