TRANSCRIPT:

So now that we talked about the radiation osteonecrosis of the jaw. Let's talk about the medication, induced osteonecrosis of the jaw. I'd like to show you this update that was published by Lazarchik in 2013 and the reason I like this update is because it fits cleanly into like a little decision tree and he discusses bisphosphonates, antiangiogenics, and antiresorptive medication.

These are some of the key findings from his update first. Up here, patients, who have taken oral bisphosphonates for less than 4 years, you can continue with their implant surgery without any modifications to the treatment. So you just inform them of the lower risk of medication-related osteonecrosis of the jaw and you can contact their medical provider. But really, these patients are at a lower risk, now for patients who are, who have taken oral bisphosphonates for less than 4 years and are taking corticosteroids or anti-angiogenic or for Patients who have taken oral bisphosphonates for more than 4 years, so less than 4 years and these things or oral BP for more than four years.

What you should do is contact their physician and discuss a drug holiday. So these patients can be on a 2 month Drug holiday and not continue, or not Start up again their bisphosphonates until after healing from the procedures.

So now this page describes some of the IV bisphosphonate patients. Patients who are about to start ID bisphosphonates the really the name of the game is to avoid trauma and to remove any kind of infections. And so if oral surgery is needed. It's mainly if there's if there's teeth with big infections want to get those teeth out and you want to do is atraumatic as possible and you want to delay the start of the IV bisphosphonate treatment for about 2 or 3 weeks depending on how invasive the extraction is. And now, you want to be as minimally as invasive as possible until some teeth It might even be a good idea to just do a root canal and cut off the crowns and just leave them like that. That's how important is to be very minimally invasive.

For these patients, you want to check their Dentures. Make sure that they're not irritating. Any any areas of the gums you want to put them on a really, really hard core maintenance and hygiene program And now patients who have already taken IV bisphosphonates And have taken, and have developed osteonecrosis of the jaw we're not doing any implants on them at all. Actually none of these patients are implant candidates in my practice. And these patients right here, we're avoiding all oral surgery procedures. These have already taken IV bisphosphonates or they've already had osteonecrosis of the jaw We're not doing any surgeries on them.

Like I said it fits cleanly into this little decision tree that I made and so the patients that have taken IV bisphosphonates over here. Really I think the best thing for these patients is to find an alternative to implants and they're like I said they're not candidates in my practice so as far as patients that have taken oral bisphosphonates, the question you want to ask them is have they taken it for over four years? If yes. Then you want to contact their physician to discuss the cessation of medications, two months, prior to any kind of implant procedure and start up the medication after the healing after the implant healing. Now for patients who have taken oral bisphosphonates for less than 4 years You want to ask them if they're taking corticosteroids or anti-angiogenic, If they are, then you follow that same protocol of contacting their physician and discussing the two months of drug holiday and starting the medication After they heal from the procedure. If no, so they're not taking corticosteroids and they're not taking anti-angiogenics and they haven't taken oral bisphosphonates for over four years. Then you can tell him. It's low risk of medication-related osteonecrosis of the jaw and move forward with the procedure.

So I like this tree, it makes it really easy for you to see what category your patient falls into. Here's just a quick reference for me, I provided it also it's a downloadable file in the next section so this is kind of helps me keep these medications top mind so that these patients, get properly filtered and properly managed.

Lesson Summary

Here is a summary of the information from the update published by Lazarchik in 2013:

Patient category: Oral bisphosphonates for less than 4 years

• For patients taking oral bisphosphonates for less than 4 years, with no corticosteroids or anti-angiogenic medications, no modifications to the treatment are needed for implant surgery.
• Inform patients of the lower risk of medication-related osteonecrosis of the jaw and contact their medical provider.

Patient category: Oral bisphosphonates for less than 4 years with corticosteroids or anti-angiogenic medications, and oral bisphosphonates for more than 4 years

• Contact their physician to discuss a drug holiday.
• Patients can be on a 2-month drug holiday and should not start bisphosphonates until after healing from the procedures.

Patient category: IV bisphosphonate patients

• Avoid trauma and remove infections.
• If oral surgery is needed, be as minimally invasive as possible, including considering root canal and crown removal instead of extraction.
• Ensure dentures are not irritating any areas of the gums.

Patient category: Patients who have already taken IV bisphosphonates or have developed osteonecrosis of the jaw

• Avoid all oral surgery procedures and implants.

For patients who have taken IV bisphosphonates

• Consider alternative options to implants.

For patients who have taken oral bisphosphonates:

If taken for over four years:

• Contact their physician to discuss the cessation of medications two months prior to any implant procedure.
• Start the medication after the implant healing.

If taken for less than four years:

• Ask if they are taking corticosteroids or anti-angiogenic medications.
• If yes, follow the same protocol of contacting their physician and discussing a two-month drug holiday, starting the medication after the procedure healing.
• If no, it is a low risk of medication-related osteonecrosis of the jaw, and the procedure can proceed.

Overall, this decision tree makes it easy to categorize patients and determine the appropriate course of action based on their medication history.