Escolar Documentos
Profissional Documentos
Cultura Documentos
Objectives
Bisphosphonates
Clinical applications
Drug chemistry
Biologic action
BRONJ
Pathogenesis
Treatment of BRONJ
Latest management recommendations
Updates in the literature
Case Presentations
remodeling
IV and oral formulations
postmenopausal women
Increase bone mass in men with osteoporosis
Tx of glucocorticoid-induced osteoporosis
Tx of Pagets disease of bone
Hypercalcemia of malignancy
Bone metastases of solid tumors
Anti-corrosive in pipelines
Osteopathies
Anti-resorptive effect
compound
Substitution of Carbon for
Oxygen
Resistance to hydrolysis
Bone matrix accumulation
Extremely long half-life
Nitrogen-containing side
chain
Apoptosis
Inhibited release of bone
induction proteins
sclerotic changes in
lamina dura of alveolar
bone
hypercalcemia
RANKL-mediated
osteoclastic resorption
PTH-like peptide
osteoclastic resorption
Osteoporosis
Pharmacokinetics
Oral BPs
Biologic Catch 22
Etidronate (Didronel)
Available in both oral and IV
preparations
Oral: FDA approved for Pagets
disease
Dose: 5 mg/kg per day
IV: approved for use in
hypercalcemia of malignancy
Dose: 7.5 mg/kg per day for 3
days
Risk of osteomalacia w/
prolonged therapy
do not treat >2 yrs
No documented cases of BRONJ
Pamidronate (Aredia)
Available only as IV preparation
hypercalcemia of malignancy
Zolendronate (Zometa)
Only available in IV preparation
Approved for tx of hypercalcemia of
malignancy
4mg IV over no less than 15 mins
Alendronate (Fosamax)
Available as oral preparation
Osteoporosis
Risedronate (Actonel)
Also available as oral
preparation
Approved for tx of
osteoporosis
5 mg daily and 35 mg
weekly
Ibandronate (Boniva)
Most recently approved for tx
BRONJ
Exposed, devitalized bone in
maxillofacial region
Prior history or current use
of BP
Vague pain, discomfort
Spontaneous occurrence,
or
2 surgery or trauma to oral
soft tissue/bone
asymptomatic
radiographic signs
Sclerosis of lamina
dura
Widening of PDL space
AND
Pathologic Fracture
Staging of BRONJ
Proposed by AAOMS:
BRONJ: IV BPs
More frequently
Lesions more
extensive
All stages
II, III more
common
Lower success with
Tx
Patients generally
sicker
Stage I Lesions
Stage II Lesions
Stage 0 Lesions
Spontaneous onset
Sclerosis
Positive bone scan
Clinical presentation
Miles, Hunter:
Pre-antibiotic era
Conservative treatment
Selective debridement
Minimal mucosal manipulation
Topical agents: copper sulfate
Osteopetrosis
Loss of osteoclastic
function
Hypermineralization
Fractures, nonunions,
open oral wounds
Endpoint: bone necrosis,
+/- infection
Osteoradionecrosis
(ORN):
Osteomyelitis:
Steroid-induced
osteonecrosis:
Increased recognition
Increased duration of exposure
Increased followup
worldwide
Marx:
Merck study:
administration of alendronate:
0.01% to 0.04%
After extractions, increased to 0.09% to 0.34%
Another few years for BRONJ to reveal itself among the oral BP
population
Potency of BP
Duration of therapy
Local factors
Dentoalveolar surgery
Local anatomy
Race: Caucasian
Cancer diagnosis
Corticosteroid therapy
Diabetes
Smoking
EtOH
Poor oral hygiene
Chemotherapeutic drugs
Radiographs
Panoramic, PA films
Sclerosis of alveolus, lamina dura
Widening of PDL space
Clinical exam
Tooth mobility
Unrelated to alveolar bone loss
Deep bone pain with no apparent etiology
AP, osteocalcin
Treatment Goals
Preserve Quality of Life
Pain
Control
Treat 2 infection
Prevent extension
dental prophylaxis
nonoperative periodontal care
restorative procedures
conventional fixed and removable prosthodontics
Treatment Strategies
Patients about to initiate IV bisphosphonate tx
Treatment Strategies
Asymptomatic patients receiving IV BPs
Treatment Strategies
Asymptomatic patients receiving oral BPs
Treatment Strategies
Asymptomatic patients receiving oral BPs
(continued)
CTX???
Treatment Strategies
Patients with Established Diagnosis of BRONJ
Treatment Strategies
Stage III disease
Summary
BPs are associated with BRONJ
Summary
Pts with BRONJ: