December 14, 2018 at 10:26 pm #1261Archives_AdminKeymaster
Patient now off zometa….
Wants implants and needs an extraction…. How long does one wait???
If Zometa was given in dosage for treatment of metastasis, etc., then it doesn’t matter how long ago the patient
discontinued use. I think half-life is ~11 years. If you are talking about dosage used as in Reclast, then you should
treat it like an oral bisphosphonate. You should be aware that the highest reported incidence of BRONJ associated with
the IV’s is about 11%. So your decision becomes one of relative risk. Is it riskier to keep the tooth or have exposure to
BRONJ secondary to extraction?
Attached are the recommendations for consultations for all sorts of medical conditions from Nova Southeastern Univ.
I don’t think they were meant for general distribution, so please use some discretion as to who you quote material to.
For completeness, I am also attaching the latest information about antibiotic prophylaxis for joint replacement
for anyone that has not seen this. Once again, the rules change.
To quote from Lexi-Comp’s Drug Info Handbook for Dentistry:
“There are no data available to suggest whether discontinuation of bisphosphonate treatment reduces the risk of ONJ”.
My interpretation of this is that the theory of putting the patient on a “drug vacation” for a certain period of time is
just that– a theory. With the lack of studies, data and hard evidence upon which we can base our decisions regarding these
patients, it’s basically a crap shoot for each individual clinician.
I just had a fully edentulous, 68 year-old female referred for implants in the mandible.
She was on a bisphosphonate for years, but has been off for about 1 year. CTX was 150.
Call me a wimp (or preferably call me very conservative), but after a good discussion with the lady,
we made the decision to not go ahead with treatment. My outlook: If she were my mother, would I subject her to a purely
elective procedure that has even a remote possibility of inducing ONJ?
An emergency or necessary procedure is a different story, but a case like this one? I opted not to treat.
These are the thoughts of a simple Seattle periodontist. Don’t know if that helps at all, but at least it keeps the discussion active. This is a great forum. Alan, thanks for being the force behind it.
Wow, Lloyd, send her to Florida. If you look at some of the early reports on BRONJ, you will see that many of the
patients that presented were edentulous and had not had any surgical treatment. How can this be?
The theory is that denture movement, irritations, ulcerations, etc. can cause trauma that could lead to BRONJ.
So she may be considered to be at similar risk doing something (implants) or nothing.
I truly believe that her quality of life, which should be considered for the next 20-30 years, can be
measurably improved with a (preferably) fixed dentition than dentures. And looking at her history
(which presumably indicates that she has not had BRONJ) suggests that she is not likely to develop the complication
with or without surgical intervention.
So feel free to give her my contact information.
Jeff thanks for sharing the information from NOVA
Everyone PLEASE DO NOT PASS THIS AROUND, IT IS FOR THE GROUP ONLY …THANK YOU!
Getting back to a patient treated for cancer with Zometa, is there any information as to when the patient may
be able to have an implant?
Or are we just guessing at this point?
Any input would be appreciated.
If you are waiting for bone metabolism to return to normal, then the answer is never. On the other hand, if the
patient is in trouble and needs dental surgery, then you should go ahead and treat, recognizing that the possiblity of
developing BRONJ is probably somewhere between 1-11%. If the benefit of the planned surgery outweighs the risk of the
complication, then you should do the surgery with the patient aware of these risks and numbers. If not, then decline
the procedure more or less forever (or maybe a decade).
There may be some minor benefit to hyperbaric oxygen treatment in treating BRONJ, which I think is going on at U Miami.
To my knowledge, results are not compelling or definitive. I have no idea if pre-treatment has any effect on likelihood
of developing the complications. I would also document a conversation with the patient’s oncologist about the relative
advisability and value of treatment before going ahead.
I will check with Michael Seigel and Cesar Migliorati whether they are cool with releasing Nova’s guidelines regarding
all medically compromised patients If so, I will send it to all ASAP. Bottom line: if patient received it via IV then
greater risk; if oral then much less risk (less than 1%). No evidence removing pt from meds will have any effect and do not
do it without medical consent; pretty much minimally invasive procedures are fine; more invasive procedures then pay more
attention to informed consent (counseling and written consent signed by pt); CTX testing not supported by scientific
evidence and should not be used to justify or decline surgery.
Here’s the NOVA publication on Medical conditions significant in dentistry. By my account,
a primer of a publication.
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