7.11.24

Quick Review #175 - #pathology #oralpathology #doctorgallagher #oralsurgery #oralsurgeon #dentist #dentistry #dental #bisphosphonates

Preoperative Considerations

1. Patient Assessment:

• Comprehensive medical and dental history review.

• Evaluate the duration and type of bisphosphonate therapy (oral vs. intravenous).

2. Risk Stratification:

• High-risk patients: Those on intravenous bisphosphonates or long-term oral bisphosphonates (more than 3 years).

• Low-risk patients: Those on short-term oral bisphosphonates (less than 3 years) without other risk factors.

Drug Holiday Considerations

1. Oral Bisphosphonates:

• A drug holiday of 2-3 months before dental extractions can be considered, followed by a 3-month period post-extraction to allow for healing before resuming the medication.

2. Intravenous Bisphosphonates:

• Drug holidays are generally not recommended due to the nature of the conditions treated with IV bisphosphonates (e.g., cancer metastases).

• These patients should be managed with close coordination with their oncologist, and extractions should be approached with extreme caution.

Surgical Technique

1. Atraumatic Extractions: Use minimally invasive techniques to reduce trauma to bone and soft tissues.

2. Primary Closure: Aim for primary wound closure to reduce the risk of infection and promote healing.

Postoperative Care

1. Antibiotic Prophylaxis:

• Use antibiotics pre- and post-operatively to prevent infection.

• Common antibiotics include amoxicillin or clindamycin if the patient is allergic to penicillin.

2. Antimicrobial Rinses:

• Use chlorhexidine mouth rinses pre- and post-operatively to reduce bacterial load.

Monitoring and Follow-up

1. Regular Follow-up: Close monitoring of the extraction site for signs of delayed healing or osteonecrosis.

2. Management of Complications:

• Early intervention if signs of BRONJ develop.

• Conservative management includes antimicrobial rinses, systemic antibiotics, and possible surgical debridement in severe cases.

References:

1. Zhang, K. (n.d.). MRONJ lesions induced by long-term bisphosphonate use [Figure]. ResearchGate.

2. Allen, M. R., & Hellstein, J. W. (2021). Management of patients on bisphosphonates: The risk of osteonecrosis of the jaw. Journal of the American Dental Association, 152(3), 255-261.

3. Fedele, S., Porter, S., D’Aiuto, F., & Manfredi, M. (2019). Osteonecrosis of the jaw in patients taking intravenous bisphosphonates for cancer therapy: Are the mean time and risk of developing osteonecrosis of the jaw predictable? Journal of Clinical Oncology, 37(22), 1910-1916.

4. Ruggiero, S. L., Dodson, T. B., Fantasia, J., Goodday, R., Aghaloo, T., Mehrotra, B., & O’Ryan, F. (2022). American Association of Oral and Maxillofacial Surgeons position paper on medication-related osteonecrosis of the jaw—2022 update. Journal of Oral and Maxillofacial Surgery, 80(7), 1154-1166.

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