PREVENTION IS THE BEST STRATEGY, THE SAME AS FOR ANY OTHER ILLNESS

(IF YOU RECOGNIZE IT, YOU AVOID IT)

PATIENTS BEING TREATED WITH BPS FOR LESS THAN FIVE YEARS

NO CHANGE IN THE SURGICAL TREATMENT PLAN

PATIENTS BEING TREATED WITH BPS FOR MORE THAN FIVE YEARS

IT IS ADVISABLE TO SUSPEND BISPHOSPHONATE THERAPY THREE MONTHS BEFORE SURGERY AND

RESUME THERAPY THREE MONTHS AFTER, POSSIBLY WITH A NON-AMINOBISPHOSPHONATE

ONJ : Stage 1ONJ : Stage 1

CLINICAL CONDITIONCLINICAL CONDITION

Exposed boneExposed bone

AsymptomaticAsymptomatic

TREATMENTTREATMENT

Rinsing with baking sodaRinsing with baking sodaPut gel Put gel chlorexidinechlorexidine on on

onsteonecrotic areaonsteonecrotic area

Check-ups every 15-20 daysCheck-ups every 15-20 days

Teaching the patient oral Teaching the patient oral hygienehygiene

Continue treatment with bps?Continue treatment with bps?

ONJ : Stage 2ONJ : Stage 2

CLINICAL CLINICAL CONDITIONCONDITION

Exposed boneExposed bone

InfectionInfection

TREATMENTTREATMENT

Broad-spectrum antibiotics for 2-3 Broad-spectrum antibiotics for 2-3 monthsmonths

Antimicotics for 15 daysAntimicotics for 15 days

Rinsing with baking sodaRinsing with baking soda

Put gel Put gel chlorexidinechlorexidine on on osteonecrotic areaosteonecrotic area

Controlling pain with analgesics Controlling pain with analgesics and anti-inflammatory drugsand anti-inflammatory drugs

Very light, minimum bone Very light, minimum bone curettage curettage

ONJ : Stage 3ONJ : Stage 3CLINICALCLINICAL

CONDITIONCONDITION

Exposed boneExposed bone

Infections, Fractures, Infections, Fractures, FistulaeFistulae

TREATMENTTREATMENT

- Specifically placed antibiotics based on - Specifically placed antibiotics based on culture testculture test

- Rinsing with chlorexidine- Rinsing with chlorexidine- Controlling the pain- Controlling the pain- Delicate bone curettage (carried out by - Delicate bone curettage (carried out by

experts in maxillofacial surgery)experts in maxillofacial surgery)- prpl- prpl- frp- frp- Tissue engineering- Tissue engineering- Low dose intermittent recombinant - Low dose intermittent recombinant

parathyroid hormone ( 1-34) parathyroid hormone ( 1-34)

PATIENTS TAKING ORAL BISPHOSPHONATES HEAL MORE

EASILY THAN PATIENTS ADMINISTERED

BISPHONSPHONATES INTRAVENOUSLY

(ONCOLOGIC PATIENTS)

SISBO (Italian society of study bisphosphonates in Odontostomatology)

UPDATE

Oncologic patients who take corticosteroids are those most at risk. It is to note that an increase of jaw osteonecrosis has been reported in patients treated with antineoplastic drugs who have never taken bisphosphonates nor undergone radiotherapy.Diabetic patients and those who have an arteriovenous insufficiency should be kept under observation. Thrombophylia, hypofibrinolysis, and hypercholesterolemia are considered important instigating factors.We advise (only for very high risk patients: oncologic patients who have been taking high doses of bps for several years and who are more than seventy years old) to carry out: serum CTX, urinary NTX (which must be evaluated by expert colleagues), a blood clotting check-up, (PT, INR, PTT), platelet count, vitamin K dosage, calcemia, vitamin D dosage (1,25)D and PTH. Measuring the vitamin D dosage is very important because a deficiency is the cause of secondary osteoporosis, secondary hyperparathyroidism, and also of disreactive immune response. Chronic alteration of the calcium balance damages the formation of new bone.

TREATMENT PLANFor all patients taking bisphosphonates orally or intramuscularly

(except oncologic patients) without ONJ

1. Antibiotic therapy starting 5 days before the oral surgery until 8-10 days after;

2. Taking vitamins E and D

3. Always carry out surgical sutures when possible

4. Advise mouthwashing with bicarbonate of soda

5. Teach the patient to apply chlorexidine gel and vitamin E gel on the surgical wounds.

6. Substitute the amino-bisphosphonate therapy with a non-aminobisphosphonate (chlodronate) one.

7. Check-ups every 15 days for the first two months.

8. The patients must abstain from smoking or drinking alcohol.9) Intermittent doses of PTH ricombinate (1-34)( Forteo ) 10) Pentoxiphylline

For all patients taking bisphosphonates with ONJ 1. Antibiotic and antimicotic therapy

2. Warm mouthwashes with bicarbonate of soda : neutralise the Ph acid, the accumulation of phosphorous in the jaw bones and inhibit the release of the bisphosphonates

3. Mouthwashes with warm physiologic solution

4. High doses of vitamin E (tocopherol)1000 UI daily for 2-3 months

5. Pentoxiphylline (improves the calcium pump, is vasoactive and defibrinogenating)

6. Chlodronate( Volpi et al.), (Takefumi et al)

7.Low doses of low-molecular-wieght Enoxaparin (anticoagulant)

8. Vitamin D and Vitamin K

9. Intermittent doses of PTH (1-34) ( don’t use in patient with metastasis)

10 .ACTH ??

11. Hyperbaric oxygen

12. Ozone therapy

13. Electrical stimulation

14. Intermittent low frequency laser

15. Magneteterapy

TREATMENT PLAN

THE FUTURE OF BISPHOSPHONATES:

1. IMPERFECT OSTEOGENESIS

2. PAGET’S BONE DISEASE

3. PERIPROSTHESIS BMD LOSS

4. PERIMPLANT BONE LOSS

5. DELAYED BONE UNION ( BONE GRAFTS)

6. OSTEONECROSI S OF THE FEMORAL HEAD

7. PERIODONTAL DISEASES

8. ORAL IMPLANTS

9. BIOMATERIALS FOR BONE RIGENERATION

10.AUTOIMMUNE DISEASES

11.ANTIBIOTIC RESISTANCE

ALWAYS REMEMBER: PREVENTION IS IMPERATIVE!

-CASE HISTORY (FUNDAMENTAL)

-FEAR (NO)

-PANIC (NO)

-CARE (YES)

the company is available to all colleagues :

Presidente sisbo: raff.volpi@tiscali.itReferente sisbo: info@sisbo.it