3BDS: Oral surgery- bisphosphonates. oral surgery 1

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what is the purpose of bone turn over?
to allow replacement of old brittle bone and acts a reservoir for calcium and phosphate ions
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what is the bone turnover process regulated by?
parathyroid hormone, calcitriol, calcitonin, sex hormones , growth hormone, thyroid hormone and cortisol
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what does the bone turnover involve, what two types of cells
osteoblasts and osteoclasts
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what are the phases in remodelling/ bone turn over
- activation
- osteoclast recruitment and resorption
- reversal
- osteoblast recruitment and bone formation
- termination (quiescence)
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what is osteoporosis?
often associated with post men and female patients where they lose bone volume making their bones far more brittle and more likely to fracture. so these people are on drugs which can affect dental treatment
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what is glucocorticoid- induced osteoporosis
glucocorticoid steroids, long term use of such steroids induced osteoporosis. example- patient with COPD. this would lead to reduced volume and brittle bone- implications for dentists
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what are the 2 genetic abnormalities of bone. describe what the are
osteogenesis imperfecta: this affects the whole skeleton. defect of collagen formation
osteopetrosis: defect of osteoclastic bone resorption. also called marble bone disease because the bone has increased density
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what are the 3 metabolic diseases which affect bone remodelling
fibrosis dysplasia
pagets disease
hyperparathyroidism
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what disease is secondary inflammatory change?
rheumatoid arthritis and and you get bone loss within joints
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what happens following extractions?
there is physiological osteoclastic bone resorption. alveolar bone is physiologically resorbed. the bone is mobilised and used elsewhere as part of this dynamic remodelling process
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where is the greatest amount of bone loss following extraction of teeth
is in the horizontal dimensions and occurs mainly on the facial and labial aspect of the ridge
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what does the resorption process result in?- talk about the new aspect of the ridge.
what is the effect of this resorptive pattern?
narrower, shorter ridge
the effect of this resorptive pattern is the relocation of the ridge to a more palatal/ lingual position
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where is the loss of vertical ridge height most pronounced
on the buccal and facial aspect
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what is the clinical relevance of the remodelling process? why should we consider it, as dentists? how long is the remodelling process
6 months
provision and design of bridges
the need for immediate dentures
the timing of dental implant placement
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what are some of the drugs that affect bone remodelling
bisphosphonates, denosumab+ anti-angiogenic drugs, steroids, NSAIDs
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what do bisphosphoantes mainly do?
inhibit osteoclastic function
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simply, how do bisphosphonates inhibit osteoclastic function
bind to exposed bone mineral around resorbing osteoclasts= high levels of bisphosphonates in the resorption lacunae
+ are internalised by the osteoclast-causing disruption of mediated bone resorption
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bisphosphonates are also... and what does this mean
anti-angiogenic= can have an effect on the vasculature of the area which will inhibit bone remodelling as well
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what are the two classes of bisphosphonates give example for each
non-nitrogen containing= clodronate
nitrogen containing= alendronate
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what conditions are treated with bisphosphonates
prostate cancer, breast cancer, Osteoporosis, mutiple myeloma
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what does SDCEP say about lower risk patient. what puts a patient in the lower risk category
-not yet started taking bisphosphonates
- taking bisphosphonates for the prevention or management of osteoporosis
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what puts a patient in the higher risk category according to SDCEP guidelines
-previous diagnosis of MRONJ
- taking bisphosphonates as part of the management of a malignant condition
- other non malignant condition of the bone like Paget's disease
- under the care of a specialist for a rare condition like osteogenesis imperfecta
-
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what is MRONJ
Medication related osteo necrosis of the jaw - abnormality that occurs when you get bone death as a consequence of the impact of the drug on the bone remodelling process
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how does radiotherapy impact on the bone
damages the vasculature to the bone if radiotherapy of the head and neck and itll compromise the bone’s ability to heal and the more likely to go to develop necrosis anyway
radio necrosis of the mandible -death of the jaw bone secondary to radiotherapy wh
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according to SDCEP, how should you manage a low risk patient
- if unavoidable then atraumatic extraction, avoid raising flaps, achieve good haemostasis
- review at 4 weeks
- if not healing at 4-6 weeks then refer to oral/ maxillofacial surgeon
-dont use antibiotics or topical antiseptics
(avoid LA- has high dose
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according to SDCEP , how would you manage a high risk patient?
contact oral/maxillofacial surgeon for advice whether case should be treated in primary care or whether referral appropriate
- included full details of medical and dental hoister by letter
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what is the criteria for MRONJ
3 characteristics
- current or previous treatment with bisphosphonates, anti-angiogenic drugs or RANKL inhibitors
- exposed bone in the maxillofacial region or bone that can be probed that has persisted for more than 8 weeks
- no history of radiation th
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what are the signs and symptoms of MRONJ
- pain/ painless
- areas of necrotic bone exposed
- internal or external discharging fistulas
- loose teeth
- bony sequestrate
- mobile teeth
-paraesthesia
- mandibular preference 60-70%
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how would you treat an established MRONJ lesion
no definitive guidelines.
conservative management best: irrigation, antibiotics (swab)
remove small, loose sequestrae
stop bisphosphonates if safe to do so (some benefit but they have a long half life
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what is Denosumab
human monoclonal antibody that inhibits osteoclast function
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how does denosumab work
acts by inhibiting the receptor activator of nuclear factor kappa B ligand (RANKL) a protein that as the primary signal for bone removal. mimic the function of endogenous osteoprotegerin
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when would be the best time to do treatment involving extraction if they take denosumab?
just before they are due to have their next 6 months subquantanous injection. so when yiou are timing for a denosumab treatment, you are timing before the next subquantanous injection so that the durb is at its lowest point of impacting bone turn over.
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give some examples of newer drugs which may cause MRONJ
Everolimus, raloxifene, teriparatide
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what do patient take steroids for?
high dose steroids for conditions such as COPD or autoimmune disease and as a consequence it could induce osteoporosis and get put on bisohosphonates and then develop MRONJ .
they are strong anti-inflamatory drugs for a number of conditions- from asthma
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why do steroids cause MRONJ
The reason for this is thought to be due to decreased immune cells and delayed wound healing related to steroid use, which in turn exacerbates oral inflammation and increases the risk of MRONJ.
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Examples of steroid meds
prednisolone, hydrocortisone
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what meds can people with rheumatoid arthritis be on
- immunosuppressants
- monoclonal antibody for anti inflammatory use
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why should long term NSAIDs be avoided following bone augmentation surgery for dental implants
long-term NSAIDS can impact on bone healing
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what other drugs have an impact on bone healing and bone turnover
-drugs that affect absorption of calcium from the stomach (anti-seizures drugs like carbamazepine , phenytoin and long term proton pomp inhibitors)
- drugs that increase renal excretion of calcium (diuretics)
- drugs that reduce androgen and oestrogen lev
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what is the bone turnover process regulated by?

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parathyroid hormone, calcitriol, calcitonin, sex hormones , growth hormone, thyroid hormone and cortisol

Card 3

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what does the bone turnover involve, what two types of cells

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Preview of the front of card 3

Card 4

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what are the phases in remodelling/ bone turn over

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Card 5

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what is osteoporosis?

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