1
Q
What type of drugs are alendronic acid, risedronate sodium, zoledronic acid, ibandronic acid, pamidronate disodium and sodium clodronate?
A
Bisphosphonates
2
Q
What type of drug is Denosumab?
A
RANKL inhibitor
3
Q
What type of drug is bevacizumab, sunitinib and aflibercept?
A
Anti-angiogenic
4
Q
What patients are at no risk of MRONJ?
A
If the patient has NOT:
- being treated with anti-resorptive or anti-angiogenic drugs for the management of cancer.
- currently taking a bisphosphonate drug or have taken one in the past.
- currently taking denosumab or have taken denosumab in the last nine months.
5
Q
What patients have a higher risk of MRONJ?
A
- If they have had a previous diagnosis of MRONJ
- If the patient is being treated with anti-resorptive or anti-angiogenic drugs for the management of cancer
- if they have taken/did take bisphosphonates for longer than 5 years
- if they have taken/did take bisphosphonates for less than 5 years, and is being concurrently treated with a systemic glucocorticoid.
- if the patient is taking denosumab or have taken denosumab in the last nine months and is being concurrently treated with systemic glucocorticoid.
6
Q
What patients have a low risk of MRONJ?
A
- if the patient is currently taking denosumab or have taken denosumab in the last nine months. ( + no glucocorticoid)
- if the patient has taken bisphosphonates for less than 5 years (+ no glucocorticoid)
7
Q
A patient had a previous diagnosis of MRONJ? What is their risk of MRONJ?
A
High risk
8
Q
A patient is being treated with anti-resorptive or anti-angiogenic drugs for the management of cancer. What MRONJ risk are they?
A
High risk
9
Q
The patient has taken bisphosphonates for over five years. What MRONJ risk are they?
A
High risk
10
Q
A patient has taken bisphosphonates for less than five years, but is concurrently taking systemic glucocorticoids/ What MRONJ risk are they?
A
High risk
11
Q
A patient is currently taking denosumab/has taken denosumab in the last nine months. The patient is also taking systemic glucocorticoids. What MRONJ risk are they?
A
High risk
12
Q
A patient has taken bisphosphonates for 3 years. What MRONJ risk are they?
A
Low risk
13
Q
A patient is taking denosumab/has taken it in last 9 months. What risk are they?
A
Low risk
14
Q
A patient took denosumab 2 years ago. What MRONJ risk are they?
A
NO risk
15
Q
What should happen before commencement of anti-resorptive or anti-angiogenic drug therapy or as soon as possible thereafter?
A
Aim to get the patient as dentally fit as feasible, prioritising preventive care.
16
Q
What should you advise the patient about the risk of developing MRONJ?
A
That the risk is small, as not to discourage them from undergoing dental treatment.
- in cancer pts treated with anti-resorptive or anti-angiogenic drugs = <5%
- in osteoporosis pts treated with anti-resorptive drugs <0.05%
17
Q
What personalised preventive advice should help the patient optimise their oral health? (MRONJ)
A
- having a healthy diet and reducing sugary snacks and drinks.
- maintaining excellent OH.
- using fluoride toothpaste and fluoride mouthwash.
- stopping smoking.
- limiting alcohol intake
- regular dental checks
- reporting any symptoms such as exposed bone, loose teeth, non-healing sores or lesions, pus or discharge, tingling, numbness or altered sensations, pain or swelling as soon as possible.
18
Q
What symptoms should we ask patients to report? (MRONJ)
A
> exposed bone
loose teeth
non-healing sores or lesions
pus or discharge
tingling
numbness or altered sensations
unexpected pain or swelling
- report asap rocky
19
Q
How do you prioritise care that will reduce mucosal trauma or may help avoid future extractions or any oral surgery or procedure that may impact bone?
A
- radiographs to identify possible areas of infection and pathology
- undertake any remedial dental work
- extract any teeth of poor prognosis without delay
- focus on minimising periodontal/dental infection or disease
- adjust or replace poorly fitting dentures to minimise future mucosal trauma
- consider prescribing high fluoride toothpaste.
20
Q
Should you prescribe antibiotic or antiseptic prophylaxis following extractions or other bone-impacting treatments specifically to reduce the risk of MRONJ?
A
NO!
21
Q
What is important to do if an extraction or any oral surgery or procedure which may impact on bone is necessary with MRONJ patient?
A
Ensure valid consent by discussing the risk of the procedure.
Follow recommended management strategy for each patient based on allocated risk group.
22
Q
What is the recommended management for low MRONJ risk pts?
A
Perform straightforward extractions and procedures that may impact on bone in primary care.
Do not prescribe antibiotic or antiseptic prophylaxis unless required for other clinical reasons.
23
Q
What is the recommended management strategy for higher MRONJ risk pts?
A
Explore all possible alternative to extraction where teeth could potentially be retained e.g. retaining roots in absence of infection.
If extraction remains the most appropriate tx, proceed as for low risk patients.
24
Q
When should you review healing for MRONJ pt?
A
If the extraction socket is not healed at 8 weeks and you suspect that the pt has MRONJ, refer to an oral surgery/special care dentistry specialist as per local protocols.
25
What should you do if you suspect a patient has spontaneous MRONJ?
Refer to an oral surgery/special care dentistry specialist as per local protocols.
26
What is the definition of MRONJ?
Exposed bone, or bone that can be probed through an intraoral or extraoral fistula, in the maxillofacial region that has persisted for more than eight weeks in patients with a history of treatment with anti-resorptive or anti-angiogenic drugs, and where there has been no history of radiation therapy to the jaw or no obvious metastatic disease to the jaws.
27
How do anti-resorptive drugs work?
They inhibit differentiation and function, leading to decreased bone resorption and remodelling.
28
Why are the jaw more affected by anti-resorptive drugs than other parts of the body?
The jaw has increased remodelling rate compared to other skeletal sites and therefore viability of bone in this region may be adversely affected by the action of these drugs.
29
How does bisphosphonate work? How long do they remain in the body?
- It reduces bone resorption by inhibits enzymes essential to the formation, recruitment and function of osteoclasts.
- These drugs have a high affinity for hydroxyapatite and persist in the skeletal tissue for a significant period of time, with alendronate having a half-life in bone of around 10 years.
30
What are indications for bisphosphonates?
- They are used to reduce the symptoms and complications of metastatic bone disease (particularly that associated with breast cancer, prostate cancer and multiple myeloma). Normally high doses intravenously
- Treatment of osteoporosis and other less common disorders of the bone such as Paget's disease, osteogenesis imperfecta and fibrous dysplasia. *
- Prophylaxis to counteract the osteoporotic effects of glucocorticoids and to prevent bone-related/skeletal complications in pts with primary hyperparathyroidism and cystic fibrosis. *
* Can take drugs orally (usually once a week) or given as quarterly or yearly infusions.
31
What is denosumab and how does it work? How long does it last in the body?
Denosumab is a fully human monoclonal antibody which inhibits osteoclast function and associated bone resorption by binding to RANKL.
Denosumab does not bind to bone and its effects on bone turnover diminish within nine months of treatment completion.
32
When is denosumab indicated?
It is indicated for the prophylaxis and tx of osteoporosis and to reduce skeletal-related events related to metastatic disease.
It is administered subcutaneously in pts every six months in osteoporosis pts, with a higher dose given monthly in pts with metastatic disease.
33
How do anti-angiogenic drugs work?
They target the processes by which new blood vessels are formed and are used in cancer treatment to restrict tumour vascularisation.
34
Is there evidence for drug holidays? (MRONJ)
NO - / the decision should be made by prescribing physician and dental practitioners should not discourage pts from continuing with their medication.
No evidence for bisphosphonates since drugs persist in skeletal tissues for years.
35
After how long does the effect of denosumab on bone turnover dimish?
Within nine months of treatment completion.
36
Do you carry out routine dental tx as normal on MRONJ risk pts?
For low risk pts: perform straightforward extracts and other bone-impacting txs.
For higher risk pts: more conservative approach, given greater consideration to other, less invasive alternative tx options before performing extractions and other bone-impacting treatments in primary care.
37
What questions can you ask to prompt recall as to whether patients are taking MRONJ drugs?
- Have you ever been prescribed a medicine for your bones?
- Do you take medicine once a week?
- Have you ever had a drug infusion for your bones?
- Do you take any long-term steroid tablets for any condition.
38
What is general advice for all pts taking anticoagulants or antiplatelet drugs requiring dental treatment likely to cause bleeding?
- Plan treatment for early in the day and week
- Provide pre-treatment instructions
- Treat atraumatically, use appropriate local measures and only discharge the pt once haemostasis has been achieved.
- If travel time to emergency care is a concern, place particular emphasis on the use of measure to avoid complications
- Provide patient with post-treatment advice and emergency contact details.
39
What can you do if an anticoagulant or antiplatelet drug is time-limited?
Delay non-urgent, invasive dental procedures where possible.
40
What do you do if an anticoagulant/antiplatelet pt has other relevant medical complications?
Consult with prescribing clinician, specialist or general medical practitioner, if required.
41
When do you NOT interrupt anticoagulant or antiplatelet therapy?
- Patient with prosthetic metal heart valves or coronary stents.
- Patients who have had pulmonary embolism or deep vein thrombosis in the last three months.
- Patients on anticoagulant therapy for carioversion.
42
What dental procedures are unlikely to cause bleeding?
- LA by infiltration, intraligamentary or mental nerve block.
- LA by IDB or other regional nerve blocks.
- BPE
- Supra PMPR
- Direct or indirect restorations with supragingival margins.
- Endodontics - orthograde
- Impressions and other prosthetics procedures
- Fitting and adjustment of orthodontic appliances
43
What are dental procedures that are likely to cause bleeding but are at low risk of post-operative bleeding complications?
- Simple extractions (1-3 teeth, with restricted wound size)
- Incision and drainage of intra-oral swellings.
- Detailed six-point full periodontal examination.
- Root surface debridement (RSD)
- Direct of indirect restorations with subgingival margins.
44
What dental procedures are likely to cause bleeding and are at higher risk of post-operative complications?
- Complex extractions, adjacent extractions that will cause a large wound or more than 3 extractions at once.
- Flap raising procedures including:
> elective surgical extractions
> periodontal surgery
> preprosthetic surgery
> periradicular surgery
> crown lengthening
> dental implant surgery
- Gingival recontouring
- Biopsies
45
What type of drug is Apixaban, Dabigatran, Rivaroxaban or Edoxaban?
Direct Oral Anticoagulants (DOACs)
46
How does dabigatran work?
Direct inhibitor of coagulation factor thrombin
47
How does apixaban, rivaroxaban and edoxapan work?
Inhibit factor Xa of coagulation cascade
48
How do antiplatelet drugs work?
They interfere with platelet aggregation by reversibly or irreversibly inhibiting various steps in the platelet activation required for primary haemostasis.
Primary haemostasis = platelets within the blood become activated locally, resulting in an increased tendency to adhere to each other and to damaged blood vessel endotherlium.
49
How do anticoagulants work?
They inhibit the production or activity of the factors that are required for the coagulation cascade and in this way impair secondary haemostasis.
Secondary haemostasis = A cascade of reactions converts inactive coagulation factors to their active forms, ultimately leading the production of protein fibres. Fibrin stabilises the platelet plug by cross-linking the platelets to each other and to the damaged blood vessel wall to prevent further blood loss.
50
How does warfarin work?
It inhibits vitamin K-dependent modification of prothrombin and other coagulation factors, which is required for their normal function.
51
What are limitations of warfarin?
A narrow therapeutic window
Sensitivity to diet and drug interactions
The requirement for frequent monitoring and dose adjustment
52
What type of drugs are unfractionated heparin and low molecular weight heparins (LMWHs), dalteparin, enoxaparin, and tinzaparin?
Injectable anticoagulants
53
What type of drugs are aspirin, clopidogrel, dipyridamole, prasugrel, ticagrelor?
Antiplatelets
54
How do you treat a pt taking DOACs with a low bleeding risk dental procedure?
Treat without interrupting medication
- treat early in day
- limit initial treatment areas and assess bleeding before continuing
- consider staging extensive or complex procedures
- pack and suture
55
How do you treat pts taking DOACs with higher bleeding risk dental procedures?
Advise pt to miss or delay morning dose before treatment*
* apixaban and dabigatran (taken 2x/day) = missing morning dose, take usual time in evening (as long as no earlier than 4 hours after haemostasis achieved)
* rivaroxaban and edoxaban (taken once a day morning or evening) = either delay morning dose and take 4 hours after haemostasis has been achieved, or just take evening dose as normal.
- Treat early in day
- Limit initial treatment area and assess bleeding before continuing.
- Consider staging extensive or complex procedures
- Pack and sutures
56
How do you treat a pt taking Warfarin (or a vitamin K antagonist - acenocoumarol or phenindione)?
Check INR, ideally no more than 24 hours before procedure (or up to 72 hours if patient is stably anticoagulated.
If INR is below 4:
- Treat without interrupting medication
- Consider limiting initial treatment area and staging extensive or complex procedures. Pack and suture.
If INR is 4 or above, delay invasive treatment or refer if urgent.
57
How do you treat a patient taking prophylactic (low) dose injectable anticoagulants (dalteparin, enoxaparin, tinzaparin)?
Treat without interrupting mediation
- Consider limiting initial treatment area and staging extensive or complex procedures. Pack and suture.
58
How do you treat a patient taking treatment (high) dose injectable anticoagulants (dalteparin, enoxaparin, tinzaparin)?
Consult with prescribing clinician for more information.
59
How do you treat a pt taking aspirin alone?
Treat without interrupting medication
- Consider limiting initial treatment area, staging extensive or complex procedures. Use local haemostatic measures.
60
How do you treat a pt taking clopidogrel, dipyridamole, prasugrel or ticagrelor single or dual therapy (in combination with aspirin)?
Treat without interrupting medication
- Expect prolonged bleeding; limit initial treatment area and consider staging extensive or complex procedures; strongly consider suturing and packing.
61
How do you treat a pt taking anticoagulant/antiplatelet combination?
Consult with the pt's prescribing clinician in order to assess the likely impact of the particular drug combination and the patient's medical condition on their bleeding risk.
62
What are haemostatic measures a dental practitioner should have available? (3)
1. Absorbant gauze
2. Haemostatic packing material (e.g. oxidized cellulose, collagen sponge)
3. Suture kit (needle holders, tissue forceps, suture material, scissors).
63
What is infective endocarditis?
It is a rare condition with significant morbidity and mortality.
It is an infection of the lining of the hart, often involving heart valves, caused mainly by bacteria which enter the blood from outside the body.
It may arise after bacteraemia in a person with a predisposing cardiac lesion.
Risk in general population is less than 1 case per 10,000 people per year. However cardiac condition increases risk.
64
Do you give antibiotic prophylaxis to IE risk pts?
2016 NICE update: Antibiotic prophylaxis is NOT recommended routinely for people undergoing dental procedures.
* special subgroup - discuss with pt/carer and consult with their cariology consultant, cardiac surgeon or local cardiology centre.
65
What adults and children with structural cardiac defects are at risk of developing infective endocarditis?
1. Acquired valvular heart disease with stenosis or regurgitation.
2. Hypertrophic cardiomyopathy.
3. Previous history of endocarditis *
4. Structural congenital heart disease*, including surgically corrected or palliated structural conditions.
5. Valve replacement*
* = these categories include a sub-group of pts who will require special consideration.
66
What information should health care professionals offer people at increased risk of IE?
1. The benefits and risks of antibiotic prophylaxis, and an explanation of why antibiotic prophylaxis is no longer routinely recommended.
2. The importance of maintaining good OH.
3. Symptoms that may indicate infective endocarditis and when to seek expert advise.
4. The risks of undergoing invasive procedures, including non-medical procedures such as body piercing or tattooing.
67
What are invasive dental procedures for IE risk?
> placement of matrix bands
> placement of sub-gingival rubber dam clamps
> sub-gingival restorations including fixed prosthodontic
> endodontic tx before apial stop has been established
> Preformed metal crowns (PMC/SSCs)
> Full periodontal examinations
> Sub PMPR
> Incision and drainage of abscess
> Dental extractions
> Surgery involving elevation of muco-periosteal flap or muco-gingival area.
> Placement of dental implants including temporary anchorage devices, mini-implants
> uncovering implant sub-structures.
68
For a pt who has received a course of Abx for a medical or dental infection in the preceding six weeks, what antibiotic do you choose? IE risk
Select a drug from a different antibiotic class for the prophylaxis prescription.
69
What antibiotic prophylaxis can you use in IE risk?
Advise pt to bring the antibiotic with them to the dental practice on the day of the procedure(s). Alternatively, pt takes it at home.
Give advise on possible adverse events such as hypersensitivity, anaphylaxis and antibiotic-related colitis.
Amoxicillin, 3g Oral Powder Sachet
- Give 3g (1 sachet) 60 minutes before procedure)
= 3g prophylactic dose
In pts who are allergic to penicillin, an appropriate oral regimen is:
> Clindamycin Capsules, 300mg
- Give 600mg (2 capsules) 60 minutes before procedure)
= 600mg prophylactic dose.
70
Why is good oral hygiene + diet + check ups important to reduce risk of oral bacteria and IE?
Everyday activities, such as toothbrushing, flossing and chewing can cause transient bacteraemia.
Excellent oral hygiene is the best way to prevent oral diseases that could require invasive dental treatment and will also reduce the chance of oral bacteria getting into the blood stream.
Advise pt to reduce the frequency of sugary snacks and drinks to prevent tooth decay.
Regular dental check-ups ensure that any dental disease is treated before invasive dental surgery is required.
71
What are the benefits and risks of antibiotic prophylaxis, and an explanation of why antibiotic prophylaxis is no longer routinely recommended? (IE risk)
> Dental procedures are no longer thought to be the main cause of infective endocarditis.
> It is unclear whether antibiotic prophylaxis prevents IE and therefore it may occur whether or not prophylaxis is given.
> Antibiotics can cause side effects, such as nausea, diarrhoea and hypersensitivity/ allergic reactions and, in rare cases, anaphylaxis and antibiotic-related colitis (diarrhoea, which can be severe).
> Discuss the issues surrounding antibiotic resistance.
72
What are the symptoms of IE that would prompt a pt to contact their GMP?
A high temperature (fever) of 38 degrees or above.
Sweats or chills, especially at night.
Breathlessness, especially during physical activity.
Weight loss
Tiredness (fatigue)
Muscle, joint or back pain (unrelated to recent physical activity).
> Emphasise that these symptoms are more likely to be caused by a less serious type of infection but should be investigated.
> Ensure the patient knows to tell any medical professional they seek advice from about any recent invasive dental treatment they may have had.
73
