Consideration for GBR multiple extractions for a patient with very short term exposure of Fosamax?
I have a 58 year old female with multiple missing teeth in her maxillary arch and periodontally compromised mandibular anterior teeth who wants only fixed prostheses. A preliminary orthopantomograph and CT scans show the need for block grafting in maxillary right anterior region up to the premolar region. Patient agreed to the extraction of all teeth due to poor prognosis and for GBR . Patient on review before the procedure showed prescription of her her orthopedist which showed Fosamax [alendronate]. She was prescribed 4 tabs of 70mg, one tab to be taken once a week and she took her last tablet a week ago.I would like to know what would be the protocol for doing the multiple extractions and GBR procedure and how long do I need to wait to begin?
9 Comments on Consideration for GBR multiple extractions for a patient with very short term exposure of Fosamax?
New comments are currently closed for this post.
Dr Yevnin DMD
12/2/2014
In the first three monthes of Fossomax therapy you have no contraidications and any risk for surgical procedures. The risk of developing osteonecrosis is about 0,3 % in the osteoporotic patients only after 4 years of such therapy.
Dime Sapundziev
12/2/2014
It is not clear how long she is taking Fosamax. If it is less than 2 years the risk for MRONJ is little. If you already have extracted the teeth and the extraction have healed univentfully there is nothing to worry about. I would not recomend GBR at the same time during the extraction to avoid graft infection that can contribute to MRONJ. The patient is on your side because it seams that she is prepared to take all risks. Maybue before implant placement is fine to check CTX just to be sure that the bone turnover is not supressed.
Make simple solutions minimum number of implants, proper loading and easy access for maintenance.
Good luck.
Dime
Cpb
12/2/2014
Oral bisphosphonates is not a contraindication for implant placement. Only iv bisphosphonates
CRS
12/2/2014
Correct me if I am wrong but the Marx protocol is three years oral Bisphosphanates and IV one year before osteonecrosis is a risk.Drug holiday 3-6 months can be used prior to oral surgery. CTX does not tell much.How about an all on four so that the block graft is not needed, I think that would be risky vs particulate grafting. If the patient only got four pills then no risk. I would get a really good consent before starting the half life on the Bisphos is very long. Hard to advise without films good luck.
anand
12/2/2014
thank u for all the comments.i have done the case two days back. i will post the case soon
Dime Sapundziev
12/3/2014
According to the first recomendations from the AAOMFS it was 4 years for patients on p.o. In the second edition of Marx's book it is 2 years. But anyway the general rule is patients on p.o. are at low risk compared to patients on i.v.
As far as CTX is concerned I agree that it dose not tell much and the corelation of the CTX value and osteonecrosis is questionable. But it is a marker that can help us make up our mind. I would not recomend dental implants to a patient with low values.
I have treated a patient that was 10 years on bisohosphonates with sinus floor augmentation before I startednto use CTX and everything is ok, two yers foloe up no bone resorbtion.
It is a little bit of lotary.
I think that for the patients on p.o. BP the most important thing is patient information and his willingness to take the risk, to be active part of the team.
Best regards.
Dime Sapundziev
CRS
12/3/2014
Great advice, and yes some of these patients on Bisphos have really hard bone!
peter Fairbairn
12/3/2014
Hi Dima , hope you are well and your patient was happy. I agree there are risks but they must be put into context as negligible in implant placement .In fact their oral use appears to help osseo-integration significantly !( JOMI systemic review about 18 months ago ) .
Extractions are the main concern and an interesting notion here is the use of L-Prf as described by Choukron .
Regards
Peter
Dime Sapundziev
12/3/2014
Hi Peter. You are wright there are articles especially in the field of orthoperic implantology that descibe BP coated implants to slow resorbtion rate around implants and to improve their stability. Even in oral implantology BP were used for the same reason.
The connection of dental extraction with osteonecrosis to my opinion can be a matter of debate. I have treated a lot of patients with BP on have a lot of unpublished data on that topic. For now until I carefully analize the data I dont dare to make any statements.
Best regards.
Dime Sapundziev
