risk stratification and dental management of patients with

RISK STRATIFICATION RISK STRATIFICATION AND DENTAL AND DENTAL

MANAGEMENT OF MANAGEMENT OF PATIENTS WITH PATIENTS WITH

ENDOCRINE-METABOLICENDOCRINE-METABOLICDISORDERSDISORDERS

GGééza T. Terza T. Teréézhalmy, D.D.S., M.A. zhalmy, D.D.S., M.A. Professor and Dean Emeritus Professor and Dean Emeritus

School of Dental Medicine Case School of Dental Medicine Case Western Reserve UniversityWestern Reserve University

Terezhalmy 204/12/23

Risk stratification of patients with DMRisk stratification of patients with DM

• Insulin Lantus (long-acting insulin glargine)

– Mechanisms of action• Stimulates cellular glucose uptake, i.e., it is a

hypoglycemic agent

– Clinical indications• Type 1 and type 2 DM



• Oral hypoglycemic agents: sulfonylureasglyburide

– Mechanisms of action• Decreases hepatic glucose production• Stimulates the release of insulin from pancreatic

beta-cells• Decreases insulin resistance, i.e., improves insulin’s

effectiveness

– Clinical indications• Type 2 DM



• Biguanide oral hypoglycemic agentsmetformin

– Mechanisms of action• Decreases intestinal absorption of glucose• Decreases hepatic glucose production• Decreases insulin resistance, i.e., improves insulin’s

effectiveness




• Thiazolidinediones oral hypoglycemic agents

Actos (pioglitazone) Avandia (rosiglitazone)

– Mechanisms of action • Inhibit hepatic gluconeogenesis• Decrease insulin resistance, i.e., improve insulin’s

effectiveness




• The oral disease burden of patients with DM

– Periodontal disease

– Xerostomia• Dental caries• Candidiasis

– Other• Burning mouth

syndrome• Altered taste• Lichen planus• Bell’s palsy• Trigeminal

neuralgia



– Periodontal disease• The association

between uncontrolled or poorly controlled DM and periodontal disease is well established

*J Periodontol 1999;70:935-949



– Xerostomia• An association has

been demonstrated between lower resting and stimulated saliva flow and elevated HbA1c as well as elevated plasma glucose concentrations

*Diabetes Care 1992;15:900-904

*Oral Surg Oral Med Oral Pathol Oral Radiol

Endod 2001:92:281-291



– Dental caries • An association has

been observed between resting salivary flow rates less than 0.01 mL/min (normal: 0.3-0.5 mL/min) and a slightly higher incidence of dental caries*Oral Surg Oral Med Oral

Pathol Oral Radiol Endod 2001:92:281-291



– Candidiasis• The reported

frequency in patients with DM is as high as 51% and its presence is inversely related to glycemic control

*J Oral Pathol 1987;16:282-284



• Strategies for the dental management of patients with DM– Glycemic control– Cardiac function– Physiological

“stress” of the procedure



• Risk stratification– 8 million cases of DM undiagnosed

• Polyuria, nocturia, polydipsia, polyphasia, weakness, obesity, weight loss, pruritus

– Co-morbidities• Hypertension• Dyslipidemia



– Microvascular disease• Retinopathy• Renal dysfunction

– Macrovascular disease• Coronary artery disease

– Unstable coronary syndromes– Cardiac arrhythmias– Heart failure

• Cerebrovascular disease• Peripheral vascular disease



– Neuropathy• Peripheral sensory neuropathy• Peripheral autonomic neuropathy

– Tachycardia– Silent myocardial ischemia– Exercise intolerance, i.e., reduced functional capacity

– Glycemic control• SMBG• HbA1c



• Functional capacity– An individuals ability to perform a spectrum of

common daily tasks• Expressed in terms of metabolic equivalents

(METs). – 1 MET

» The oxygen consumption of a 70-kg, 40-year-old man in a resting state, i.e., 3.5 ml per kg per minute

J Am Coll Cardiol 2002;39:542-553.



– Excellent functional activities (>10 METs)– Strenuous recreational activities

– Good functional capacity (7-10 METs)• Scrubbing floors, lifting or moving heavy furniture• Moderate recreational activities

– Moderate functional capacity (4-7 METs)• Climb a flight of stairs or walk up a hill• Mow the grass, rake leafs, do light carpentry• Walk a block on level ground at 6.4 km/h• Run a short distance



– Poor functional capacity (<4 METs)• Dress, eat, or use the toilet• Walk around the house indoors• Do light work around the house (dusting, washing

dishes)• Walk a block on level ground at 3.2 km/h

– Cardiac risk is increased in patients unable to meet 4-METs• DM is an intermediate predictor of cardiovascular

risk association with non-cardiac procedures• Peripheral autonomic neuropathy leads to reduced

exercise tolerance, i.e., reduced functional capacity



– Procedure-related CV risk with non-cardiac surgical procedures• Predicated on procedure-specific variables

– Fluid shifts– Blood loss– Duration of the procedure– Physiological stress

• Cardiac risk for various dental procedures– Low to very low risk (<001%)

* Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1996;82:42-46.

*Arch Intern Med 2001;161:1509-1512.



• Physical examination– Blood pressure

• Useful marker for coronary artery disease• BP <180/110 mm Hg is not an independent risk

factor for cardiovascular risk • BP >180/110 mm Hg constitutes a medical

emergency– Pulse pressure, rate, and rhythm

• Pulse pressure correlates closely with systolic BP– Reliable cofactor to either rule out or confirm

significant CAD• Pulse rate <50 or >120 beats/min constitutes a

medical emergency• PVCs

– Significant finding



• Timing and length of appointments– Patients should preferably be treated in the

morning• Long stressful procedures should be avoided



• Local anesthetic agents– Provide the greatest margin of safety when

treating patients with DM• Absence of profound anesthesia

– Increased insulin utilization– Myocardial ischemia

• The physiological stress associated with 4 METs– Equivalent to the effect of 0.045 mg of

epinephrine• Epinephrine has an action opposite of that of insulin

– No appreciable rise in blood glucose levels

*Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2000;90:171-181.



• Antibacterial agents– Uncontrolled or poorly controlled DM and

increased susceptibility to oral infections • No studies directly support antibacterial prophylaxis

• Pain management– Opioid-based analgesics contribute to

cardiovascular stability• ASA to prevent thromboembolic events

– Opioid w/ASA – Opioid w/ibuprofen– Opioid w/APAP



Diabetic and CV risk

Physical examination

Treatment options

Consultation or referral

FBG 70 to 200 mg/dLANDMinor or intermediate predictors of cardiovascular risk

Blood pressure < 80/110 mm HgANDNormal pulse pressure, rate, and rhythmANDFunctional capacity >4 METs

Comprehensive care

Routine referral for medical management and risk factor modification





Treatment options



Blood pressure <180/110 mm HgANDNormal pulse pressure, rate, and rhythmANDFunctional capacity <4 METs

Limited care






Treatment options



Blood pressure >180/110 mm HgAND/ORAbnormal pulse pressure, rate, and rhythm

Emergency care

If patient is asymptomatic, routine referral for medical management and risk factor modification If patient is symptomatic, immediate referral for medical management and risk factor modification





Treatment options


FBG <70 or >200 mg/dL AND/OR Major predictors of cardiovascular risk

Establish baseline vital signs

Emergency care

Immediate referral for medical management and risk factor modification



• Postoperative glycemic control– Procedures may affect the patient’s ability to

eat• Consult with patient’s physician

– Ensure that targeted BG levels are maintained» Balanced intake and appropriate regimen of

medications



• Preventive strategies– Oral hygiene

• Conventional vs. electromechanical toothbrushes

– Antibacterial mouthwashes– Topical fluorides– Sialagogues

• Pilocarpine (Salagen)• Cevimeline (Evoxac)



• Potential medical emergencies– Hypoglycemia– Syncope– Postural

hypotension– Hypertensive

crises– Arrhythmias– Angina pectoris

• Myocardial infarction– Silent



• Miley DD, Terezhalmy GT. The patient with diabetes mellitus: etiology, epidemiology, principles of medical management, oral disease burden, and principles of dental management. Quintessence Int 2005;36:779-795.


Risk stratification of patients with ADRisk stratification of patients with AD

• Glucocorticosteroidsmethylprednisolone

prednisoneAdvair Diskus (fluticasone propionate w/

salmeterol)Flovent (fluticasone propionate)

fluticasone propionateNasonex (mometasone furoate)

– Mechanisms of action• Decrease inflammation • Suppress the immune system



– Clinical indications• Allergic rhinitis and asthma• Treatment of a variety of inflammatory and

autoimmune diseases• Therapeutic immunosuppression in organ transplant

patients• Neoplastic diseases

– Lymphocytic leukemia• Adrenocortical insufficiency

– Addison’s disease



• The oral disease burden of patients with AD

– Addison’s disease• Patchy brown

pigmentation– Face, buccal

mucosa, tongue, gingivae, lips

• Chronic mucocutaneous candidiasis

– Cushing syndrome• Red cheek, moon

face, hirsutism, acne• Arrested dental

development• Oral candidiasis• Mucocutaneous

pigmentation


• Addison disease



• Cushing syndrome




• Strategies for the dental management of patients with DM– Adaptive stress

response– Physiological




• Risk stratification– Cushing syndrome

• Hypothalamic abnormalities• Pituitary tumors• Adrenal adenoma or carcinoma• Small cell lung carcinoma• Chronic use of glucocorticoids



– Addison disease• Autoimmune adrenal disease• Autoimmune thyroid disease• Type 1 and 2 DM• Pituitary abnormalities• Tuberculosis• AIDS• Mucocutaneous candidiasis• HPA-axis suppression




• Useful marker for both Cushing syndrome Addison disease

• BP <180/110 mm Hg is not an independent risk factor for cardiovascular risk

• BP >180/110 or <90/50 mm Hg constitutes a medical emergency

– Pulse pressure, rate, and rhythm• Pulse pressure correlates closely with systolic BP

– Reliable cofactor to either rule out or confirm significant CAD

• Pulse rate <50 or >120 beats/min constitutes a medical emergency

• PVCs– Significant finding



• Adrenal insufficiency– HPA axis suppression in patients on

exogenous glucocorticoids• Addisonian crisis

– Precipitated by an overwhelming stressor » Surgery» Sepsis » Fever

– Characterized by» Hypotension» Cardiogenic shock



• Suppression of the HPA axis– Wide variability in HPA axis suppression in

patients on exogenous glucocorticoids• In general, it does not correlate well with the

– patient’s age and sex – dosage administered – duration of treatment

• The persistence of HPA axis suppression after cessation of systemic glucocorticoid therapy is equivocal

• Topical and inhaled corticosteroids can suppress the HPA axis but rarely cause clinical adrenal insufficiency



• Factors related to HPA axis suppression– No HPA axis suppression

• Less than 5 mg of prednisone or equivalent per day for any duration

• Alternate-day single morning dose of short-acting glucocorticoid, such as hydrocortisone, of any dose or duration

• Any dose of glucocorticoids for less than 3 weeks

– HPA axis suppression uncertain• 5-20 mg of prednisone or equivalent for more than 3

weeks within the past year– Low-dose ACTH stimulatory test to determine HPA

axis suppression



– HPA axis suppression presumed or documented• More than 20 mg of prednisone or equivalent for

more than 3 weeks within the past year• Cushingoid appearance• Biochemical adrenal insufficiency documented by

low-dose ACTH stimulation test



• Supplemental glucocorticoid regimens– The decision to give supplemental

glucocorticoids must weigh the risks• Fluid retention• Hypertension• Hyperglycemia• Increased risk of infection• Impaired wound healing• Gastrointestinal bleeding• Psychiatric disturbances

– Administer glucocorticoids only in the amount equivalent to the normal physiological response to surgical stress (“stress dose”)



• Anticipated magnitude of stress– Major surgical stress

• Examples– Pancreatoduodenectomy, esophagogastrectomy,

total proctolectomy, cardiac surgery involving cardiopulmonary bypass

• Recommended prophylaxis– 100 to 150 mg of hydrocortisone or equivalent for

2 to 3 days OR

– 100 mg IV hydrocortisone prior to induction of anesthesia, 50 mg hydrocortisone q8h for 48-72 h, then resume normal regimen



– Moderate surgical stress• Examples

– Nonlaporoscopic cholecystectomy, lower extremity revascularization, segmental colon resection, total joint replacement, abdominal hystorectomy

• Recommended prophylaxis– 50 to 75 mg of hydrocortisone or equivalent for 1

to 2 days OR

– 50 mg IV hydrocortisone prior to induction of anesthesia, 25 mg hydrocortisone q8h for 24-48 h, then resume normal regimen



– Minor surgical stress• Examples

– Local anesthesia– Inguinal herniography

• Recommended prophylaxis– Usual daily glucocorticoid dose during

perioperative period



• Procedure-specific variables– Fluid shifts– Blood loss– Duration of the procedure– Physiological stress

• General anesthesia• Dental procedures

– Low to very low risk• Recommended prophylaxis

– Usual daily glucocorticoid dose during perioperative period

Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1996;82:42-46.Arch Intern Med 2001;161:1509-1512.

ADA 2001;132:1570-1579.



• Local anesthetic agents– Physiological stress with the use of local

anesthetic agents in patients with adrenal dysfunction is low

– Cortisol plays a permissive role for epinephrine• Cardiac risk is increased in patients unable to meet

a 4-MET demand for oxygen– Equivalent to the effect of 0.045 mg of

epinephrine

Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2000;90:171-181.Med Clin North Am 2003;87:175-192.



Addisonian or cardiac risk


Treatment options


Minor procedure-related stress level

–Dental care

AND–Local

anesthesia

Blood pressure <180/110 mm HgANDNormal pulse pressure, rate, and rhythmANDFunctional capacity >4 METs

Comprehensive care

• Usual daily corticosteroid dose during perioperative period






Treatment options



–Dental care

AND–Local

anesthesia


Limited care• Usual daily

corticosteroid dose during perioperative period






Treatment options



–Dental care

AND–Local

anesthesia

Blood pressure >180/110 mm Hg OR<90/50 mm Hg AND/ORAbnormal pulse pressure, rate, and rhythm

Emergency care

• Usual daily corticosteroid dose during perioperative period




• Potential medical emergencies– The likelihood of

an Addisonian crisis in the oral health care setting is extremely remote• Other medical

emergencies may be anticipated based on the patient’s medical history and vital signs



• Huber MA, Terezhalmy GT. Risk stratification and dental management of patients with adrenal dysfunction. Quintessence Int 2007;38:325-338.


Risk stratification of patients with TDRisk stratification of patients with TD

• Thyroid hormones levothyroxine sodium

Levoxyl (levothyroxine sodium) Synthroid (levothyroxine sodium)

– Mechanisms of action• Regulate carbohydrate, protein, and lipid

metabolism; and oxygen consumption• Thermoregulation, calorigenesis• Act synergistically with epinephrine

Glycogenolysis and hyperglycemia

– Clinical indications• Hypothyroidism



• The oral disease burden of patients with TD

– Hypothyroidism• Cretinism

– Puffy face– Large cranium– Flat and broad

nose– Macroglossia– Thick elevated

lips– Open mouth– Altered

calcification of teeth

– Delayed eruption of teeth



– Hypothyroidism• Myxedema

– Edematous nose, eyelids, and lips

– Macroglossia– Possible

increased caries risk

– Possible impaired periodontal health

– Dysgeusia– Enlarged

salivary glands



– Hyperthyroidism• Exophthalmos• Early loss of

deciduous teeth• Early eruption of

permanent teeth• Tremor of the lips

and tongue• Increased risk of

caries• Accelerated

alveolar ridge atrophy



• Strategies for the dental management of patients with DM– Cardiac function– Physiological




• Risk stratification– Hyperthyroidism

• Increased cardiac output may limit cardiac reserve during surgery– T3 exerts direct inotropic and chronotropic effects

on cardiac muscle–

T3 appears to act synergistically with epinephrine– Hypothyroidism

• Co-morbidities– Dyslipidemia

» CAD





(METs). – 1 MET





– Poor functional capacity (<4 METs)• Dress, eat, or use the toilet• Walk around the house indoors• Do light work around the house (dusting, washing

dishes)• Walk a block on level ground at 3.2 km/h

– Cardiac risk is increased in patients unable to meet 4-METs• Increased cardiac output associated with

hypothyroidism may limit cardiac reserve during surgery






Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1996;82:42-46.

Arch Intern Med 2001;161:1509-1512. JADA 2001;132:1570-1579.





factor for cardiovascular risk • BP >180/110 or <90/50 mm Hg constitutes a

medical emergency– Pulse pressure, rate, and rhythm







• The use of local anesthetic agents with epinephrine– The hypothyroid patient

• There is no evidence to justify deferring needed surgery in patients with mild to moderate hypothyroidism

• No evidence of adverse effects associated with epinephrine infusion in patients with hypothyroidism

Clin Endocrinol 1995;43:747-751.Am J Med 1983;14:893-897.Am J Med 1984:77:261-266.



– The hyperthyroid patient• Increased cardiac output may limit cardiac reserve

during surgery– The effects of undiagnosed or undertreated

hyperthyroidism on the heart carries perioperative risks» Thyroid hormones act synergistically with

epinephrine» Use epinephrine with caution

N Engl J Med 2001;344:501-509



• The use of analgesics– The hypothyroid patient

• Hyper-reactive to opioid analgesics– Use judiciously

– The hyperthyroid patient• ASA displaces thyroid hormones from their protein

binding sites



Thyroid or cardiac risk


Treatment options


EuthyroidORMild to

moderate thyroid dysfunction

AND/ORMinor or

intermediate predictors of CV risk

Blood pressure <180/110 mm HgANDNormal pulse pressure, rate, and rhythmANDFunctional capacity >4 METs

Comprehensive care






Treatment options


EuthyroidORMild to


AND/ORMinor or



Limited care






Treatment options


EuthyroidORMild to


AND/ORMinor or


Blood pressure >180/110 mm Hg ORSystolic BP <90 mm HgAND/ORAbnormal pulse pressure, rate, and rhythm

Emergency care






Treatment options


Severe hypo-thyroidism

ORThyrotoxicosisAND/ORMajor

predictors of CV risk

Establish baseline vital signs

Emergency care

Immediate referral for medical management and risk factor modification



• Potential medical emergencies– The likelihood of

myxedema coma or a thyroid crisis in the oral health care setting is extremely remote• Other medical

emergencies may be anticipated based on the patient’s medical history and vital signs



• Huber MA, Terezhalmy GT. Risk stratification and dental management of the patient with thyroid dysfunction. Quintessence Int 2008;39:139-150.


Risk stratification of patients with RTDRisk stratification of patients with RTD

• ContraceptivesNuvaring (ethinyl estradiol w/etonogestrel)

Ortho Tri-Cycline (ethinyl estradiol w/norgestimate)Trinessa-28 (ethinyl estradiol w/norgestimate)

Yasmin (ethinyl estradiol w/drospirenone)Yaz-28 (ethinyl estradiol w/drospirenone)

– Mechanisms of action• Inhibit LH and FSH release

– Suppresses follicular development– Prohibit proper transport of both egg and sperm

– Indications• Prevention of pregnancy



• EstrogensPremarin (conjugated estrogen)

– Mechanism of action• Promotes growth and development of female

reproductive system• Conserves calcium and phosphorus and

encourages bone formation• Overrides stimulatory effect of testosterone

– Indications• Hypogonadism, menopause, uterine bleeding • Prevention and treatment of osteoporosis• Metastatic prostate cancer


Reproductive tract dysregulationReproductive tract dysregulation

• Selective estrogen receptor modulators Evista (raloxifene)

– Mechanism of action• Estrogen receptor agonist activity in bone• Estrogen antagonist activity in breast and

endometrial tissue

– Indications• Prevention of osteoporosis in post menopausal

women• Palliative and supportive care in metastatic breast

and endometrial carcinoma



• The oral disease burden of patients with RTD

– Periods of hormonal imbalance are associated with subtle but definite tissue changes hormones

– Gingivitis hormones

– Mucosal atrophy» Burning mouth

syndrome



• Strategies for the dental management of patients with RTD– Cardiac function– Physiological




• Risk stratification– Drug history

• Contraceptives• Hormone agonists or antagonists

– Tumors• Breast• Prostate

– CVD– Stroke





(METs). – 1 MET





– Poor functional capacity (<4 METs)• Dress, eat, or use the toilet• Walk around the house indoors• Do light work around the house (dusting,

washing dishes)• Walk a block on level ground at 3.2 km/h

– Cardiac risk is increased in patients unable to meet 4-METs






Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1996;82:42-46.

Arch Intern Med 2001;161:1509-1512. JADA 2001;132:1570-1579.





factor for cardiovascular risk • BP >180/110 or <90/50 mm Hg constitutes a

medical emergency– Pulse pressure, rate, and rhythm







• Local anesthetic agents– Provide the greatest margin of safety when

treating patients with CVD• Absence of profound anesthesia

– Myocardial ischemia• The physiological stress associated with 4 METs

– Equivalent to the effect of 0.045 mg of epinephrine

*Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2000;90:171-181.



• Contraceptives and antibacterial agents– Scientific evidence regarding the alleged

interaction between antibacterial agents and contraceptives does not satisfy the “Daubert standard” of causality

J Law Med Ethics 1996;24:273-274.

– There are no pharmacokinetic data to support the contention that antibacterial agents reduce the efficacy of contraceptives

J Am Acad Dermato 2002;46:917-923.



• Potential medical emergencies– Anticipate medical

emergencies based on the patient’s medical history and vital signs


Risk stratification of patients on Risk stratification of patients on bisphosphonatesbisphosphonates

• BisphosphonatesFosamax (alendronate)Actonel (risendronate)Boniva (ibandronate)

– Mechanisms of action• Inhibit osteoclastic and reduce osteoblastic activity

– Indications• Prevention and treatment of osteoporosis• Paget’s disease• Hypercalcemia of malignancy (IV formulations)



• The oral disease burden of patients with DBM

– An increasing body of literature suggests that bisphosphonate use, especially intravenous preparations, may be associated with osteonecrosis of the jaws



• Bisphosphonate-related osteonecrosis of the jaw (BRONJ)– Systematic review of the literature from 1966

through 31 January 2006 - 368 cases• Female to male ration - 3:2• Mandible - 65%; maxilla - 26%; both jaws - 9%• Multifocal or bilateral involvement

– Maxilla - 31%; Mandible 23%• Most lesions were posterior to the lingual mandible

near the mylohyoid ridge• 60% of the cases occurred after a tooth extraction

or other dentoalveolar surgery• 94% of the patients were treated with IV

bisphosphonates

(Ann Intern Med 2006;144:753-761.)



• IV bisphosphonate-related osteonecrosis of the jaw (BRONJ)– Population-based analysis based on data

from the Surveillance, Epidemiology, and End Results (SEER) program linked to Medicare claims - 16,072 cancer patients and 28,698 controls• Absolute risk of inflammatory conditions or surgery

of the jaw at 6 years– 5.48 events per 100 patients using IV BPs– 0.30 events per 100 patients not using B

(J Natl Cancer Inst 2007;991016-1024.)



• Oral bisphosphonate-related osteonecrosis of the jaw (BRONJ)– Data from the fracture intervention trial (FIT)

long-term extension (FLEX) - 1099 women with osteoporosis• After being on alendronate for 5 years, 5 mg or 10

mg– 5 year extension: alendronate, 5mg (n=329;

alendronate 10 mg (n=333); placebo (n=537 for 5 years)

• No cases of BRONJ– Even the long-term use of oral BPs caries little

risk of BRONJ

(JAMA 2006;296:2927-2938.)



• Bisphosphonate-related osteonecrosis of the jaw (BRONJ)– Case definition must meet all of the following

• Current or previous treatment with BPs• Exposed, necrotic bone in the maxillofacial region

that has persisted for more than 8 weeks• No history of radiation therapy to the jaws

(J Oral Maxillofac Surg 2007;65:369-376.)



• Strategies for the dental management of patients on bisphosphonates



• Risk stratification– At risk category A

• Patients who have been treated with oral BPs– No apparent exposed/necrotic bone

• Treatment strategies– Patient education– No alteration or delay in planned dental care




– At risk category B• Patients who have been treated with IV BPs

– No apparent exposed/necrotic bone• Treatment strategies

– Patient education– Non-restorable teeth may be treated by removal

of the crown » Endodontic treatment of the remaining roots




– Stage 1 BRONJ• Exposed/necrotic bone in patients who are

asymptomatic– No evidence of infection

• Treatment strategies– Antimicrobial mouth rinse– Removal of mobile segments of bony

sequestrum– Clinical follow-up on a quarterly basis– Patient education




– Stage 2 BRONJ• Exposed/necrotic bone associated with infection

– Pain and erythema in the region of the exposed bone with or without purulent drainage

• Treatment strategies– Symptomatic treatment with a broad-spectrum

oral antibacterial agent – Antimicrobial mouth rinse– Pain control– Superficial debridement to relieve soft tissue

irritation– Patient education




– Stage 3 BRONJ• Exposed/necrotic bone in patients

– Pain, infection, and one or more of the following » Pathologic fracture» Extraoral sinus tract» Osteolysis extending to the inferior border

• Treatment strategies– As in Stage 2 BRONJ– Surgical debridement/resection for longer term

palliation of infection and pain


risk stratification and dental management of patients with

Documents

dental management of

j oral pathol198716

poor functional capacity

insulin lantus

release of insulin

cellular glucose uptake

elevated hba1c

mets scrubbing floors