Transcript Effect of Black Tea Extract on Oral Pathogens Guoxian Wei

Ұ Department
Head of Oral and Maxillofacial Surgery, College of Dentistry, University of Illinois-Chicago, Chicago, IL
Instructor of Oral and Maxillofacial Surgery, College of Dentistry, University of Illinois-Chicago, Chicago, IL,
* Intern for the department of Oral and Maxillofacial Surgery, College of Dentistry, University of Illinois-Chicago, Chicago, IL, USA
** 3rd year resident for the department of Oral and Maxillofacial Surgery, College of Dentistry, University of Illinois-Chicago, Chicago, IL
***4th year resident/chief for the department Head of Oral and Maxillofacial Surgery, College of Dentistry, University of Illinois-Chicago,
Chicago, IL, USA
¥ Clinical
Algorithm for Clinical Treatment of Bisphosphonate related
Osteonecrosis of the Jaw (BRONJ)
Patricia Lukasavage, DDS**; David Telles, DDS*; William Flick DDS, MS ¥; Gene Sbalchiero DDS Ұ
ABSTRACT
The rise in bisphosphonate treatment of degenerative osseous diseases is
accompanied by a proportional increase in the number of reported cases of
bisphosphonate related osteonecrosis of the jaw (BRONJ). BRONJ is
precipitated by surgical procedures and may occur spontaneously (Marx et
al.)5; the presentation of this pathology varies by route of administration.
Ruggiero7 et al. demonstrated a more aggressive clinical course in cases of
intravenous administration in contrast to administration per os (po). This
has been correlated with a potential difference in the relative potency of the
different drug forms, the intravenous suspension being more potent.
Although the intravenous form is more efficacious, the relative ease of
administration in oral form translates into a greater prevalence of this drug
among patients.
As the use of bisphosphonates increases, dental practitioners are
encountering BRONJ more often. The typical clinical presentation is
usually exposed bone or dehisced tissue with or without pain and swelling.
In untreated cases, these sites of osteonecrosis can progress into
orocutaneous fistulas which may become secondarily infected.
Objective
To demonstrate an algorithm for treatment of BRONJ that dental
professionals can utilize when faced with this side effect of oral
and intravenous bisphosphonates based upon clinical presentation
and symptoms.
Case Reports
Case #2 Chlorhexidine rinse, Long term antibiotic treatment
(Amoxicillin/Metronidazole) [for approx. 4 months], sequestrectomy of exposed
bone under local anesthesia
60 yo African American female with Multiple Myeloma on IV Pamidronate, had
#19 removed in 2005, painful, infected, exposed bone
Uses of bisphosphonates1
- Inhibition of bone resorption6
- Osteolytic disease (Paget’s, Multiple Myeloma)
- Metastatic bone disease
- Hypercalcemia associated with malignancy
- Osteoporosis
- Anti-tumor activity (Rosen, Theriault et.al. 2001)
Intravenous vs. Oral
- Ruggiero et. al. (2004) study - 63 cases oral osteonecrosis (56 on
IV treatment, 7 on oral treatment) 7
This poster presentation is designed to give an overview of our clinical experiences in dealing w/
BRONJ. These techniques correspond to the guidelines set forth by an expert task force in the AAOMS
1
position paper on BRONJ.
In this paper, the qualifications for BRONJ are listed as 1) current or previous treatment with
bisphosphonates 2) exposed/necrotic bone that has persisted for more than 8wks and 3) no history of
radiation therapy to the jaw. Local and systemic risk factors are also listed and outlined in
Table 1, staging of BRONJ and proposed treatment is outlined in Table 2.
Table 1
Systemic Factors
Local Factors
-Potency of bisphosphonate
-Length of bisphosphonate treatment
-Race (usually Caucasians)
-Age (usually >60)
-Primary disease
multiple myeloma >breast CA>other CA
-Misc-steroid treatment, diabetes, smoking,
alcohol, poor oral hygiene, concurrent
chemo therapy
-Recent history of invasive dental surgery
(dentoalveolar surgery i.e. exodontias,
implants, periodontal surgery is 7x more
likely to develop BRONJ)
-Anatomy – tori, mylohyoid ridge, palatal
tori
-Concomitant oral disease – periodontal
and dental abscesses are at a 7x increase for
BRONJ
Table 2
Clinical Staging of BRONJ
No exposed bone but history of oral/IV
bisphosphonate treatment
INTRODUCTION
Mechanism of Action
- Effects on osteoclasts- Precursor cells, cytoskeleton, apoptosis4 (,
Hughes et.al. 1995)
- Anti-angiogenesis - Zometa study8
70 yo hispanic female w/ h/o Breast CA, secondary metastases to spine, on
Zolendronate >1 year
She presented 3 months status post extraction of dentition in upper right
quadrant with a chief complaint of a non-healing wound and inability to
wear prosthesis
Case #1 – Superficial debridement, long term chlorhexidine rinse and
antibiotic treatment [PenVK 500 mg x 6 months]
68 yo Caucasian with history of Breast CA, Zolendronate (Zometa) x 1 yr,
mandibular anterior extractions, history of debridements x 4
In this clinical situation, dentists must determine how to treat BRONJ
without further challenging the compromised bone. The treatment
modalities range from conservative measures, such as antibiotics and
antimicrobial rinses, to more involved therapy, such as superficial
debridement, sequestrectomy and resection of the involved bone. The
purpose of this presentation is to illustrate the different modalities in treating
BRONJ and specific cases treated at this institution will be discussed.
Several cases of BRONJ will be presented with their clinical
symptoms and manifestations as well as the treatment modalities
utilized. Success of a given treatment was determined as
resolution of patient’s clinical complaints and symptoms, not
necessarily the resolution of the drug-related osteonecrosis itself.
Case #4 - Treatment Extended course of Penicillin of approx 6 months,
Peridex rinse, Long term follow-up.
Discussion
Case #3 - Oral hygiene, Chlorhexidine gluconate mouth rinse and on long term
follow up
88 yo Caucasian female, lymphoma, Zolendronate IV, multiple extractions and
debridement by private dentist, currently not painful
Case #5 – Surgical Debridement with Buccal fat pad advancement, primary
closure , Long term pen vk, Chlorhexidine gluconate rinse 2x/day
Stage 1: exposed/necrotic bone in patients
who have no infection/ no pain
Stage 2: exposed bone in patients with pain
and evidence of infection
61 yo HF, on IV Zometa 1 time per month for multiple myeloma. The pt
developed BRONJ in lower right quadrant secondary to extractions performed
by a private dentist.
Stage 3:exposed bone in patients with pain
and infection, and one or more of the
following: pathologic fracture, extraoral
fistula or osteolysis extending to the
inferior border
The patient experienced pain and bleeding of gums x 3-4 months after dental
procedure of removal of root fragment/bone in lower right side. Afterwards,
patient developed this problem on lower right quadrant, the area of necrosis
became slowly worse and as a result the patient developed numbness in lower
right jaw, lip and face (V3 distribution) about 3 months prior to presentation to
UIC. Level of numbness at initial presentation was unchanged from initial
development 3 months prior.
Treatment
Perceived risk, but no treatment necessary
Encourage oral hygiene
Chlorhexidine gluconate, encourage oral
hygiene, no surgery
Chlorhexidine gluconate, antimicrobial
therapy with cultures taken to determine if
actinomyces species present
Surgical debridement/resection in
combination with antibiotics, removal of
mobile segments of sequestrum
-If pathologic fracture present, pt may
require removal of compromised bone and
reconstruction (vascularized fibular flap,
Engroff et al)
It is recommended that patients beginning bisphosphonate therapy
obtain a thorough dental evaluation in which all compromised teeth,
implants and pre-prosthetic surgery be completed to allow for
adequate tissue healing prior to initiation of therapy.
Treatment for “at risk” patients is dictated by the type of
bisphosphonate therapy i.e. oral vs. intravenous, duration of therapy
and co-morbid conditions as outlined in Table 1 and ultimately by
patient preference. Asymptomatic patients receiving IV therapy with
nonrestorable teeth should have the coronal portion removed with
subsequent endodontic therapy.
Restoration should consist of an overlying prosthesis. Placement of
implants should be avoided. If oral bisphosphonate treatment is less
than 3 years and the patient remains asymptomatic, then the risk is
minimal. In those receiving less than 3 years of oral bisphosphonate
treatment with concomitant steroid use or those with over 3 years of
treatment, it is suggested that a drug holiday of 3 months prior to
dental surgery and 3 months post surgery occur to allow adequate
osseous healing.
This drug holiday should be coordinated with the patient’s physician
as the patient’s primary health condition allows.
CTX (C-terminal telopeptide) – Marx5
- a breakdown product of bone resorption
- used pre-operatively as a determinant for BRONJ
- inverse relationship between the risk for BRONJ and the level of
CTX
- less than 100pg/mL pose a high risk
- between 100 and 150 are at moderate risk
- over 150 are minimal risk.
With cessation of the drug, values increased an average of 25.9
pg/mL per month, therefore justifying the implementation of a drug
holiday.
In all clinical situations, well-documented informed consent should
be obtained and discussed with the patient.
Conclusion
Dental practitioners in every specialty will encounter patients on
bisphosphonate therapy who require treatment. In some instances,
the provider will be faced with asymptomatic patients that already
display BRONJ.
Though knowledge regarding BRONJ is evolving, a primary
algorithm to treatment of these patients can be utilized in order to
treat the patient’s pain and restore their function.
Acknowledgements
Dr. Tarkan Sidal*** – for photos of various cases
References
1. American Association of Oral and Maxillofacial Surgeons Position Paper on BisphosphonateRelated Osteonecrosis of the Jaws. JOMS, 65: 369-376, 2007.
2. Engroff SL. Et al Treating Bisphosphonate Osteonecrosis of the Jaws: Is there a Role for
Resection and Vascularized Reconstruction? JOMS, 65:2374-2385, 2007.
3. Grant, BT, et al Outcomes of Placing Dental Implants in Patients Taking Oral
Bisphosphonates: A Review of 115 Cases. JOMS. 66:223-230, 2008
4. Ito M, Chokki M, , Ogino Y, Satomi Y, Azuma Y, Ohta T, Kiyoki M. Comparison of cytotoxic
effects of bisphosphonates in vitro and in vivo. Calcif Tissue Int 1998:63:143-147
5. Marx, RE. Oral Bisphosphonate-Induced Osteonecrosis: Risk Factors, Prediction of Risk Using
Serum CTX Testing, Prevention and Treatment. JOMS, 65: 2397-2410, 2007.
6. Rogers MJ, Watts DJ, Russell RG. Overview of Bisphosphonates. CANCER supplement
1997;80:1652-1660
7. Ruggiero SL, Mehrotra B, Rosenberg TJ, Engroff SL. Osteonecrosis of the jaws associated with
the use of bisphosphonates: A review of 63 cases. Journal of Oram and Maxillofacial Surg
2004;62:527-534
8. Wood J, Bonjean K, Ruetz S. Novel antiangiogenic effects of the bisphosphonate compound
zoledronic acid. J Pharmacol Exp Ther 2002: 302: 1055-1061.