Biphosphonates

You and your staff may or may not be aware of the bisphosphonates alert that has been in the medical literature lately.  If not, it is something that you should review and become more familiar with.

You should add to your medical history questions concerning bisphosphonates treatment to identify those patients that might have a history of taking this medication.  Bisphosphonates are used on patients being treated for osteoporosis, in particular, postmenopausal women and also those whom have a history of chemotherapy treatment.

Hematologists use this drug intravenously and sometimes in an oral form to decrease the lytic (osteoclastic) activity of cancer cells, this does not inhibit osteoblastic activity, (lying down of bone) creating bone that is denser with decreased blood supply.  Therefore healing is slow or non-existent (non-healing sockets) causing an increased chance of secondary infection in bone (osteonecrosis).  Any type of oral surgery including extractions and extensive periodontal procedures could be an initiating event.  Recommendations for treatment before and during bisphosphonate  therapy and those patients who already have exposed bone.   Also to follow is a list of types of bisphosphonates.

Please make your staff aware of the patient’s medical history and update this every time a patient recalls.  If you suspect Bisphosphonate induced osteonecrosis, evaluate and treat accordingly.

IV Bisphosphonates Recommendations Before Therapy

1. Remove unsalvageable teeth    
2. Prophylaxis ~Plaque Contro
3. Treat Caries
4. Treat periodontitis
5. Defer bisphosphonates for 2 months

IV Bisphosphonates Recommendations During Therapy

1. Avoid invasive procedures (extractions, periosurgery, implants)
2. Treat caries; if needed RCT and amputate crown
3. Supragingival scaling
4. Splint mobile teeth
5. If extractions are unavoidable, provide informed consent of increased risk

IV Bisphosphonates Recommendations with Exposed Bone

1. Avoid debridements
2. Smooth sharp edges
3. Treat with PCn VK 500mg qid and Peridex TID
4. Use Levaquin in PCN allergic patient
5. Add Flagyl 500 mg tid x 10 day in refractory cases.
6. If surgery unavoidable, alveolectomy or continuity resection

Bisphosphonates

1. Residronate  (Actonel)*
2. Etidronate    (Didronel)
3. Tiludronate  (Skelid)
4. Alendronate (Fosamax)*
5. Pamidronate (Aredia)*
6. Zoledronate  (Zometa)*

* Nitrogen containing

Consent for Oral Surgical treatment in Patients who have received Bisphosphonate Drugs

Patients Name: ___________________________________ Date:                        

Having been treated previously with Bisphosphonate drugs you should know that there is a significant risk of future complications associated with dental treatment.  Bisphosphonate drugs appear to adversely affect the ability of bone to break down or remodel itself thereby reducing or eliminating its ordinary excellent healing capacity.  This risk is increased after surgery, especially from extraction; implant placement or other "invasive " procedures that might cause even mild trauma to bone.  Osteonecrosis may result.  This is a smoldering, long-term, destructive process in the jawbone that is often very difficult or impossible to eliminate.

Your medical/dental history is very important.  We must know the medications and drugs that you have received or taken or are currently receiving or taking. An accurate medical history, including names of physicians is important.

_____1.     Antibiotic therapy may be used to help control possible post-operative infection.  For some patients, such therapy may cause allergic responses or have undesirable side effects such as gastric discomfort, diarrhea, colitis, etc.

_____2.     Despite all precautions, there may be delayed healing, osteonecrosis, loss of bony and soft tissues, pathologic fracture of the jaw, oral-cutaneous fistula, or other significant complications.

_____3.     If osteonecrosis should occur, treatment may be prolonged and difficult, involving ongoing intensive therapy including hospitalization, long-term antibiotics and debridement to remove non-vital bone.  Reconstructive surgery may be required, including bone grafting, metal plates and screws, and/or flaps and grafts.

_____4.     Even if there are no immediate complications from the proposed dental treatment, the area is always subject to spontaneous breakdown and infection. Even minimal trauma from a toothbrush, chewing hard food, or denture sores may trigger a complication.

_____5.     Long-term post-operative monitoring may be required and cooperation in keeping scheduled appointments is important. Regular and frequent dental check-ups with your dentist are important to monitor and attempt to prevent breakdown in your oral health.

_____6.     I have read the above paragraphs and understand the possible risks of undergoing my planned treatment. I understand and agree to the following treatment plan.

_____7.    I understand the importance of my health history and affirm that I have given any and all information that may impact my care.  I understand that failure to give true health information may adversely affect care and lead to unwanted complications.

_____8.  I realize that, despite all precautions that may be taken to avoid complications; there can be no guarantee as to the result of the proposed treatment.

CONSENT

I certify that I speak, read and write English and have read and fully understand this consent for surgery, have had my questions answered and that all blanks were filled in prior to my initials or signature.

                                                                                                                        Patient's or Legal Guardian's Signature                                   Date                      

                                                                                                                        Doctor's Signature                                                                Date

                                                                                                                        Witness Signature                                                                Date