Contemporary Oral Contemporary Oral Surgery for the General Surgery for the General

DentistDentist

Iowa Dental Iowa Dental Assoc.Assoc.

May 4, 2008May 4, 2008

J. Bruce Bavitz, J. Bruce Bavitz, DMDDMD

Collect Data, Formulate Tx Plan

Collect Data, Formulate Tx Plan

•History

•Follow-up questions

•Exam

•Lab tests

•History

•Follow-up questions

•Exam

•Lab tests

Consider “Protoplasm Biopsy” Prior to Doing

Surgery

Consider “Protoplasm Biopsy” Prior to Doing

Surgery•Will they get numb and sit still?*

•Will they have a medical emergency?*

•Will they stop bleeding?*

•Will they resist infection?#

•Will they heal?#

•Will the operation “work”?#

•Will they get numb and sit still?*

•Will they have a medical emergency?*

•Will they stop bleeding?*

•Will they resist infection?#

•Will they heal?#

•Will the operation “work”?#*An intra-operative problem*An intra-operative problem

#A post-operative problem

#A post-operative problem

Common Changes/Modifications from

Normal Surgical Routine

Common Changes/Modifications from

Normal Surgical Routine• Antibiotic Pre-medication• D/c anticoagulants • Prior Radiation Therapy? Consider HBO• Oral, Nitrous oxide, or IV sedation• M.D. consult for tune up or “clearance”• Allergy (penicillin, latex, sulfite etc) • Abs + BCP…… Consider warning patient• Delay Elective TX (Pregnancy, MI, CVA)• Long acting or quickly metabolized local• Limit epi to .04 mg for “cardiac” patients• Insulin dose modification for major oral

surgery• Bisphosphonate subplots

• Antibiotic Pre-medication• D/c anticoagulants • Prior Radiation Therapy? Consider HBO• Oral, Nitrous oxide, or IV sedation• M.D. consult for tune up or “clearance”• Allergy (penicillin, latex, sulfite etc) • Abs + BCP…… Consider warning patient• Delay Elective TX (Pregnancy, MI, CVA)• Long acting or quickly metabolized local• Limit epi to .04 mg for “cardiac” patients• Insulin dose modification for major oral

surgery• Bisphosphonate subplots

Bisphosphonates…Present Thinking

Bisphosphonates…Present Thinking

• The IV forms (Aredia and Zometa) are by far the most problematic, and are typically prescribed for multiple myeloma and metastatic breast/prostate cancer.

• Currently available published incidence data for BRON are limited to retrospective studies with limited sample sizes. Based on these studies, estimates of the cumulative incidence of BRON range from 0.8%-12%. With increased recognition, duration of exposure, and follow-up, it is likely that the incidence will rise.

• The IV forms (Aredia and Zometa) are by far the most problematic, and are typically prescribed for multiple myeloma and metastatic breast/prostate cancer.

• Currently available published incidence data for BRON are limited to retrospective studies with limited sample sizes. Based on these studies, estimates of the cumulative incidence of BRON range from 0.8%-12%. With increased recognition, duration of exposure, and follow-up, it is likely that the incidence will rise.

Bisphosphonates…Present Thinking

Bisphosphonates…Present Thinking

•Oral agents (Fosamax, Actonel), often used for osteoporosis and osteopenia, may negatively influence post surgical bone healing, even years (decades) after stopping the drug.

• Incidence of BRON after oral use: .0007% (Merck) to .34% (following extractions Alastair Goss DDS, Australia).

•Oral agents (Fosamax, Actonel), often used for osteoporosis and osteopenia, may negatively influence post surgical bone healing, even years (decades) after stopping the drug.

• Incidence of BRON after oral use: .0007% (Merck) to .34% (following extractions Alastair Goss DDS, Australia).

The following other variablesare thought to be risk factors for

BRON:

1. Corticosteroid therapy 2. Diabetes 3. Smoking 4. Alcohol use 5. Poor oral hygiene 6. Chemotherapeutic drugs

The following other variablesare thought to be risk factors for

BRON:

1. Corticosteroid therapy 2. Diabetes 3. Smoking 4. Alcohol use 5. Poor oral hygiene 6. Chemotherapeutic drugs

•Serum-C- Terminal Telopeptide (CTX)•High serum levels= more osteoclast

activity (more collagen break down)•A predictor of ORN Risk?•CTX <100 pg/ml =high risk?•CTX >150 = low risk?•Take people off oral bisphosphonates,

and delay elective surgery until CTX levels rise?

•Serum-C- Terminal Telopeptide (CTX)•High serum levels= more osteoclast

activity (more collagen break down)•A predictor of ORN Risk?•CTX <100 pg/ml =high risk?•CTX >150 = low risk?•Take people off oral bisphosphonates,

and delay elective surgery until CTX levels rise?

Future?Future?

Oral Bisphosphonate-Induced Osteonecrosis: Oral Bisphosphonate-Induced Osteonecrosis: Risk Factors, Prediction of Risk Using Serum Risk Factors, Prediction of Risk Using Serum CTX Testing, Prevention, and Treatment CTX Testing, Prevention, and Treatment RE Marx, JE Cillo Jr, and JJ Ulloa RE Marx, JE Cillo Jr, and JJ Ulloa Journal of Oral and Maxillofacial SurgeryJournal of Oral and Maxillofacial Surgery Volume 65, Issue 12, December 2007Volume 65, Issue 12, December 2007

CTX levels rise about 26pg a month, once drug CTX levels rise about 26pg a month, once drug is stopped….Usually 6 month “holiday” is is stopped….Usually 6 month “holiday” is sufficientsufficient

CTX Testing Quest labsCTX Testing Quest labsMorning, fasting Study ~ $175.00Morning, fasting Study ~ $175.00

Web ResourcesWeb Resources•http://www.ada.org/prof/resources/http://www.ada.org/prof/resources/

topics/osteonecrosis.asptopics/osteonecrosis.asp•http://www.aaoms.orghttp://www.aaoms.org

/docs/position_papers/docs/position_papers/osteonecrosis.pdf/osteonecrosis.pdf

http://www.onjcme.com

May 30th , 2007 “Webinar”

Pragmatic ThoughtsPragmatic Thoughts

• On oral Agent <3 years, probably “O.K.”On oral Agent <3 years, probably “O.K.”

• On IV agent < 3 months, probably “O.K.”On IV agent < 3 months, probably “O.K.”

• Consider upgraded consent forms on all Consider upgraded consent forms on all patients, as well drug holidaypatients, as well drug holiday

• Do easiest surgical procedure first, watch and Do easiest surgical procedure first, watch and waitwait

• Avoid envelope pushing procedures like Avoid envelope pushing procedures like immediate implantsimmediate implants

• Keep eye on CTX data…is it valid or not?Keep eye on CTX data…is it valid or not?

Figure 1 SBP < 120 and DBP < 80 SBP > 120 or DBP > 80 SBP < 120 and DBP < 80 SBP 120-159 SBP > 160 Hypertensive symptoms? and or Headache, chest pain DBP 80-99 DBP > 100 Shortness of breath Visual changes, confusion No Hypertensive Symptoms (Post dental care physician referral for all below scenarios) Elective Emergency Dental Care Dental Care ASA I ASA II-IV ASA I ASA II-IV > 10 MET < 10 MET > 4 MET < 4 MET

B.P. All new patients and prior to giving local anesthesia

No modification necessary

Iatrosedation Consider nitrous oxide or oral sedation Repeat BP in 5-10 minutes

No modification necessary but consider sedation for future appointments

Proceed with procedure but limit epinephrine to .04 to .06 mg/ 15 minutes. Inform patient of elevated BP and refer to physician

Urgent physician or emergency room referral

Proceed with emergency care Limit time and epinephrine

No invasive care. Prescribe meds as necessary

Physician phone consult. Minimal emergency care only (I & D, simple extractions)

Proceed as planned. Limit time and epinephrine

The concept of metabolic equivalent or METS is in vogue. One MET is defined as 3.5 ml of 02/Kg/min. It essentially is a test of the patient’s ability to perform physical work. Some examples are:

1-4 METS (eating, dressing, walking around house, dishwashing)

4-10 METS (climbing stairs – 1 flight, walking level ground 6.4 km/hr, running short distance, game of golf)

> 10 METS (swimming, singles tennis, football)

People with capacities of 4 METS or less are at high risk for medical complications with those who can perform 10 METS or more at very low risk. A person who is anxious with a BP 200/115 but can perform 10 METS of work would likely have no problems with a simple extraction.

Ready for Surgery?Ready for Surgery?•Treatment modifications employed

•Stress diagnosed and treated (sedation)

•Consent signed and witnessed

•Pre-op vitals taken

•Antiseptic rinse

•Proper imaging

•Treatment modifications employed

•Stress diagnosed and treated (sedation)

•Consent signed and witnessed

•Pre-op vitals taken

•Antiseptic rinse

•Proper imaging

Alveolar BoneAlveolar Bone

•Reconstruction– Bone grafting

with implants– BMP/PRP– Distraction

osteogenesis

•Reconstruction– Bone grafting

with implants– BMP/PRP– Distraction

osteogenesis

•Preservation– Save teeth– Careful extraction

technique– Graft sockets?– Implants,

immediate or conventional

•Preservation– Save teeth– Careful extraction

technique– Graft sockets?– Implants,

immediate or conventional

These teeth are non restorable and the These teeth are non restorable and the patients are interested in implants.patients are interested in implants.

1.1.How can I extract to preserve as much bone as How can I extract to preserve as much bone as possible?possible?

2.2.Should I graft the socket?Should I graft the socket?

3.3.If so, what material(s)?If so, what material(s)?

4.4.Should I use a membrane?Should I use a membrane?

5.5.What type of membrane?What type of membrane?

6.6.Will insurance reimburse? Will insurance reimburse?

7.7.Is there an ADA code?Is there an ADA code?

Poor Man’s PeriotomePoor Man’s PeriotomeWoodson ElevatorWoodson Elevator

Don’t expand labial Don’t expand labial plate!plate!

No “Wimpy” No “Wimpy” ForcepsForceps

No Labial ForceNo Labial Force