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Prevention, Diagnosis, and Management of Oral Surgery Complications

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Title: Prevention, Diagnosis, and Management of Oral Surgery Complications


1
Prevention, Diagnosis, and Management of Oral
Surgery Complications
  • June 28, 2015
  • David Salehani, D.D.S., M.D.
  • Private Practice, West Hollywood, CA
  • UCLA Reagan Medical Center
  • Faculty at UCLA School of Dental Medicine

2
Complications of Dentoalveolar Surgery
  • Proper treatment planning and sound surgical
    principles should lower the incidence of
    complications.
  • Incidence of complications associated with the
    removal of third molars, the most common
    dentoalveolar surgical procedure, is 7 to 10.8
    percent. 2, 3

3
Complications of Dentoalveolar Surgery
  • Think ahead and have all proper instruments and
    medications available.
  • Proper surgical suction
  • Hemostatic agents (gelfoam, collaplug, etc.)
  • Sutures
  • Surgical blades
  • Surgical handpiece

4
Complications of Dentoalveolar Surgery
5
Complications of Dentoalveolar Surgery
  • To avoid complications
  • Have all necessary radiographs for proper
    diagnosis.
  • Always have an unobstructed view and access in
    the presence of adequate light, proper soft
    tissue reflection, and adequate suction.

6
Complications of Dentoalveolar Surgery
  • Local anesthetics complications
  • Rare
  • A more common adverse sequela hematoma
  • PSA rapid posterior buccal swelling
  • Pterygoid venous plexus slower development
  • Treatment
  • Direct pressure to the area
  • Cold packs for 24 hrs
  • Then heat to facilitate reabsorption

7
Complications of Dentoalveolar Surgery
  • Local anesthetics complications (Contd)
  • More serious situation IA artery hematoma
  • Can compromise the airway
  • Tx is directed at maintaining an airway, followed
    by local or systemic interventions if required.

8
Complications of Dentoalveolar Surgery
  • Local anesthetics complications
  • Facial ecchymosis and discoloration

9
Complications of Dentoalveolar Surgery
  • Local anesthetics complications (Contd)
  • Inadvertent posterior injection into the parotid
    capsule
  • Facial nerve palsy
  • Reassure patient of the transient nature
  • Gauze patch over the affected eye

10
Facial Nerve Palsy
11
Facial Nerve Palsy
12
Complications of Dentoalveolar Surgery
  • Local anesthetics complications (Contd)
  • Fracture of the needle within the tissues
  • No attempt to palpate the needle
  • Radiographs to orient the location in three planes

13
Complications of Dentoalveolar Surgery
  • Local anesthetics complications (Contd)
  • It is reported that the needles do not frequently
    migrate through soft tissues to vital structures.
  • However, an attempt to retrieve the needle may be
    made to alleviate patient anxiety regarding
    subsequent injury
  • Weigh the risks and benefits of surgical
    exploration
  • Refer to a surgeon

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Complications of Dentoalveolar Surgery
  • Local anesthetics complications (Contd)
  • Nerve trauma
  • Rare
  • Most common IAN (1 in 400,000 to 1 in 750,000
    cases)
  • Epineural hematoma
  • Direct needle trauma
  • Avoid excessive firm needle contact with the bone
    to prevent a needle barb.
  • Toxicity of local anesthetic
  • Reported that if spontaneous recovery has not
    been achieved within 21 days, the odds of its
    return are approximately 33.

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Complications of Dentoalveolar Surgery
  • Neurologic complications
  • Sensory nerve damage
  • Usually associated with third molar surgery
  • Typically IAN
  • Less frequently lingual nerve
  • Rarely long buccal nerve
  • 0.6 to 5 of third molar cases
  • Spontaneous recovery in 96 of IAN cases
  • Spontaneous recovery in 87 of lingual nerve
    cases
  • Mostly in the first 6-8 weeks, remaining within 9
    months
  • Total recovery after 9 months is rare.

20
Complications of Dentoalveolar Surgery
  • Neurologic complications (Contd)
  • Patient Age
  • Higher morbidity in patients older than 25 years

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Complications of Dentoalveolar Surgery
  • Neurologic complications (Contd)
  • Pre-op radiologic exam (Panorex)
  • Cortical outline and location of the canal

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Complications of Dentoalveolar Surgery
  • Paresthesia is one of the leading causes of
    liability against OMFS and has been among the top
    four in dollars awarded.

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Complications of Dentoalveolar Surgery
  • Injuries to the lingual nerve
  • 1 of lower third molar extractions
  • Most difficult for patients to accept because of
    altered taste sensation and reduced chance of
    recovery.
  • The lingual nerve may course over onto the
    retromolar pad.
  • It can be traumatized by incisions, retractions,
    flap elevation, tooth and follicle removal, and
    suturing.

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Complications of Dentoalveolar Surgery
  • Injuries to the lingual nerve
  • Unlike with IAN damage, reducing the incidence of
    lingual nerve injury is related to surgical
    technique.
  • If indicated , mandibular third molar suturing
    should be limited to the superficial tissues of
    the lingual flap to reduce trauma to the lingual
    nerve.

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Complications of Dentoalveolar Surgery
  • Injuries to the lingual nerve (Contd)
  • The return of sensation with the first 4 weeks
  • Neuropraxia, excellent px
  • Symptoms of recovery manifesting at 1 to 3 months
    indicate a less certain px
  • Failure to exhibit recovery sypmtoms for 12 or
    more weeks indicates neurotmesis, poor px for
    spontaneous recovery

36
Complications of Dentoalveolar Surgery
  • Injuries to adjacent teeth and structures
  • Iatrogenic luxation of adjacent tooth
  • Assess the mobility of the tooth
  • Reposition the tooth
  • Take out of traumatic occlusion
  • Stabilize for 10-14 days

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Complications of Dentoalveolar Surgery
  • Injuries to adjacent teeth and structures
  • The use of exuberant force when extracting teeth
    is unnecessary.
  • Force must always be applied in a controlled
    manner, using surgical finesse.
  • The most common damage fracture of the crown or
    the existing restoration (mostly with elevators
    while luxating)

39
Complications of Dentoalveolar Surgery
  • Injuries to adjacent teeth and structures
    (Contd)
  • During luxation with the elevator
  • Consider carious teeth or large restorations of
    adjacent teeth pre-op as potential risks.
  • Discuss with the patient as part of the informed
    consent form pre-op.

40
Complications of Dentoalveolar Surgery
  • Inadvertent removal of the wrong tooth
  • Attention to detail (Time-Out)
  • Atraumatic removal of a wrong tooth (if
    immediately identified)
  • Reimplant and stabilize
  • All other extractions should be delayed 4 to 6
    weeks to allow assessment and prognosis of the
    reimplanted tooth

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Complications of Dentoalveolar Surgery
  • Injuries to the opposing dentition
  • Result of excessive traction forces and sudden
    release of the tooth
  • Can cause chipped or fractured tooth
  • Minimize tractional forces, use proper elevation
  • Inform the patient

42
Complications of Dentoalveolar Surgery
  • Pain and swelling
  • Associated with all surgical procedures
  • Normal physiologic responses to surgical
    treatment
  • However, this does not preclude the surgeon from
    taking all necessary actions to lessen their
    severity.
  • Factors that may increase these complications
  • Excessive operating time
  • Poor management of soft tissue
  • Inappropriate use of irrigation
  • Ignoring other basic surgical principles

43
Complications of Dentoalveolar Surgery
  • Swelling
  • Steroid therapy should have maximal
    anti-inflammatory effects and minimal
    glucocorticoid and mineralocorticoid activity.
  • Two steroids, dexamethasone and betamethasone are
    the most popular.
  • Pre-op IV steroids and post-op oral steroids have
    the greatest effect in decreasing swelling.
  • The use of ice, which is a routine
    recommendation, was not demonstrated to be a
    considerable factor in decreasing post-op
    swelling.

44
Complications of Dentoalveolar Surgery
  • Pain
  • An inevitable sequela of dentoalveolar surgery
  • Peak pain early post-op period 3-5 hrs after
    surgery
  • Study 97 of patients suffered their highest
    level of pain on the day of surgery

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Complications of Dentoalveolar Surgery
  • Pain (Contd)
  • Associated with increased concentration of
    prostaglandins
  • Prostaglandin antagonists such as NSAIDs would be
    the most effective means of pain management.
  • Use longer-acting local anesthetics
  • Proper surgical technique
  • Reflection of flaps
  • Management of soft tissue
  • Copious irrigation when using drills
  • Use of controlled forces

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Complications of Dentoalveolar Surgery
  • Temporomandibular joint injury
  • If mandible is placed in an open position for
    extended periods, certain degree of force will be
    transmitted to the TMJ.
  • Use bite blocks, support the mandible.
  • Most successfully managed by conservative
    measures (soft diet, moist heat, jaw rest, muscle
    relaxants, NSAIDs, and on rare occasions splint
    therapy.
  • Further work-up if symptoms persist beyond two
    weeks
  • Discuss as part of the informed consent

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Complications of Dentoalveolar Surgery
  • Displacement of teeth into anatomical spaces
  • Can occur with excessive force
  • Use
  • Adequate access and visualization
  • Controlled force
  • Removal of sufficient bone
  • Placement of finger or instruments as distal stop

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Complications of Dentoalveolar Surgery
  • Displacement into infratemporal fossa
  • Distoangular maxillary third molar
  • Excessive force, poor visualization, lack of
    distal stop
  • First locate the tooth (lateral and PA cephs)
  • Possible locations
  • 1) infratemporal fossa
  • 2) maxillary sinus
  • 3) in the mouth /aspirated/ throat pack

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Complications of Dentoalveolar Surgery
  • Displacement into infratemporal fossa
  • Attempt to recover
  • Extend incision distally for better access and
    visualization
  • Subperiosteal dissection to avoid the pterygoid
    venous plexus
  • Visualize the tooth place a curette behind the
    tooth to retrieve
  • Unable to visualize the tooth close incision,
    notify the patient, antibiotics for one week or
    longer

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Complications of Dentoalveolar Surgery
  • Displacement into infratemporal fossa
  • Attempt to recover (Contd)
  • Complete exam on follow-up check for infection
    and limitation of function
  • At this point refer to specialist.

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Complications of Dentoalveolar Surgery
  • Displacement into submandibular space
  • Less common
  • More common in third molar region
  • The most common factor excessive apical force
    while attempting removal of mandibular molar
    roots.

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Complications of Dentoalveolar Surgery
  • Displacement into submandibular space
  • In the event the root or tooth is lost from the
    visual field
  • Initial attempt palpation of the lingual aspect
    of the mandible
  • If identified, attempt to guide it back into the
    surgical field
  • Attempt to locate fails closure, antibiotics,
    refer to specialist.

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Complications of Dentoalveolar Surgery
  • Foreign Body Aspiration
  • Any dentoalveolar surgery or dental procedure is
    associated with the risk of foreign body
    aspiration.
  • The risk is increased with the use of sedation or
    GA.
  • The clinical presentation is usually, but not
    always, associated with coughing or gagging.
  • In this case the patient should be allowed to
    attempt to expel the object.
  • Premature intervention may hinder the patient and
    actually facilitate aspiration.

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Complications of Dentoalveolar Surgery
  • Foreign body aspiration
  • Use throat/pharyngeal drape
  • Have suction available
  • Instruct the patient not to swallow before you
    start

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Complications of Dentoalveolar Surgery
  • Foreign Body Aspiration (Contd)
  • If true airway obstruction occurs, a BLS protocol
    should be in place, which may include the
    Heimlich maneuver, back blows, or abdominal
    thrusts.
  • No acute respiratory distress
  • Refer patient for immediate chest and abdominal
    radiographs.
  • If the foreign body is determined to have entered
    the GI tract, it is usually of little
    consequence, as it will generally pass with no
    ill effects.

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Complications of Dentoalveolar Surgery
  • Foreign Body Aspiration (Contd)
  • If displaced in trachea or bronchial tree
  • Pt requires admission to the hospital for its
    retrieval
  • Consult a physician to perform bronchoscopy
  • Keep in a monitored setting after retrieval
  • IV antibiotics to cover oral flora and prevent
    aspiration pneumonia
  • Once patient is stabilized and follow up chest
    x-rays are negative , the pt may be discharged
    and followed on an outpatient basis.

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Complications of Dentoalveolar Surgery
  • Hemorrhage
  • Refer to PMH regarding bleeding d/os
  • If bleeding persists post-op
  • Reassure, instruct direct gauze pressure
  • Persistent bleeding ? examine the patient

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Complications of Dentoalveolar Surgery
  • Exam for persistent bleeding
  • Review PMH
  • Patient's status
  • Remove gauze gently, not to disturb the clot
  • Active bleeding vs. oozing
  • Oozing
  • Direct gauze pressure 30-45 min
  • Oozing continues local anesthesia (block
    preferably), remove clot?, place hemostatic
    agent, suture (figure-of-eight), direct pressure,
    observe
  • Consider electrocautery on wound margins
    (conservative)
  • If oozing continues, treat as active bleeding

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Complications of Dentoalveolar Surgery
  • Active bleeding
  • Is it due to anticoagulants, bleeding d/os,
    liver disease, chronic antibiotics?
  • First approach conservatively as above
  • If active bleeding persists
  • REFER to specialist or ER (call PMD, ER, or
    specialist to report)

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Complications of Dentoalveolar Surgery
  • Alveolar Osteitis (dry socket)
  • Incidence following the routine extraction of
    erupted teeth 1-3
  • Impacted mandibular third molars 1-65
  • Etx
  • Oral contraceptives
  • Smoking
  • Difficulty of extraction
  • Experience of the surgeon
  • Bacterial contamination
  • Poor OH, pericoronitis, gingivitis??
  • Exact pathophysiology remains unclear.
  • Possibly due to breakdown of the normal clot

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Alveolar Osteitis
  • Symptoms
  • Presents fourth to fifth day post-op
  • Constant moderate to severe pain
  • Foul taste and odor
  • May be differentiated from a post-op infection
  • Absence of fever
  • No localized edema
  • No lymphadenopathy
  • No erythema

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Alveolar Osteitis
  • Treatment
  • Conservative
  • Primary goal relieve pain during the healing
    phase
  • Curettage of the socket is not necessary.
  • Gentle saline irrigation
  • Dry-socket dressing
  • Change dressing everyday or every other day until
    the pain subsides

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Alveolar Osteitis
  • Numerous studies have examined measures to
    prevent alveolar osteitis
  • Preop PCN? Mixed results
  • Interestingly metronidazole given
    prophylactically decreases the incidence of dry
    socket, indicating a possible role of anaerobic
    bacteria.
  • Topical tetracycline placed in the extraction
    site by itself or with Gelfoam has been shown to
    decrease the incidence of dry socket.

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Alveolar Osteitis
  • Resolves 3-5 days, sometimes 10-14 days post-op
  • If symptoms persist longer, look for other causes
    of persistent pain
  • DDX
  • Osteomyelitis or post-op infection
  • Fracture
  • Drug dependence?
  • Adjacent teeth?

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Alveolar Osteitis
  • Persistent pain
  • Thinking osteomyelitis?
  • Dry socket dressing doesnt relieve pain
  • Panorex new radiolucency
  • Clinically purulent drainage, swelling, severe
    pain
  • Tx
  • Refer to specialist
  • Debridement to bleeding bone
  • Long-term antibiotics (oral or IV)

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Osteomyelitis
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Complications of Dentoalveolar Surgery
  • Soft tissue complications
  • Most commonly a result of failing to protect the
    soft tissue
  • Most frequent tearing of the mucosal flap
  • Unintentional penetration of the soft tissues
  • Soft tissue burns and abrasions

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Complications of Dentoalveolar Surgery
  • Injuries to adjacent osseous tissues
  • Atraumatic exodontia requires the expansion of
    alveolar bone
  • Inadvertent use of excessive force often results
    in fracture of the maxilla or mandible.
  • The most common areas for traumatic bony
    fractures are the buccal cortical plate of the
    canines, premolars, and molars the floor of the
    maxillary sinus, tuberosity, and the buccal
    cortical plate of mandibular incisors and canines.

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Complications of Dentoalveolar Surgery
  • Injuries to adjacent osseous tissues
  • Prevention
  • Thorough clinical and radiographic evaluation
  • Patients age and associated osseous elasticity
  • High risk
  • Consider a surgical extraction technique
  • Provides more controlled bone removal, sectioning
    of roots, and direct visualization of the degree
    of alveolar expansion during luxation and
    elevation.

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Complications of Dentoalveolar Surgery
  • Injuries to adjacent osseous tissues
  • Use finger support on alveolar process
  • Bone that is knowingly fractured and removed with
    the delivery of the tooth should not be replaced.
  • Smooth out the sharp bony edges with bone file
  • Reposition the soft tissue
  • Mandible fracture atrophic mandible, impacted
    third molar, significant odontogenic pathology,
    use of excessive force

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Complications of Dentoalveolar Surgery
  • Maxillary sinus complication
  • Pre-op radiograph
  • Pneumatized maxillary sinus
  • Chronic or acute periapical infection
  • Periapical pathology
  • Extruded endo fill
  • Adjacent edentulous spaces
  • Traumatic extraction

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Complications of Dentoalveolar Surgery
  • Maxillary sinus complication
  • A small 1-4 mm sinus perforation is often covered
    by the post-op blood clot and usually heals
    without complications.
  • Can use hemostatic agents
  • Larger perforations, 5 mm or greater, requires
    more aggressive action.

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Complications of Dentoalveolar Surgery
  • Maxillary sinus perforation
  • An attempt should be made to attain primary
    closure
  • May need a buccal flap
  • Post-op sinus precautions, antibiotics, nasal
    decongestant, and antihistamine
  • No nose blowing for 3 weeks
  • Sneeze or cough with mouth open (3 weeks)

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Closure of Fistulous Tract
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Complications of Dentoalveolar Surgery
  • Displacement of root tips into the maxillary
    sinus
  • Take a radiograph to confirm
  • Rule out displacement under the palatal or buccal
    soft tissue
  • Decision to leave the root tip
  • Root tip between 1-3 mm
  • No infection/ pathology
  • Decision to remove
  • Root tipgt 2mm
  • Demonstrates evidence of infection or pathology

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Complications of Dentoalveolar Surgery
  • Displacement of root tips into the maxillary
    sinus
  • Attempts to retrieve
  • Conservative first (suction and proper lighting)
  • Access through the socket
  • Caldwell-Luc procedure

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Sinus Perforation
  • Pre-op consultation, informed consent
  • Document in detail
  • Explained risks pre-op
  • Consent read and signed
  • Size of perforation
  • Any radiographs
  • What was performed
  • Post-op instructions
  • Meds prescribed
  • Follow-up appt

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Complications of Dentoalveolar Surgery
  • Complications in dentoalveolar surgery are to be
    expected.
  • Timely dx and tx are important parts of
    comprehensive surgical management.
  • Avoiding complications is best achieved by
    designing an appropriate treatment plan, using
    sound surgical techniques, and obtaining thorough
    written informed consent.

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Odontogenic Infections
  • Objectives
  • Understand the microbiology of odontogenic
    infections
  • Understand the signs, symptoms and findings in
    patients with odontogenic infections
  • Review the various pathways of spread with
    odontogenic infections
  • Understand the medical and surgical management of
    odontogenic infections

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Odontogenic Infections
  • Source of the bacteria that cause most
    odontogenic infections
  • Mostly indigenous bacteria that normally live on
    or in the host.
  • These bacteria gain access to deeper tissues and
    cause infection.

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Odontogenic Infections
  • Which species of bacteria cause odontogenic
    infections?
  • Almost all odontogenic infections are caused by
    multiple bacteria (an average of five species)
  • Mostly gram-negative rods (fusobacteria,
    bacteroides)
  • Some are gram-positive cocci (streptococci and
    peptostreptococci)
  • 25 are aerobic, mostly gram-positive cocci
  • About 60 are anaerobic bacteria
  • Fusobactrium spp. is associated with severe
    infections.

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Odontogenic Infections
  • What is Gram staining?
  • Each specimen obtained from a patient with an
    infectious process initially should be stained.
  • Staining
  • Decolorizing
  • Restaining with a different stain
  • Then categorize the organisms into four groups
    based on their stain retention and morphology
  • G cocci
  • G- cocci
  • G rods
  • G- rods

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Odontogenic Infections
  • What is the clinical significance of gram stain?
  • Because gram staining can be completed within a
    few minutes, it usually narrows the list of
    likely causative organisms immediately, whereas
    culture and sensitivity testing and biochemical
    identification may take 1-5 days to complete.

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Odontogenic Infections
  • Progression of odontogenic infections
  • Early infection is often initiated by
    high-virulence aerobic organisms (commonly
    streptococci), which cause cellulitis.
  • Followed by mixed aerobic and anaerobic
    infections.
  • Abscess stage anaerobic bacteria predominate
  • Eventually exclusively anaerobic.

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Odontogenic Infections
  • What is cellulitis?
  • Warm, diffuse, erythematous, indurated, and
    painful swelling of the tissue in an infected
    area.
  • Easy to treat, but can also be severe and life
    threatening.
  • Antibiotics and removal of the cause are usually
    sufficient.
  • Surgical incision and drainage are indicated if
    no improvement is seen in 2-3 days, or if
    evidence of purulent collection is identified.

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Odontogenic Infections
  • What is an abscess?
  • A pocket of tissue containing necrotic tissue,
    bacterial colonies, and dead white cells.
  • May or may not be fluctuant.
  • The patient is often febrile at this stage.

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Odontogenic Infections
CELLULITIS ABSCESS
Duration Acute Chronic
Pain Severe and generalized Localized
Size Large Small
Localization Diffuse borders Well circumscribed
Palpation Doughy to indurated Fluctuant
Presence of pus No Yes
Degree of seriousness Greater Less
Bacteria Aerobic Anaerobic
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Odontogenic Infections
  • Signs of infection
  • Swelling
  • Erythema
  • Heat
  • Pain
  • Fever
  • Purulent drainage

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Odontogenic Infections
  • Signs and symptoms of serious orofacial
    infections
  • Airway compromise
  • Fever
  • Fatigue
  • Malaise
  • Dehydration
  • Trismus
  • Dysphagia
  • Odynophagia
  • Drooling

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Pathways of Odontogenic Infection
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Submandibular Abscess
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Sublingual Abscess
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Buccal Space Abscess
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Lateral Pharyngeal Space Abscess
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Odontogenic Infections
  • Factors that influence the spread of odontogenic
    infections
  • Thickness of bone adjacent to the offending tooth
  • Position of muscle attachment in relation to root
    tip
  • Virulence of the organism
  • Status of patients immune system

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Pathways of Odontogenic Infection
  • - Pulp necrosis results from deep decay in
    tooth, (inflammatory reaction)
  • Usual cause of odontogenic infection necrosis of
    tooth pulp and bacterial invasion through the
    pulp chamber into deeper tissues
  • Further progression leads to medullary space
    infection
  • More commonly, get fistulous tracts through
    alveolar bone
  • Fistulous tract may penetrate oral mucosa or
    facial skin

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Odontogenic Infections
  • Principles of therapy for odontogenic infections
  • Determining the severity of infection
  • Cellulitis vs. abscess
  • Status of hosts immune system
  • Treatment
  • Removing the source of infection
  • Incision and drainage
  • Antibiotics
  • Analgesics
  • Fluids
  • Nutritional support

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Odontogenic Infections
  • Different methods of drainage
  • Endodontic treatment
  • Extraction of the offending tooth
  • Incision and drainage of soft tissue collection

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Odontogenic Infections
  • Surgical principles of incision and drainage
  • Prior to incision, obtain fluid for culture
    sensitivity
  • Incision in healthy skin or mucosa
  • Cosmetically and functionally acceptable place
  • Blunt dissection
  • Placement of a drain
  • Drain removal

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Odontogenic Infections
  • Antimicrobial spectrum of the most common
    antibiotics used in treatments for oral and
    maxillofacial infections
  • Penicillin
  • Streptococcus (except group D)
  • Staphylococcus(non-beta-lactamase producing)
  • Treponema
  • Actinomyces
  • Oral anaerobes
  • Oxacillin and dicloxicillin
  • Beta-lactamase-producing staphylococci

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Criteria For Immediate Treatment
  • Dysphonia
  • Dyspnea (airway embarrassment)
  • Dysphagia
  • High fever
  • Medically compromised patient
  • Location of infection
  • Rapidly progressing cellulitis

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Odontogenic Infections
  • Amoxicillin
  • Same as penicillin plus
  • E. coli
  • H. Influenza
  • Proteus Mirabilis
  • Amoxicillin plus clavulanate
  • Above plus
  • Klebsiella
  • Staph. Aureus
  • Staph epidermidis
  • Enterocci
  • gonococci

149
Odontogenic Infections
  • Cephalexin
  • Streptococcus (except group D)
  • Staphylococcus
  • E. coli
  • P. mirabilis
  • Klebsiella
  • Erythromycin
  • Streptococcus
  • Staphylococcus
  • Mycoplasma
  • H. influenza
  • Legionella
  • Oral anaerobes

150
Odontogenic Infections
  • Clindamycin
  • Streptococcus
  • Staphylococcus
  • Actinomyces
  • Bacteroides fragilis
  • Oral anaerobes
  • Metronidazole
  • Oral anaerobes

151
Odontogenic Infections
  • Antibiotic of choice
  • Empiric therapy
  • Penicillin or penicillin plus metronidazole, if
    the patient is not allergic to these and not
    immunocompromised.
  • Allergic to penicillin
  • Clindamycin is an excellent alternative
  • Definitive antibiotic treatment should be based
    on culture and sensitivity.

152
Odontogenic Infections
  • Indications for prophylactic antibiotics
  • To prevent local wound infection
  • To prevent metastatic wound infection (SBE,
    prosthetic joints)

153
Odontogenic Infections
  • Indications for prophylactic antibiotics to
    prevent local wound infection
  • Procedures associated with a high incidence of
    infection
  • When infections may have grave consequences.
  • Immunocompromised patient
  • Long surgical procedure
  • Surgical procedure with high degree of
    contamination

154
Odontogenic Infections
  • Possible causes of failure of antibiotic therapy
  • Inadequate surgical treatment
  • Depressed host defenses
  • Presence of foreign body
  • Problems associated with use of antibiotics
  • patient compliance,
  • inadequate dose,
  • antibiotic-related infection,
  • use of wrong antibiotics.

155
Odontogenic Infections
  • What to look for at the follow-up appointment?
  • Response to treatment
  • Recurrence of infection
  • Presence of allergic reactions
  • Toxicity reactions to antibiotics
  • Secondary infection (e.g. Candida)

156
Odontogenic Infections
  • Pseudomembranous colitis
  • A toxin reaction associated with the use of an
    antibiotic that causes alteration of colonic
    flora leading to the overgrowth of Clostridium
    difficile.
  • Profuse watery diarrhea that may be bloody
  • Cramping
  • Abdominal pain
  • Fever
  • Leukocytosis

157
Odontogenic Infections
  • Risk factors associated with pseudomembranous
    colitis are related to the type of antibiotic and
    patient-related factors.
  • Type of antibiotics
  • Clindamycin (originally thought to be the main
    antibiotic, only one third of cases)
  • Ampicillin (one third)
  • Cephalosporins (one third)

158
Odontogenic Infections
  • Patient-related factors for pseudomembranous
    colitis
  • Previous GI procedures
  • Medically compromised patients
  • Advanced age
  • Female gender
  • Inflammatory bowel disease
  • Cancer chemotherapy
  • Renal disease

159
Odontogenic Infections
  • Diagnosis of pseudomembranous colitis
  • Signs and symptoms
  • Culture
  • Sigmoidoscopy to confirm the dx
  • Treatment
  • Discontinue the causative antibiotics
  • Use alternate antibiotic if necessary
  • Restoration of fluid and electrolytes balance
  • Anticlostridia antibiotics (oral vancomycin or
    metronidazole)

160
Antibiotics For Odontogenic Infections
  • Penicillin (Pfizerpen, Pen-Vee K, Beepen-VK)
  • Drug of choice effective against most aerobes
    and anaerobes.
  • Bactericidal against sensitive organisms when
    adequate concentrations are reached and most
    effective during the stage of active
    multiplication. Inadequate concentrations may
    produce only bacteriostatic effects.
  • Penicillin V (phenoxymethyl penicillin) is
    administered orally, whereas aqueous penicillin G
    is administered IV or IM.

161
Pen Vee K
  • Adult Dose
  • Penicillin V 250-500 mg PO q6h
  • Pediatric Dose
  • Penicillin V 15-62.5 mg/kg/d PO divided q4-8h
  • Contraindication
  • Documented hypersensitivity
  • Interactions
  • Probenecid can increase effects of penicillin
    coadministration of tetracyclines can decrease
    effects of penicillin
  • Pregnancy
  • B - Usually safe but benefits must outweigh the
    risks.
  • Precautions
  • Caution in impaired renal function

162
Antibiotics For Odontogenic Infections
  • Amoxicillin and clavulanate (Augmentin)
  • Amoxicillin inhibits bacterial cell wall
    synthesis by binding to penicillin-binding
    proteins. Addition of clavulanate inhibits
    beta-lactamase-producing bacteria.
  • Good alternative antibiotic for patients allergic
    or intolerant to the macrolide class. Is usually
    well tolerated and provides good coverage to most
    infectious agents.
  • The half-life of oral dosage form is 1-1.3 h.
  • For children aged 3 mo or older, base dosing
    protocol on amoxicillin content.
  • Because of different amoxicillin/ clavulanic acid
    ratios in 250-mg tab (250/125) vs. 250-mg
    chewable tab (250/62.5), do not use 250-mg tab
    until child weighs gt40 kg.

163
Augmentin
  • Adult dose
  • 500 mg PO tid for 7-10 d
  • Pediatric Doselt3 months 125 mg/5mL PO susp 30
    mg/kg/d (based on amoxicillin component) PO
    divided bid for 7-10 dgt3 months if using 200
    mg/5 mL or 400 mg/5 mL susp, 45 mg/kg/d PO q12h
    if using 125 mg/5 mL or 250 mg/5 mL susp, 40
    mg/kg/d PO q8h for 7-10 dgt40 kg Administer as
    in adults

164
Augmentin
  • Contraindications
  • Documented hypersensitivity
  • Interactions
  • Coadministration with warfarin or heparin
    increases risk of bleeding
  • Pregnancy B - Usually safe but benefits must
    outweigh the risks.
  • Precautions
  • Adjust dose in renal impairment diarrhea may
    occur cross-allergy may occur with other
    beta-lactams and cephalosporins

165
Antibiotics For Odontogenic Infections
  • Clindamycin (Cleocin)
  • Considered by many as first-line therapy because
    of emergent penicillin resistance.
  • Excellent activity against oral aerobes and
    anaerobes penetrates bone and abscess cavities,
    but its use is limited because of the danger of
    inducing pseudomembranous colitis
  • Use in patients who are allergic to penicillin.

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Clindamycin
  • Adult Dose
  • 150-450 mg PO q6-8h not to exceed 1.8 g/d
  • Pediatric Dose
  • 20-30 mg/kg/d PO divided q6h not to exceed 1.8
    g/d
  • Contraindications
  • Documented hypersensitivity regional enteritis
    ulcerative colitis hepatic impairment
    antibiotic-associated colitis
  • Interactions
  • erythromycin may antagonize effects of
    clindamycin antidiarrheals may delay absorption
    of clindamycin
  • Pregnancy B
  • Usually safe but benefits must outweigh the
    risks.
  • Precautions
  • Adjust dose in severe hepatic dysfunction no
    adjustment necessary in renal insufficiency
    associated with severe and possibly fatal colitis

167
Medication-Related Osteonecrosis of the Jaw
  • www.aaoms.org
  • (health professional section, lower right hand
    corner)

168
MRONJ
  • The Special Committee recommends changing the
    nomenclature of bisphosphonate-related
    osteonecrosis of the jaw (BRONJ).
  • The Committee favors the term medication-related
    osteonecrosis of the jaw (MRONJ).
  • The change is justified to accommodate the
    growing number of osteonecrosis cases involving
    the maxilla and mandible associated with other
    antiresorptive (denosumab) and antiangiogenic
    therapies.

169
Antiresorptive Preparations Commonly Used in the
U.S.
Primary Nitrogen Indication Containing Dose Route Primary Nitrogen Indication Containing Dose Route Primary Nitrogen Indication Containing Dose Route Primary Nitrogen Indication Containing Dose Route Primary Nitrogen Indication Containing Dose Route Primary Nitrogen Indication Containing Dose Route
Alendronate (Fosamax) Osteoporosis Yes 10 mg/day 70 mg/wk Oral
Residronate (Actonel) Osteoporosis Yes 5 mg/day 35mg/wk Oral
Ibandronate (Boniva) Osteoporosis Yes 2.5 mg/day 150mg/ month Oral
Pamidronate (Aredia) Bone metastasis Yes 90 mg/ 3 wks Intravenous
Zoledronate (Zometa) (Reclast) Bone metastasis Osteopororsis Yes 4 mg/ 3 wks 5mg/yr Intravenous
Denosumab (Xgeva) (Prolia) Bone metastasis Osteoporosis NO Humanized monoclonal Ab 120 mg/4 weeks 60mg/6 months SQ SQ
170
MRONJ
  • Oral bisphosphonates are approved for treatment
    of
  • Osteoporosis
  • Osteopenia
  • They are also used for a variety of less common
    conditions such as Pagets disease of bone, and
    osteogenesis imperfecta.
  • The most common use, however, is for osteopenia
    and osteoporosis.

171
MRONJ
  • Intravenous (IV) bisphosphonates (BPs) are
    antiresorptive medications used to manage
  • Cancer-related conditions including hypercalcemia
    of malignancy,
  • Skeletal-related events (SRE) associated with
    bone metastases in the context of solid tumors
    such as breast cancer, prostate cancer and lung
    cancers, and
  • For management of lytic lesions in the setting of
    multiple myeloma.

172
MRONJ
  • IV BPs once yearly infusion of zolendronate
    (Reclast) and a parenteral formulation of
    ibandronate (Boniva) administered every three
    months, have FDA approval for management of
    osteoporosis.

173
MRONJ
  • RANK ligand inhibitor (denosumab)
  • is an antiresorptive agent
  • fully humanized antibody against RANK ligand
    (RANK-L) and inhibits osteoclast function and
    associated bone resorption.
  • When denosumab (Prolia) is administered
    subcutaneously every 6 months
  • reduction in the risk of vertebral,
    non-vertebral, and hip fractures in osteoporotic
    patients.
  • Denosumab (Xgeva) is also effective in reducing
    SRE related to metastatic bone disease from solid
    tumors when administered monthly.
  • Denosumab therapy is not indicated for the
    treatment of multiple myeloma.
  • Interestingly, in contrast to bisphosphonates,
    RANK ligand inhibitors do not bind to bone and
    their effects on bone remodeling are mostly
    diminished within 6 months of treatment cessation.

174
MRONJ
  • Angiogenesis inhibitors
  • interfere with the formation of new blood
    vessels.
  • These novel medications have demonstrated
    efficacy in the treatment of gastrointestinal
    tumors, renal cell carcinomas, neuroendocrine
    tumors and others.

175
MRONJ
  • Oral and maxillofacial surgeons first recognized
    and reported cases of non-healing exposed bone in
    the maxillofacial region in patients treated with
    IV bisphosphonates.
  • In September 2004, Novartis, the manufacturer of
    the IV bisphosphonates pamidronate (Aredia) and
    zoledronic acid (Zometa), notified healthcare
    professionals of additions to the labeling of
    these products, which provided cautionary
    language related to the development of
    osteonecrosis of the jaws.

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MRONJ
  • This was followed in 2005 by a broader drug class
    warning of this complication for all
    bisphosphonates including the oral preparations.
  • More recently, other antiresorptive agents and
    novel anti-cancer drugs have been linked to the
    development of jaw necrosis.

180
MRONJ
  • Patients may be considered to have MRONJ if all
    of the following characteristics are present
  • 1. Current or previous treatment with
    antiresorptive or antiangiogenic agents
  • 2. Exposed bone or bone that can be probed
    through an intraoral or extraoral fistula(e) in
    the maxillofacial region that has persisted for
    more than eight weeks and
  • 3. No history of radiation therapy to the jaws or
    obvious metastatic disease to the jaws.

181
MRONJ
  • It is important to understand that patients at
    risk for or with established MRONJ can also
    present with other common clinical conditions not
    to be confused with MRONJ.

182
MRONJ
  • Commonly misdiagnosed conditions may include, but
    are not limited to
  • alveolar osteitis,
  • sinusitis,
  • gingivitis/periodontitis,
  • caries,
  • periapical pathology,
  • fibro-osseous lesion,
  • sarcoma,
  • chronic sclerosing osteomyelitis, and
  • TMJ disorders.
  • It is also important to remember that ONJ occurs
    in patients not exposed to antiresorptive or
    antiangiogenic agents.

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Pathophysiology
  • A. Inhibition of osteoclastic bone resorption and
    remodeling
  • Bisphosphonates (BP), and other antiresorptives
    such as denosumab, inhibit osteoclast
    differentiation and function, and increase
    apoptosis, all leading to decreased bone
    resorption and remodeling.
  • Osteoclast differentiation and function plays a
    vital role in bone healing and remodeling in all
    skeletal sites, but osteonecrosis of the jaws
    only occurs primarily within the alveolar bone of
    the maxilla and mandible.
  • An increased remodeling rate in the jaws may
    explain the differential predisposition to ONJ
    compared to other bones in the axial or
    appendicular skeleton.

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Pathophysiology
  • B. Inflammation/Infection
  • Both systemic and local oral risk factors have
    been implicated in ONJ.
  • From these clinical studies, several animal
    models have been developed to demonstrate that
    both inflammation or bacterial infection and
    systemic antiresorptives are sufficient to induce
    ONJ.

193
Pathophysiology
  • C. Inhibition of Angiogenesis
  • Angiogenesis is a process that involves growth,
    migration and differentiation of endothelial
    cells to form new blood vessels.
  • Angiogenesis favorably influences tumor growth
    and also influences tumor invasion of vessels,
    resulting in tumor metastasis.
  • Angiogenesis requires binding of signaling
    molecules such as vascular endothelial growth
    factor (VEGF) to receptors on the endothelial
    cells. This signaling promotes new blood vessel
    growth.

194
Pathophysiology
  • Osteonecrosis is classically considered an
    interruption in vascular supply or avascular
    necrosis, and therefore, it is not surprising
    that inhibition of angiogenesis is a leading
    hypothesis in ONJ.

195
Risk Factors for MRONJ
  • A) Medication related risk factors
  • 1) MRONJ risk among cancer patients
  • The risk for ONJ among cancer patients enrolled
    in clinical trials and assigned to placebo groups
    ranges from 0 to 0.019 (0-1.9 cases per 10,000
    cancer patients)
  • The risk of ONJ among cancer patients exposed to
    zolendronate ranges between 50-100 times higher
    than cancer patients treated with placebo.

196
Risk Factors for MRONJ
  • 2. MRONJ risk among osteoporosis patients
  • Most dentists and oral and maxillofacial surgeons
    see patients in their practices who have been
    exposed to antiresorptive therapy, eg oral BPs,
    for management of osteoporosis.
  • When evaluated by age, 5.1 million patients over
    the age of 55 years received a prescription for a
    bisphosphonate in year 2008.

197
Risk Factors for MRONJ
  • Based on the current review of data, the risk of
    developing ONJ among osteoporotic patients
    exposed to oral, IV BPs, or denosumab is real but
    remains very low.

198
Risk Factors for MRONJ
  • 3. Duration of medication therapy as a risk
    factor for MRONJ
  • Regardless of indications for therapy, the
    duration of BP or antiresorptive therapy
    continues to be a risk factor for developing ONJ.
  • When compared to cancer patients receiving
    antiresorptive treatment, the risk of ONJ for
    patients with osteoporosis exposed to
    antiresorptive medications is about 100 times
    smaller.

199
Risk Factors for MRONJ
  • B) Local Factors
  • 1) Operative Treatments
  • Dentoalveolar surgery is considered a major risk
    factor for developing MRONJ.
  • Most clinicians and patients want to know Among
    patients exposed to antiresorptive medications,
    what is the risk for developing ONJ following
    tooth extraction (or other dentoalveolar
    procedures such as implant placement or
    periodontal procedures)?

200
Risk Factors for MRONJ
  • The best current estimate for the risk of ONJ
    among patients exposed to oral bisphosphonates
    following tooth extraction is 0.5.
  • Absent data, the committee considers the risk for
    ONJ after dental implant placement and endodontic
    or periodontal procedures that require exposure
    and manipulation of bone to comparable to the
    risk associated with tooth extraction.

201
Risk Factors for MRONJ
  • 2. Anatomic factors
  • MRONJ is more likely to appear in the mandible
    (73) than the maxilla (22.5) but can appear in
    both jaws (4.5).
  • Denture use was associated with an increased risk
    for ONJ among cancer patients exposed to
    zolendronate.

202
Risk Factors for MRONJ
  • C. Demographic and systemic factors and other
    medication factors
  • Age and sex are variably reported as risk factors
    for MRONJ. The higher prevalence of this
    complication in the female population is likely a
    reflection of the underlying disease for which
    the agents are being prescribed (i.e.
    osteoporosis, breast cancer).
  • Corticosteroids are associated with an increased
    risk for MRONJ.
  • Co-morbid conditions among cancer patients
  • include anemia (hemoglobin lt 10g/dL) and
    diabetes.
  • Tobacco use has been inconsistently reported as a
    risk factor for MRONJ.

203
Risk Factors for MRONJ
  • D. Genetic factors
  • Collectively, studies suggest that a germ line
    sensitivity to bisphosphonates may exist.

204
Risk Factors for MRONJ
  • In summary, the current literature reaffirms that
    the risk of MRONJ is significantly greater in
    cancer patients receiving antiresorptive therapy
    as compared to treatment regimens for
    osteoporosis.
  • Moreover, the risk of MRONJ in osteoporosis
    patients receiving antiresorptive therapy
    continues to be very low regardless of drug type
    (bisphosphonates, denosumab) or dosing schedule.

205
Management Strategies for Patients Treated with
Antiresorptives or Antiangiogenics
  • 1. Prevention of MRONJ
  • Early screening and initiation of appropriate
    dental care
  • 2. Cessation of at-risk medication therapy prior
    to tooth extraction or other procedures, which
    involve osseous injury (eg dental implant
    placement, periodontal or apical endodontic
    treatment) DRUG HOLIDAY??

206
Management Strategies for Patients Treated with
Antiresorptives or Antiangiogenics
  • Drug Holiday??
  • a. Antiresorptive Therapy for Osteoporosis/Osteope
    nia
  • Damm and Jones note that since 50 of serum BP
    undergoes renal excretion the major reservoir of
    BP is the osteoclast whose life span is 2 weeks.
    Thus the majority of free BP within the serum
    would be extremely low 2 months following the
    last dose of an oral bisphosphonate and a 2-month
    drug free period should be adequate prior to an
    invasive dental procedure.

207
Management Strategies for Patients Treated with
Antiresorptives or Antiangiogenics
  • Drug Holiday??
  • b. Oncology Patients Receiving Monthly
    Antiresorptive Therapy
  • There are no data to support or refute the
    cessation of antiangiogenic therapy in the
    prevention or management of MRONJ and therefore
    continued research in the area is indicated.

208
Management Strategies
  • A. Patients about to initiate intravenous
    antiresorptive or antiangiogenic treatment for
    cancer therapy
  • The treatment objective minimize the risk of
    developing MRONJ.
  • Non-restorable teeth and those with a poor
    prognosis should be extracted.
  • Other necessary elective dentoalveolar surgery
    should also be completed at this time.
  • Based on experience with osteoradionecrosis, it
    appears advisable that antiresorptive or
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