Transcript Slide 1

Contemporary Oral Surgery
for the General Dentist
Iowa Dental Assoc.
May 4, 2008
J. Bruce Bavitz, DMD
Collect Data, Formulate Tx Plan
• History
• Follow-up questions
• Exam
• Lab tests
Consider “Protoplasm Biopsy”
Prior to Doing Surgery
• Will they get numb and sit still?*
• Will they have a medical emergency?*
• Will they stop bleeding?*
• Will they resist infection?#
• Will they heal?#
• Will the operation “work”?#
*An intra-operative problem
#A post-operative problem
Common Changes/Modifications
from Normal Surgical Routine
• Antibiotic Pre-medication
• D/c anticoagulants
• Prior Radiation Therapy? Consider HBO
• Oral, Nitrous oxide, or IV sedation
• M.D. consult for tune up or “clearance”
• Allergy (penicillin, latex, sulfite etc)
• Abs + BCP…… Consider warning patient
• Delay Elective TX (Pregnancy, MI, CVA)
• Long acting or quickly metabolized local
• Limit epi to .04 mg for “cardiac” patients
• Insulin dose modification for major oral surgery
• Bisphosphonate subplots
Bisphosphonates…
Present Thinking
• The IV forms (Aredia and Zometa) are by far the
•
most problematic, and are typically prescribed for
multiple myeloma and metastatic breast/prostate
cancer.
Currently available published incidence data for
BRON are limited to retrospective studies with
limited sample sizes. Based on these studies,
estimates of the cumulative incidence of BRON
range from 0.8%-12%. With increased
recognition, duration of exposure, and follow-up,
it is likely that the incidence will rise.
Bisphosphonates…
Present Thinking
• Oral agents (Fosamax, Actonel), often
used for osteoporosis and osteopenia,
may negatively influence post surgical
bone healing, even years (decades)
after stopping the drug.
• Incidence of BRON after oral use:
.0007% (Merck) to .34% (following
extractions Alastair Goss DDS, Australia).
The following other variables
are thought to be risk factors for BRON:
1.
2.
3.
4.
5.
6.
Corticosteroid therapy
Diabetes
Smoking
Alcohol use
Poor oral hygiene
Chemotherapeutic drugs
Future?
• Serum-C- Terminal Telopeptide (CTX)
• High serum levels= more osteoclast activity
(more collagen break down)
• A predictor of ORN Risk?
• CTX <100 pg/ml =high risk?
• CTX >150 = low risk?
• Take people off oral bisphosphonates, and
delay elective surgery until CTX levels rise?
Oral Bisphosphonate-Induced Osteonecrosis: Risk
Factors, Prediction of Risk Using Serum CTX Testing,
Prevention, and Treatment
RE Marx, JE Cillo Jr, and JJ Ulloa
Journal of Oral and Maxillofacial Surgery
Volume 65, Issue 12, December 2007
CTX levels rise about 26pg a month, once drug is
stopped….Usually 6 month “holiday” is sufficient
CTX Testing Quest labs
Morning, fasting Study ~ $175.00
Web Resources
• http://www.ada.org/prof/resources/to
pics/osteonecrosis.asp
• http://www.aaoms.org
/docs/position_papers
/osteonecrosis.pdf
http://www.onjcme.com
May 30th , 2007 “Webinar”
Pragmatic Thoughts
• On oral Agent <3 years, probably “O.K.”
• On IV agent < 3 months, probably “O.K.”
• Consider upgraded consent forms on all patients,
•
•
•
as well drug holiday
Do easiest surgical procedure first, watch and wait
Avoid envelope pushing procedures like immediate
implants
Keep eye on CTX data…is it valid or not?
Figure 1
SBP < 120 and
DBP < 80
B.P.
All new patients and prior to
giving local anesthesia
No modification necessary
SBP > 120 or
DBP > 80
Iatrosedation
Consider nitrous oxide or oral sedation
Repeat BP in 5-10 minutes
SBP
DBP
120-159
and
80-99
SBP > 160
or
DBP > 100
SBP < 120 and
DBP < 80
No modification necessary but
consider sedation for future
appointments
Hypertensive symptoms?
Headache, chest pain
Shortness of breath
Visual changes, confusion
Urgent physician or
emergency room
referral
Proceed with procedure but limit
epinephrine to .04 to .06 mg/
15 minutes. Inform patient of
elevated BP and refer to
physician
No Hypertensive Symptoms
(Post dental care physician referral
for all below scenarios)
Elective
Dental Care
ASA I
> 10 MET
Proceed as planned.
Limit time and
epinephrine
ASA II-IV
< 10 MET
No invasive care.
Prescribe meds as
necessary
Emergency
Dental Care
ASA I
> 4 MET
Proceed with
emergency care
Limit time and
epinephrine
ASA II-IV
< 4 MET
Physician phone consult.
Minimal emergency
care only (I & D,
simple extractions)
The concept of metabolic equivalent or METS is in
vogue. One MET is defined as 3.5 ml of 02/Kg/min. It
essentially is a test of the patient’s ability to perform
physical work. Some examples are:
1-4
METS (eating, dressing, walking around house,
dishwashing)
4-10 METS (climbing stairs – 1 flight, walking level
ground 6.4 km/hr, running short distance, game of golf)
> 10 METS (swimming, singles tennis, football)
People with capacities of 4 METS or less are at high
risk for medical complications with those who can perform 10
METS or more at very low risk. A person who is anxious with
a BP 200/115 but can perform 10 METS of work would likely
have no problems with a simple extraction.
Ready for Surgery?
• Treatment modifications employed
• Stress diagnosed and treated (sedation)
• Consent signed and witnessed
• Pre-op vitals taken
• Antiseptic rinse
• Proper imaging
Alveolar Bone
• Preservation
– Save teeth
– Careful extraction
technique
– Graft sockets?
– Implants,
immediate or
conventional
• Reconstruction
– Bone grafting
with implants
– BMP/PRP
– Distraction
osteogenesis
These teeth are non restorable and the patients
are interested in implants.
1. How can I extract to preserve as much bone as
possible?
2. Should I graft the socket?
3. If so, what material(s)?
4. Should I use a membrane?
5. What type of membrane?
6. Will insurance reimburse?
7. Is there an ADA code?
Poor Man’s Periotome
Woodson Elevator
Don’t expand labial plate!
No “Wimpy” Forceps
No Labial Force