PDS June 28 2015 Isak 1

Prevention, Diagnosis,
and Management of
Oral Surgery
Complications
June 28, 2015
David Salehani, D.D.S., M.D.
Private Practice, West Hollywood, CA
UCLA Reagan Medical Center
Faculty at UCLA School of Dental
Medicine
Complications of Dentoalveolar
Surgery
Proper treatment planning and sound surgical
principles should lower the incidence of
complications.
Incidence of complications associated with the
removal of third molars, the most common
dentoalveolar surgical procedure, is 7 to 10.8
percent. 2, 3
Surgery
Think ahead and have all proper instruments
and medications available.
Proper surgical suction
Hemostatic agents (gelfoam, collaplug, etc.)
Sutures
Surgical blades
Surgical handpiece
Surgery
Surgery
To avoid complications:
Have all necessary radiographs for proper
diagnosis.
Always have an unobstructed view and access in
the presence of adequate light, proper soft tissue
reflection, and adequate suction.
Surgery
Local anesthetics complications:
Rare
A more common adverse sequela: hematoma
PSA: rapid posterior buccal swelling
Pterygoid venous plexus: slower development
Treatment:
Direct pressure to the area
Cold packs for 24 hrs
Then heat to facilitate reabsorption
Surgery
Local anesthetics complications: (Contd)
More serious situation: IA artery hematoma
Can compromise the airway
Tx is directed at maintaining an airway, followed by
local or systemic interventions if required.
Surgery
Local anesthetics
complications:
Facial ecchymosis and
discoloration:
Surgery
Inadvertent posterior injection into the parotid
capsule:
Facial nerve palsy:
Reassure patient of the transient nature
Gauze patch over the affected eye
Facial Nerve Palsy:
Facial Nerve Palsy:
Surgery
Fracture of the needle within the tissues
No attempt to palpate the needle
Radiographs to orient the location in three planes
Surgery
It is reported that the needles do not frequently migrate
through soft tissues to vital structures.
However, an attempt to retrieve the needle may be made
to alleviate patient anxiety regarding subsequent injury
Weigh the risks and benefits of surgical exploration
Refer to a surgeon
Surgery
Nerve trauma:
Rare
Most common: IAN (1 in 400,000 to 1 in 750,000 cases)
Epineural hematoma
Direct needle trauma
Avoid excessive firm needle contact with the bone to prevent a
needle barb.
Toxicity of local anesthetic
Reported that if spontaneous recovery has not been achieved within
21 days, the odds of its return are approximately 33%.
Surgery
Neurologic complications:
Sensory nerve damage
Usually associated with third molar surgery
Typically IAN
Less frequently lingual nerve
Rarely long buccal nerve
0.6% to 5% of third molar cases
Spontaneous recovery in 96% of IAN cases
Spontaneous recovery in 87% of lingual nerve cases
Mostly in the first 6-8 weeks, remaining within 9 months
Total recovery after 9 months is rare.
Surgery
Neurologic complications: (Contd)
Patient Age:
Higher morbidity in patients older than 25 years
Surgery
Neurologic complications: (Contd)
Pre-op radiologic exam: (Panorex)
Cortical outline and location of the canal
Surgery
Paresthesia is
one of the
leading causes of
liability against
OMFS and has
been among the
top four in
dollars awarded.
Surgery
Injuriestothelingualnerve:
1%oflowerthirdmolarextractions
Mostdifficultforpatientstoacceptbecauseof
alteredtastesensationandreducedchanceof
recovery.
Thelingualnervemaycourseoverontothe
retromolarpad.
Itcanbetraumatizedbyincisions,retractions,flap
elevation,toothandfollicleremoval,andsuturing.
Surgery
Injuries to the lingual nerve:
Unlike with IAN damage, reducing the incidence
of lingual nerve injury is related to surgical
technique.
If indicated , mandibular third molar suturing
should be limited to the superficial tissues of the
lingual flap to reduce trauma to the lingual nerve.
Surgery
Injuries to the lingual nerve: (Contd)
The return of sensation with the first 4 weeks:
Neuropraxia, excellent px
Symptoms of recovery manifesting at 1 to 3
months indicate a less certain px
Failure to exhibit recovery sypmtoms for 12 or
more weeks indicates neurotmesis, poor px for
spontaneous recovery
Surgery
Injuries to adjacent teeth and structures:
Iatrogenic luxation of adjacent tooth:
Assess the mobility of the tooth
Reposition the tooth
Take out of traumatic occlusion
Stabilize for 10-14 days

Surgery
Injuries to adjacent teeth and structures:
The use of exuberant force when extracting teeth is
unnecessary.
Force must always be applied in a controlled
manner, using surgical finesse.
The most common damage: fracture of the crown
or the existing restoration (mostly with elevators
while luxating)
Surgery
Injuries to adjacent teeth and structures
(Contd):
During luxation with the elevator
Consider carious teeth or large restorations of
adjacent teeth pre-op as potential risks.
Discuss with the patient as part of the informed
consent form pre-op.
Surgery
Inadvertent removal of the wrong tooth:
Attention to detail (Time-Out)
Atraumatic removal of a wrong tooth: (if
immediately identified)
Reimplant and stabilize
All other extractions should be delayed 4 to 6 weeks to
allow assessment and prognosis of the reimplanted tooth
Surgery
Injuries to the opposing dentition:
Result of excessive traction forces and sudden
release of the tooth
Can cause chipped or fractured tooth
Minimize tractional forces, use proper elevation
Inform the patient

Surgery
Painandswelling:
Associatedwithallsurgicalprocedures
Normalphysiologicresponsestosurgicaltreatment
However,thisdoesnotprecludethesurgeonfromtaking
allnecessaryactionstolessentheirseverity.
Factorsthatmayincreasethesecomplications:
Excessiveoperatingtime
Poormanagementofsofttissue
Inappropriateuseofirrigation
Ignoringotherbasicsurgicalprinciples
Surgery
Swelling:
Steroid therapy should have maximal anti-inflammatory
effects and minimal glucocorticoid and mineralocorticoid
activity.
Two steroids, dexamethasone and betamethasone are the
most popular.
Pre-op IV steroids and post-op oral steroids have the
greatest effect in decreasing swelling.
The use of ice, which is a routine recommendation, was not
demonstrated to be a considerable factor in decreasing
post-op swelling.
Surgery
Pain:
Aninevitablesequelaofdentoalveolarsurgery
Peakpain:earlypostopperiod35hrsafter
surgery
Study:97%ofpatientssufferedtheirhighestlevel
ofpainonthedayofsurgery
Surgery
Pain (Contd):
Associated with increased concentration of prostaglandins
Prostaglandin antagonists such as NSAIDs would be the
most effective means of pain management.
Use longer-acting local anesthetics
Proper surgical technique:
Reflection of flaps
Management of soft tissue
Copious irrigation when using drills
Use of controlled forces
Surgery
Temporomandibular joint injury:
If mandible is placed in an open position for extended
periods, certain degree of force will be transmitted to the
TMJ.
Use bite blocks, support the mandible.
Most successfully managed by conservative measures (soft
diet, moist heat, jaw rest, muscle relaxants, NSAIDs, and
on rare occasions splint therapy.
Further work-up: if symptoms persist beyond two weeks
Discuss as part of the informed consent
Surgery
Displacement of teeth into anatomical spaces:
Can occur with excessive force
Use:
Adequate access and visualization
Controlled force
Removal of sufficient bone
Placement of finger or instruments as distal stop

Surgery
Displacement into infratemporal fossa:
Distoangular maxillary third molar
Excessive force, poor visualization, lack of distal
stop
First locate the tooth (lateral and PA cephs)
Possible locations:
1) infratemporal fossa
2) maxillary sinus
3) in the mouth /aspirated/ throat pack
Surgery
Attempt to recover
Extend incision distally for better access and
visualization
Subperiosteal dissection to avoid the pterygoid
venous plexus
Visualize the tooth: place a curette behind the tooth to
retrieve
Unable to visualize the tooth: close incision, notify the
patient, antibiotics for one week or longer
Surgery
Attempt to recover (Contd)
Complete exam on follow-up: check for infection and
limitation of function
At this point refer to specialist.
Surgery
Displacement into submandibular space:
Less common
More common in third molar region
The most common factor: excessive apical force

while attempting removal of mandibular molar
roots.
Surgery
Displacement into submandibular space:
In the event the root or tooth is lost from the visual
field:
Initial attempt: palpation of the lingual aspect of the
mandible
If identified, attempt to guide it back into the surgical
field
Attempt to locate fails: closure, antibiotics, refer to
specialist.
Surgery
ForeignBodyAspiration:
Anydentoalveolarsurgeryordentalprocedureis
associatedwiththeriskofforeignbodyaspiration.
TheriskisincreasedwiththeuseofsedationorGA.
Theclinicalpresentationisusually,butnotalways,
associatedwithcoughingorgagging.
Inthiscasethepatientshouldbeallowedtoattemptto
expeltheobject.
Prematureinterventionmayhinderthepatientandactually
facilitateaspiration.
Surgery
Foreign body aspiration:
Use throat/pharyngeal drape
Have suction available
Instruct the patient not to swallow before you start

Surgery
Foreign Body Aspiration: (Contd)
If true airway obstruction occurs, a BLS protocol
should be in place, which may include the
Heimlich maneuver, back blows, or abdominal
thrusts.
No acute respiratory distress:
Refer patient for immediate chest and abdominal
radiographs.
If the foreign body is determined to have entered the GI
tract, it is usually of little consequence, as it will
generally pass with no ill effects.
Surgery
ForeignBodyAspiration:(Contd)
Ifdisplacedintracheaorbronchialtree
Ptrequiresadmissiontothehospitalforitsretrieval
Consultaphysiciantoperformbronchoscopy
Keepinamonitoredsettingafterretrieval
IVantibioticstocoveroralfloraandpreventaspiration
pneumonia
Oncepatientisstabilizedandfollowupchestxraysare
negative,theptmaybedischargedandfollowedonan
outpatientbasis.
Surgery
Hemorrhage:
Refer to PMH regarding bleeding d/os
If bleeding persists post-op
Reassure, instruct direct gauze pressure
Persistent bleeding examine the patient
Surgery
Exam for persistent bleeding:
Review PMH
Patient's status
Remove gauze gently, not to disturb the clot
Active bleeding vs. oozing
Oozing:
Direct gauze pressure 30-45 min
Oozing continues: local anesthesia (block preferably), remove clot?, place
hemostatic agent, suture (figure-of-eight), direct pressure, observe
Consider electrocautery on wound margins (conservative)
If oozing continues, treat as active bleeding
Surgery
Active bleeding:
Is it due to anticoagulants, bleeding d/os, liver
disease, chronic antibiotics?
First approach conservatively as above
If active bleeding persists:
REFER to specialist or ER (call PMD, ER, or specialist
to report)
Surgery
Alveolar Osteitis (dry socket):
Incidence following the routine extraction of erupted teeth: 1-3 %
Impacted mandibular third molars: 1-65 %
Etx:
Oral contraceptives
Smoking
Difficulty of extraction
Experience of the surgeon
Bacterial contamination
Poor OH, pericoronitis, gingivitis??
Exact pathophysiology remains unclear.
Possibly due to breakdown of the normal clot
Alveolar Osteitis
Symptoms:
Presents fourth to fifth day post-op
Constant moderate to severe pain
Foul taste and odor
May be differentiated from a post-op infection:
Absence of fever
No localized edema
No lymphadenopathy
No erythema
Alveolar Osteitis
Treatment:
Conservative
Primary goal: relieve pain during the healing phase
Curettage of the socket is not necessary.
Gentle saline irrigation
Dry-socket dressing
Change dressing everyday or every other day until

the pain subsides
Alveolar Osteitis
Numerous studies have examined measures to
prevent alveolar osteitis:
Preop PCN? Mixed results
Interestingly metronidazole given prophylactically
decreases the incidence of dry socket, indicating a
possible role of anaerobic bacteria.
Topical tetracycline placed in the extraction site by
itself or with Gelfoam has been shown to decrease
the incidence of dry socket.
Alveolar Osteitis
Resolves 3-5 days, sometimes 10-14 days
post-op
If symptoms persist longer, look for other
causes of persistent pain:
DDX:
Osteomyelitis or post-op infection
Fracture
Drug dependence?
Adjacent teeth?
Alveolar Osteitis
Persistent pain:
Thinking osteomyelitis?
Dry socket dressing doesnt relieve pain
Panorex: new radiolucency
Clinically: purulent drainage, swelling, severe pain
Tx:
Refer to specialist
Debridement to bleeding bone
Long-term antibiotics (oral or IV)
Osteomyelitis
Surgery
Soft tissue complications:
Most commonly a result of failing to protect the
soft tissue
Most frequent: tearing of the mucosal flap
Unintentional penetration of the soft tissues
Soft tissue burns and abrasions
Surgery
Injuries to adjacent osseous tissues:
Atraumatic exodontia requires the expansion of alveolar
bone
Inadvertent use of excessive force often results in fracture
of the maxilla or mandible.
The most common areas for traumatic bony fractures are
the buccal cortical plate of the canines, premolars, and
molars; the floor of the maxillary sinus, tuberosity, and the
buccal cortical plate of mandibular incisors and canines.
Surgery
Prevention:
1) Thoroughclinicalandradiographicevaluation
2) Patientsageandassociatedosseouselasticity
Highrisk:
Considerasurgicalextractiontechnique
Providesmorecontrolledboneremoval,sectioningofroots,
anddirectvisualizationofthedegreeofalveolarexpansion
duringluxationandelevation.
Surgery
Use finger support on alveolar process
Bone that is knowingly fractured and removed
with the delivery of the tooth should not be
replaced.
Smooth out the sharp bony edges with bone file
Reposition the soft tissue
Mandible fracture: atrophic mandible, impacted
third molar, significant odontogenic pathology, use
of excessive force
Surgery
Maxillary sinus complication:
Pre-op radiograph:
Pneumatized maxillary sinus
Chronic or acute periapical infection
Periapical pathology
Extruded endo fill
Adjacent edentulous spaces
Traumatic extraction
Surgery
Maxillary sinus complication:
A small 1-4 mm sinus perforation is often covered
by the post-op blood clot and usually heals without
complications.
Can use hemostatic agents
Larger perforations, 5 mm or greater, requires

more aggressive action.
Surgery
Maxillary sinus perforation:
An attempt should be made to attain primary
closure
May need a buccal flap
Post-op sinus precautions, antibiotics, nasal

decongestant, and antihistamine
No nose blowing for 3 weeks
Sneeze or cough with mouth open (3 weeks)

Closure of Fistulous Tract
Surgery
Displacement of root tips into the maxillary sinus:
Take a radiograph to confirm
Rule out displacement under the palatal or buccal soft
tissue
Decision to leave the root tip:
Root tip between 1-3 mm
No infection/ pathology
Decision to remove:
Root tip> 2mm
Demonstrates evidence of infection or pathology
Surgery
Displacement of root tips into the maxillary
sinus:
Attempts to retrieve:
Conservative first (suction and proper lighting)
Access through the socket
Caldwell-Luc procedure
Sinus Perforation:
Pre-op consultation, informed consent
Document in detail
Explained risks pre-op
Consent read and signed
Size of perforation
Any radiographs
What was performed
Post-op instructions
Meds prescribed
Follow-up appt
Surgery
Complicationsindentoalveolarsurgeryareto
beexpected.
Timelydxandtxareimportantpartsof
comprehensivesurgicalmanagement.
Avoidingcomplicationsisbestachievedby
designinganappropriatetreatmentplan,using
soundsurgicaltechniques,andobtaining
thoroughwritteninformedconsent.
Odontogenic Infections
Objectives:
Understand the microbiology of odontogenic
infections
Understand the signs, symptoms and findings in
patients with odontogenic infections
Review the various pathways of spread with
odontogenic infections
Understand the medical and surgical management
of odontogenic infections
Source of the bacteria that cause most
odontogenic infections:
Mostly indigenous bacteria that normally live on
or in the host.
These bacteria gain access to deeper tissues and
cause infection.
Which species of bacteria cause odontogenic
infections?
Almost all odontogenic infections are caused by
multiple bacteria (an average of five species)
Mostly gram-negative rods (fusobacteria, bacteroides)
Some are gram-positive cocci (streptococci and
peptostreptococci)
25% are aerobic, mostly gram-positive cocci
About 60% are anaerobic bacteria
Fusobactrium spp. is associated with severe infections.
What is Gram staining?
Each specimen obtained from a patient with an infectious
process initially should be stained.
Staining
Decolorizing
Restaining with a different stain
Then categorize the organisms into four groups based on
their stain retention and morphology:
G+ cocci
G- cocci
G+ rods
G- rods
What is the clinical significance of gram stain?
Because gram staining can be completed within a
few minutes, it usually narrows the list of likely
causative organisms immediately, whereas culture
and sensitivity testing and biochemical
identification may take 1-5 days to complete.
Progression of odontogenic infections;
Early infection is often initiated by high-virulence
aerobic organisms (commonly streptococci), which
cause cellulitis.
Followed by mixed aerobic and anaerobic
infections.
Abscess stage: anaerobic bacteria predominate
Eventually exclusively anaerobic.

What is cellulitis?
Warm, diffuse, erythematous, indurated, and
painful swelling of the tissue in an infected area.
Easy to treat, but can also be severe and life
threatening.
Antibiotics and removal of the cause are usually
sufficient.
Surgical incision and drainage are indicated if no
improvement is seen in 2-3 days, or if evidence of
purulent collection is identified.
What is an abscess?
A pocket of tissue containing necrotic tissue,
bacterial colonies, and dead white cells.
May or may not be fluctuant.
The patient is often febrile at this stage.

CELLULITIS ABSCESS
Duration Acute Chronic
Pain Severe and generalized Localized

Size Large Small
Localization Diffuse borders Well circumscribed
Palpation Doughy to indurated Fluctuant
Presence of pus No Yes
Degree of Greater Less

seriousness
Bacteria Aerobic Anaerobic
Signs of infection:
Swelling
Erythema
Heat
Pain
Fever
Purulent drainage
Signs and symptoms of serious orofacial infections:
Airway compromise
Fever
Fatigue
Malaise
Dehydration
Trismus
Dysphagia
Odynophagia
Drooling
Pathways of Odontogenic Infection
Submandibular Abscess
Sublingual Abscess
Buccal Space Abscess
Lateral Pharyngeal Space Abscess
Factors that influence the spread of
odontogenic infections:
Thickness of bone adjacent to the offending tooth
Position of muscle attachment in relation to root
tip
Virulence of the organism
Status of patients immune system

Pathways of Odontogenic Infection
- Pulp necrosis results from deep decay in tooth,
(inflammatory reaction)
Usual cause of odontogenic infection: necrosis of
tooth pulp and bacterial invasion through the pulp
chamber into deeper tissues
Further progression leads to medullary space
infection
More commonly, get fistulous tracts through alveolar
bone
Fistulous tract may penetrate oral mucosa or facial
skin
Principles of therapy for odontogenic infections:
Determining the severity of infection
Cellulitis vs. abscess
Status of hosts immune system
Treatment:
Removing the source of infection
Incision and drainage
Antibiotics
Analgesics
Fluids
Nutritional support
Different methods of drainage:
Endodontic treatment
Extraction of the offending tooth
Incision and drainage of soft tissue collection

Surgical principles of incision and drainage:
Prior to incision, obtain fluid for culture +
sensitivity
Incision in healthy skin or mucosa
Cosmetically and functionally acceptable place
Blunt dissection
Placement of a drain
Drain removal
Antimicrobial spectrum of the most common
antibiotics used in treatments for oral and
maxillofacial infections:
Penicillin:
Streptococcus (except group D)
Staphylococcus(non-beta-lactamase producing)
Treponema
Actinomyces
Oral anaerobes
Oxacillin and dicloxicillin:
Beta-lactamase-producing staphylococci
Criteria For Immediate Treatment
Dysphonia
Dyspnea (airway embarrassment)
Dysphagia
High fever
Medically compromised patient
Location of infection
Rapidly progressing cellulitis
Amoxicillin:
Same as penicillin plus:
E. coli
H. Influenza
Proteus Mirabilis
Amoxicillin plus clavulanate:
Above plus:
Klebsiella
Staph. Aureus
Staph epidermidis
Enterocci
gonococci
Cephalexin:
Streptococcus (except group D)
Staphylococcus
E. coli
P. mirabilis
Klebsiella
Erythromycin:
Streptococcus
Staphylococcus
Mycoplasma
H. influenza
Legionella
Oral anaerobes
Clindamycin:
Streptococcus
Staphylococcus
Actinomyces
Bacteroides fragilis
Oral anaerobes
Metronidazole:
Oral anaerobes
Antibiotic of choice:
Empiric therapy:
Penicillin or penicillin plus metronidazole, if the patient
is not allergic to these and not immunocompromised.
Allergic to penicillin:
Clindamycin is an excellent alternative
Definitive antibiotic treatment should be based
on culture and sensitivity.
Indications for prophylactic antibiotics:
To prevent local wound infection
To prevent metastatic wound infection (SBE,
prosthetic joints)
Indications for prophylactic antibiotics to
prevent local wound infection:
Procedures associated with a high incidence of
infection
When infections may have grave consequences.
Immunocompromised patient
Long surgical procedure
Surgical procedure with high degree of

contamination
Possible causes of failure of antibiotic therapy:
Inadequate surgical treatment
Depressed host defenses
Presence of foreign body
Problems associated with use of antibiotics:

patient compliance,
inadequate dose,
antibiotic-related infection,
use of wrong antibiotics.

What to look for at the follow-up
appointment?
Response to treatment
Recurrence of infection
Presence of allergic reactions
Toxicity reactions to antibiotics
Secondary infection (e.g. Candida)

Pseudomembranous colitis:
A toxin reaction associated with the use of an
antibiotic that causes alteration of colonic flora
leading to the overgrowth of Clostridium difficile.
Profuse watery diarrhea that may be bloody
Cramping
Abdominal pain
Fever
Leukocytosis
Risk factors associated with
pseudomembranous colitis are related to the
type of antibiotic and patient-related factors.
Type of antibiotics:
Clindamycin (originally thought to be the main
antibiotic, only one third of cases)
Ampicillin (one third)
Cephalosporins (one third)

Patient-related factors for pseudomembranous
colitis:
Previous GI procedures
Medically compromised patients
Advanced age
Female gender
Inflammatory bowel disease
Cancer chemotherapy
Renal disease
Diagnosis of pseudomembranous colitis:
Signs and symptoms
Culture
Sigmoidoscopy to confirm the dx
Treatment:
Discontinue the causative antibiotics
Use alternate antibiotic if necessary
Restoration of fluid and electrolytes balance
Anticlostridia antibiotics (oral vancomycin or
metronidazole)
Antibiotics For Odontogenic
Infections:
Penicillin (Pfizerpen, Pen-Vee K, Beepen-VK)
Drug of choice; effective against most aerobes and
anaerobes.
Bactericidal against sensitive organisms when adequate
concentrations are reached and most effective during the
stage of active multiplication. Inadequate concentrations
may produce only bacteriostatic effects.
Penicillin V (phenoxymethyl penicillin) is administered
orally, whereas aqueous penicillin G is administered IV or
IM.
Pen Vee K
Adult Dose:
Penicillin V: 250-500 mg PO q6h
Pediatric Dose:
Penicillin V: 15-62.5 mg/kg/d PO divided q4-8h
Contraindication:
Documented hypersensitivity
Interactions:
Probenecid can increase effects of penicillin; coadministration of
tetracyclines can decrease effects of penicillin
Pregnancy:
B - Usually safe but benefits must outweigh the risks.
Precautions:
Caution in impaired renal function
Infections:
Amoxicillin and clavulanate (Augmentin):
Amoxicillin inhibits bacterial cell wall synthesis by
binding to penicillin-binding proteins. Addition of
clavulanate inhibits beta-lactamase-producing bacteria.
Good alternative antibiotic for patients allergic or intolerant
to the macrolide class. Is usually well tolerated and
provides good coverage to most infectious agents.
The half-life of oral dosage form is 1-1.3 h.
For children aged 3 mo or older, base dosing protocol on
amoxicillin content.
Because of different amoxicillin/ clavulanic acid ratios in
250-mg tab (250/125) vs. 250-mg chewable tab (250/62.5),
do not use 250-mg tab until child weighs >40 kg.
Augmentin
Adult dose:
500 mg PO tid for 7-10 d
Pediatric Dose<3 months: 125 mg/5mL PO susp; 30
mg/kg/d (based on amoxicillin component) PO
divided bid for 7-10 d
>3 months: if using 200 mg/5 mL or 400 mg/5 mL
susp, 45 mg/kg/d PO q12h; if using 125 mg/5 mL or
250 mg/5 mL susp, 40 mg/kg/d PO q8h for 7-10 d
>40 kg: Administer as in adults
Augmentin
Contraindications:
Documented hypersensitivity
Interactions:
Coadministration with warfarin or heparin increases risk of
bleeding;
Pregnancy B - Usually safe but benefits must
outweigh the risks.
Precautions:
Adjust dose in renal impairment; diarrhea may occur; cross-
allergy may occur with other beta-lactams and
cephalosporins
Infections:
Clindamycin (Cleocin):
Considered by many as first-line therapy because
of emergent penicillin resistance.
Excellent activity against oral aerobes and
anaerobes; penetrates bone and abscess cavities,
but its use is limited because of the danger of
inducing pseudomembranous colitis;
Use in patients who are allergic to penicillin.
Clindamycin
Adult Dose:
150-450 mg PO q6-8h; not to exceed 1.8 g/d
Pediatric Dose:
20-30 mg/kg/d PO divided q6h; not to exceed 1.8 g/d
Contraindications:
Documented hypersensitivity; regional enteritis; ulcerative colitis; hepatic impairment;
antibiotic-associated colitis
Interactions:
erythromycin may antagonize effects of clindamycin; antidiarrheals may delay absorption
of clindamycin
Pregnancy B:
Usually safe but benefits must outweigh the risks.
Precautions
Adjust dose in severe hepatic dysfunction; no adjustment necessary in renal
insufficiency; associated with severe and possibly fatal colitis
Medication-Related
Osteonecrosis of the Jaw
www.aaoms.org
(health professional
section, lower right hand
corner)
MRONJ
The Special Committee recommends changing the

nomenclature of bisphosphonate-related
osteonecrosis of the jaw (BRONJ).
The Committee favors the term medication-related
osteonecrosis of the jaw (MRONJ).
The change is justified to accommodate the growing
number of osteonecrosis cases involving the maxilla
and mandible associated with other antiresorptive
(denosumab) and antiangiogenic therapies.
Antiresorptive Preparations
Commonly Used in the U.S.
Primary Nitrogen
Indication Containing Dose
Route
Alendrona
10 mg/day;
te Osteoporosis Yes Oral
70 mg/wk
(Fosamax)
Residrona
5 mg/day;
te Osteoporosis Yes Oral
35mg/wk
(Actonel)
Ibandrona 2.5 mg/day;
te Osteoporosis Yes 150mg/ Oral
(Boniva) month
Pamidron
Bone Intraveno
ate Yes 90 mg/ 3 wks
metastasis us
(Aredia)
Bone
Zoledrona metastasis 4 mg/ 3 wks
te Intraveno
(Zometa) Yes
us
Osteopororsi 5mg/yr
MRONJ
Oral bisphosphonates are approved for
treatment of:
Osteoporosis
Osteopenia
They are also used for a variety of less
common conditions such as Pagets disease of
bone, and osteogenesis imperfecta.
The most common use, however, is for
osteopenia and osteoporosis.
MRONJ
Intravenous (IV) bisphosphonates (BPs) are
antiresorptive medications used to manage:
Cancer-related conditions including hypercalcemia of
malignancy,
Skeletal-related events (SRE) associated with bone
metastases in the context of solid tumors such as
breast cancer, prostate cancer and lung cancers, and
For management of lytic lesions in the setting of
multiple myeloma.
MRONJ
IV BPs once yearly infusion of zolendronate
(Reclast) and a parenteral formulation of
ibandronate (Boniva) administered every three
months, have FDA approval for management
of osteoporosis.
MRONJ
RANK ligand inhibitor (denosumab):
is an antiresorptive agent
fully humanized antibody against RANK ligand (RANK-L) and inhibits
osteoclast function and associated bone resorption.
When denosumab (Prolia) is administered subcutaneously every 6 months;

reduction in the risk of vertebral, non-vertebral, and hip fractures in
osteoporotic patients.
Denosumab (Xgeva) is also effective in reducing SRE related to metastatic

bone disease from solid tumors when administered monthly.
Denosumab therapy is not indicated for the treatment of multiple myeloma.

Interestingly, in contrast to bisphosphonates, RANK ligand inhibitors do
not bind to bone and their effects on bone remodeling are mostly
diminished within 6 months of treatment cessation.
MRONJ
Angiogenesis inhibitors:
interfere with the formation of new blood vessels.
These novel medications have demonstrated
efficacy in the treatment of gastrointestinal tumors,
renal cell carcinomas, neuroendocrine tumors and
others.
MRONJ
Oral and maxillofacial surgeons first recognized and
reported cases of non-healing exposed bone in the
maxillofacial region in patients treated with IV
bisphosphonates.
In September 2004, Novartis, the manufacturer of the
IV bisphosphonates pamidronate (Aredia) and
zoledronic acid (Zometa), notified healthcare
professionals of additions to the labeling of these
products, which provided cautionary language related
to the development of osteonecrosis of the jaws.
MRONJ
This was followed in 2005 by a broader drug
class warning of this complication for all
bisphosphonates including the oral
preparations.
More recently, other antiresorptive agents and
novel anti-cancer drugs have been linked to
the development of jaw necrosis.
MRONJ
Patients may be considered to have MRONJ if
all of the following characteristics are present:
1. Current or previous treatment with antiresorptive or
antiangiogenic agents;
2. Exposed bone or bone that can be probed through an
intraoral or extraoral fistula(e) in the maxillofacial
region that has persisted for more than eight weeks; and
3. No history of radiation therapy to the jaws or obvious
metastatic disease to the jaws.
MRONJ
It is important to understand that patients at
risk for or with established MRONJ can also
present with other common clinical conditions
not to be confused with MRONJ.
MRONJ
Commonly misdiagnosed conditions may include, but are not
limited to:
alveolar osteitis,
sinusitis,
gingivitis/periodontitis,
caries,
periapical pathology,
fibro-osseous lesion,
sarcoma,
chronic sclerosing osteomyelitis, and
TMJ disorders.
It is also important to remember that ONJ occurs in patients not
exposed to antiresorptive or antiangiogenic agents.
Pathophysiology
A. Inhibition of osteoclastic bone resorption and
remodeling
Bisphosphonates (BP), and other antiresorptives such as
denosumab, inhibit osteoclast differentiation and function, and
increase apoptosis, all leading to decreased bone resorption and
remodeling.
Osteoclast differentiation and function plays a vital role in
bone healing and remodeling in all skeletal sites, but
osteonecrosis of the jaws only occurs primarily within the
alveolar bone of the maxilla and mandible.
An increased remodeling rate in the jaws may explain the
differential predisposition to ONJ compared to other bones in
the axial or appendicular skeleton.
Pathophysiology
B. Inflammation/Infection
Both systemic and local oral risk factors have
been implicated in ONJ.
From these clinical studies, several animal
models have been developed to demonstrate
that both inflammation or bacterial infection
and systemic antiresorptives are sufficient to
induce ONJ.
Pathophysiology
C. Inhibition of Angiogenesis
Angiogenesis is a process that involves growth,
migration and differentiation of endothelial cells to
form new blood vessels.
Angiogenesis favorably influences tumor growth and
also influences tumor invasion of vessels, resulting in
tumor metastasis.
Angiogenesis requires binding of signaling molecules
such as vascular endothelial growth factor (VEGF) to
receptors on the endothelial cells. This signaling
promotes new blood vessel growth.
Pathophysiology
Osteonecrosis is classically considered an
interruption in vascular supply or avascular
necrosis, and therefore, it is not surprising that
inhibition of angiogenesis is a leading
hypothesis in ONJ.
Risk Factors for MRONJ
A) Medication related risk factors:
1) MRONJ risk among cancer patients:
The risk for ONJ among cancer patients
enrolled in clinical trials and assigned to
placebo groups ranges from 0% to 0.019% (0-
1.9 cases per 10,000 cancer patients)
The risk of ONJ among cancer patients exposed
to zolendronate ranges between 50-100 times
higher than cancer patients treated with
placebo.
2. MRONJ risk among osteoporosis patients
Most dentists and oral and maxillofacial surgeons
see patients in their practices who have been
exposed to antiresorptive therapy, eg oral BPs, for
management of osteoporosis.
When evaluated by age, 5.1 million patients over
the age of 55 years received a prescription for a
bisphosphonate in year 2008.
Based on the current review of data, the risk of
developing ONJ among osteoporotic patients
exposed to oral, IV BPs, or denosumab is real
but remains very low.
3. Duration of medication therapy as a risk
factor for MRONJ:
Regardless of indications for therapy, the duration
of BP or antiresorptive therapy continues to be a
risk factor for developing ONJ.
When compared to cancer patients receiving
antiresorptive treatment, the risk of ONJ for
patients with osteoporosis exposed to
antiresorptive medications is about 100 times
smaller.
B) Local Factors:
1) Operative Treatments:
Dentoalveolar surgery is considered a major risk
factor for developing MRONJ.
Most clinicians and patients want to know:
Among patients exposed to antiresorptive
medications, what is the risk for developing ONJ
following tooth extraction (or other dentoalveolar
procedures such as implant placement or
periodontal procedures)?
The best current estimate for the risk of ONJ
among patients exposed to oral bisphosphonates
following tooth extraction is 0.5%.
Absent data, the committee considers the risk for ONJ
after dental implant placement and endodontic or
periodontal procedures that require exposure and
manipulation of bone to comparable to the risk
associated with tooth extraction.
2. Anatomic factors:
MRONJ is more likely to appear in the mandible
(73%) than the maxilla (22.5%) but can appear in
both jaws (4.5%).
Denture use was associated with an increased risk
for ONJ among cancer patients exposed to
zolendronate.
C. Demographic and systemic factors and other
medication factors:
Age and sex are variably reported as risk factors for
MRONJ. The higher prevalence of this complication in the
female population is likely a reflection of the underlying
disease for which the agents are being prescribed (i.e.
osteoporosis, breast cancer).
Corticosteroids are associated with an increased risk for
MRONJ.
Co-morbid conditions among cancer patients:
include anemia (hemoglobin < 10g/dL) and diabetes.
Tobacco use has been inconsistently reported as a risk
factor for MRONJ.
D. Genetic factors:
Collectively, studies suggest that a germ line
sensitivity to bisphosphonates may exist.
In summary, the current literature reaffirms that the
risk of MRONJ is significantly greater in cancer
patients receiving antiresorptive therapy as compared
to treatment regimens for osteoporosis.
Moreover, the risk of MRONJ in osteoporosis
patients receiving antiresorptive therapy continues to
be very low regardless of drug type (bisphosphonates,
denosumab) or dosing schedule.
Management Strategies for
Patients Treated with
Antiresorptives or Antiangiogenics
1. Prevention of MRONJ:
Early screening and initiation of appropriate dental
care
2. Cessation of at-risk medication therapy
prior to tooth extraction or other procedures,
which involve osseous injury (eg dental
implant placement, periodontal or apical
endodontic treatment): DRUG HOLIDAY??
Drug Holiday??
a. Antiresorptive Therapy for
Osteoporosis/Osteopenia :
Damm and Jones note that since 50% of serum BP
undergoes renal excretion the major reservoir of BP is
the osteoclast whose life span is 2 weeks. Thus the
majority of free BP within the serum would be
extremely low 2 months following the last dose of an
oral bisphosphonate and a 2-month drug free period
should be adequate prior to an invasive dental
procedure.
Drug Holiday??
b. Oncology Patients Receiving Monthly

Antiresorptive Therapy:
There are no data to support or refute the cessation
of antiangiogenic therapy in the prevention or
management of MRONJ and therefore continued
research in the area is indicated.
Management Strategies
A. Patients about to initiate intravenous
antiresorptive or antiangiogenic treatment for
cancer therapy :
The treatment objective: minimize the risk of developing
MRONJ.
Non-restorable teeth and those with a poor prognosis should be
extracted.
Other necessary elective dentoalveolar surgery should also be
completed at this time.
Based on experience with osteoradionecrosis, it appears
advisable that antiresorptive or antiangiogenic therapy should
be delayed, if systemic conditions permit, until the extraction
site has mucosalized (14-21 days) or until there is adequate
osseous healing.
B. Patients about to initiate antiresorptive

treatment for osteoporosis:
At the initiation of treatment, patients should be
educated as to the potential risks of MRONJ as the
antiresorptive therapy is likely to exceed beyond 4
years treatment. The importance of optimizing
dental health throughout this treatment period and
beyond should be stressed.
C. Asymptomatic patients receiving intravenous
bisphosphonates or antiangiogenic drugs for cancer :
Maintaining good oral hygiene
Procedures that involve direct osseous injury should be
avoided.
Non-restorable teeth may be treated by removal of the
crown and endodontic treatment of the remaining roots.
Placement of dental implants should be avoided in the
oncology patient receiving intravenous antiresorptive
therapy or antiangiogenic medications.
Endodontically Treated
IV Meds
The risk of developing MRONJ associated

with oral bisphosphonates, while exceedingly
small, appears to increase when the duration of
therapy exceeds 4 years.
The efficacy of utilizing a systemic marker of

bone turnover to assess the risk of developing
jaw necrosis in patients at risk has not been
validated. Therefore the use of systemic
markers of bone turnover as a measure of
MRONJ risk is not recommended although the
Committee supports continued research in this
area.
For individuals who have taken an oral

bisphosphonate for less than four years and
have no clinical risk factors, no alteration or
delay in the planned surgery is necessary. This
includes any and all procedures common to
oral and maxillofacial surgeons, periodontists
and other dental providers.
For those patients who have taken an oral

bisphosphonate for less than four years and
have also taken corticosteroids or
antiangiogenic medications concomitantly:
the prescribing provider should be contacted to
consider discontinuation of the oral
bisphosphonate (drug holiday) for at least two
months prior to oral surgery, if systemic conditions
permit.
For those patients who have taken an oral

bisphosphonate for more than four years with
or without any concomitant medical therapy:
the prescribing provider should be contacted to
consider discontinuation of the antiresorptive
for two months prior to oral surgery, if systemic
conditions permit. The bisphosphonate should
not be restarted until osseous healing has
occurred.
Staging and Treatment
Strategies
At risk category:
No apparent necrotic bone in patients who have
been treated with either oral or IV bisphosphonates
Management:
No treatment indicated
Patient education
Strategies
Stage 0:
No clinical evidence of necrotic bone,
But non-specific clinical findings
radiographic changes
and symptoms
Systemic management, including the use of

pain medication and antibiotics
Strategies
Stage 1:
Exposed and necrotic bone,
or fistula that probes to bone,
- in patients who are asymptomatic and have no evidence of

infection
Management:
Antimicrobial mouthrinse
Clinical follow-up on a quarterly basis
Patient education and review of indications for
continued bisphosphonate therapy
Strategies
Stage 2:
or fistula that probes to bone,
associated with infection as evidenced by pain and erythema in the
region of the exposed bone with or without purulent drainage.
Management:
Symptomatic treatment with oral antibiotics
Oral antibacterial mouth rinse
Pain control
Debridement to relieve soft tissue irritation and
infection control
Strategies
Stage 3:
or a fistula that probes to bone in patients with pain,
infection, and one or more of the following:
exposed and necrotic bone extending beyond the region of
alveolar bone,(i.e., inferior border and ramus in the
mandible, maxillary sinus and zygoma in the maxilla)
resulting in pathologic fracture, extra-oral fistula, oral
antral/oral nasal communication, or osteolysis extending to
the inferior border of the mandible of sinus floor
Strategies
Stage 3 management:
Antibacterial mouth rinse
Antibiotic therapy and pain control
Surgical debridement/resection for longer term

palliation of infection and pain
Regardless of the disease stage, mobile

segments of bony sequestrum should be
removed without exposing uninvolved bone.
The extraction of symptomatic teeth within
exposed, necrotic bone should be considered
since it is unlikely that the extraction will
exacerbate the established necrotic process.
Oral BP
Oral BP
After Debridement
IV BP
April 2013
IV BP
IV BP
August 2013
IV BP
After Debridement

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Prevention, Diagnosis,

Take out of traumatic occlusion

Stabilize for 10-14 days

Minimize tractional forces, use proper elevation

Inform the patient

Removal of sufficient bone

Placement of finger or instruments as distal stop

The most common factor: excessive apical force

Instruct the patient not to swallow before you start

Curettage of the socket is not necessary.

Gentle saline irrigation

Change dressing everyday or every other day until

Extruded endo fill

Adjacent edentulous spaces

Larger perforations, 5 mm or greater, requires

Post-op sinus precautions, antibiotics, nasal

Sneeze or cough with mouth open (3 weeks)

Eventually exclusively anaerobic.

The patient is often febrile at this stage.

Pain Severe and generalized Localized

Degree of Greater Less

Status of patients immune system

Incision and drainage of soft tissue collection

Long surgical procedure

Surgical procedure with high degree of

Presence of foreign body

Problems associated with use of antibiotics:

use of wrong antibiotics.

Presence of allergic reactions

Toxicity reactions to antibiotics

Secondary infection (e.g. Candida)

Cephalosporins (one third)

The Special Committee recommends changing the

When denosumab (Prolia) is administered subcutaneously every 6 months;

Denosumab (Xgeva) is also effective in reducing SRE related to metastatic

Denosumab therapy is not indicated for the treatment of multiple myeloma.

b. Oncology Patients Receiving Monthly

B. Patients about to initiate antiresorptive

The risk of developing MRONJ associated

The efficacy of utilizing a systemic marker of

For individuals who have taken an oral

For those patients who have taken an oral

For those patients who have taken an oral

Systemic management, including the use of

- in patients who are asymptomatic and have no evidence of

Surgical debridement/resection for longer term

Regardless of the disease stage, mobile

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