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Patients on Oral Bisphosphonates by Mind Map: Patients on Oral Bisphosphonates
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Patients on Oral Bisphosphonates

What are Bisphosphonates?

drugs aim to prevent bone resorption and remodeling

Who Take the drug?

Patient with bone resorption secondary to metastatic tumors

Osteolytic lesions

Osteoporosis

Osteopenia

Side Effects

Capillary network in bone not maintained

Avascular bone necrosis

Osteochemonecrosis

Bisphosphonates Related OsteoNecrosis of the Jaw (BRONJ)

BRONJ

Exposed, devitalized bone in maxillofacial regoin

Spontaneous or secondary sergery, trauma to oral soft tissue/bone

Stages of BRONJ

At Risk Category

Exposed to IV/oral Bisphosphonates but no clinical evidence of exposed / necrotic bone

Stage 1

Exposed/ necrotic bone in asymptomatic patients

No clinical evidence of infection

Stage 2

Exposed / necrotic bone associated with pain and soft tissue /bone infection

Stage 3

Exposed / necrotic bone associated with pain , infection and pathological fracture or extraoral fistula or osteolysis extending to the inferior border

Managment of Patient requring extractions

Taking the drug more than 3 yrs

Difficult or surgical extractions, AB regime 1 (1 hr pre-op), 1 g amoxicillin and 400 mg metronidazole, 5 days course of both

Routine extraction, AB regime 2 (1 hr pre-op), 1 g amoxicillin and 400 mg metronidazole, 5 days course of either

Perio extraction, AB regime 3 ( 1 hr pre-op), 1 g amoxicillin and 400 mg metronidazole, No post-op AB

Taking the drug less than 3 yrs

Difficult or surgical extractions, AB regime 2 (1 hr pre-op), 1 g amoxicillin and 400 mg metronidazole, 5 days course of either

Routine extraction, AB regime 3 (1 hr pre-op), 1 g amoxicillin and 400 mg metronidazole, no post-op AB

Perio extraction, No AB

All need CHX MW 1 week before 1 week after

When the patient is safe ?

Complete healing

Soft tissue complete coverage

No sinus, redness and swelling

No exposed bone no sequestrate

No pain

No other S&S

Updated Recommendations

Periodontal disease

Non-surgical therapy

Bone recontouring tech

GTR & grafts

Primary soft tissue closure

Oral & Maxillofacial Surgery

Risk is small

Alternative Tx

Bridges & RPD instead of implants

CHX and AB as recommended

Endodontics

Preferable

Beyond the apex

Restorative & Prosthodontics

All routine restorative

Prevent ulcerations

Orthodontics

Difficult when taking the drug

References

Bisphosphonates related osteonecrosis of the jaws (Nik desai 2010)

ISDH website

Oral Surgery ( Wiley 2010)

JADA 136 & 139