CTX Level: What Level is Risky?

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Dr. C. asks:
I have a patient that requires 2 mandibular extractions and is interested in dental implant replacements. She has been taking Actonel for more than 3 years. I ordered serum CTX study which returned with a level of 137. According to Marx, this puts her in the moderate risk category.

I currently have started her on a 3 month drug holiday, and am planning to do the extractions soon after that. I am going to wait to place dental implants until I assess complete healing of the extraction sites in 4-6 months. Does anyone know of any value in retesting the CTX after a drug holiday period? Do you have any thoughts / recommendations regarding this treatment plan based on any experience with patients with CTX levels <150?

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11 Responses to “ CTX Level: What Level is Risky? ”

• Dinh X. Bui December 11th, 2007

  
  

  I have place implant in patient with Actonel. First, evaluate the healing of extraction site for tissue necrosis (usually bone exposure). Second, contemplating on doing the implant procedure flapless since you already visualize the extraction site (implant site) during the extraction. Flapless technique is the way to go with these patients.

• Bruce Bay area OMFS December 11th, 2007

  
  

  I would bet after 4 months her CTX level will be significantly higher. Eventhough the oral drugs have a very long half life, my experience has been that the CTX bounces back a lot faster than patients that were on the intravenous form and that is consistent even with patient on much greater than 36 months. Minimizing bone insults, flapless, reduce heat, avoid over-torquing, and antibiotics pre and post surgery should help.

  However, I have one case that came across my desk to review for an attorney. Lost 19, treatment planned for an implant, fosamax 5 years and on low dose prednisone for arthritis. CTX 109, after 4 months 180, implant failed, ON occurred, progressed to Stage IIIb (pathological fracture) loss of mandibular body from K9 to mandibular angle. The case ended up settling as the crux of the argument was that the patient was not informed of the potential severity of the possible sequela of treatment in the face of bisphosphonate, failure to recognize that she had other co-morbidities and taking a drug, prednisone, that can exacerbate the problem and she had an excellent alternative, namely a bridge that wasn’t explained to her well. So even with a good CTX, the entire patient must be taken under consideration and sometimes the older methods of tooth replacement are sometimes wiser. This case is unusual, but I will always remember it.

• Bob December 12th, 2007

  
  

  I don`t know which assays Prof. Marx has in use to determine CTX values. The Least Significant Change for Resorption Markers like CTX is usually between 60-80%. There is one study in the literature which showed changes of up to 66 % for Serum CTX values during a single day !
  It is pretty reasonable that patients with corticoid induced osteoporosis treated with Aminobisphosphonates are at a higher risk for ONJ.
  The American Society for Bone and Mineral Research recently published a Statement on the whole Bisphosphonate/ ONJ issue. That statement has zero recommendation of the Marx Protocol.

• Harper December 12th, 2007

  
  

  Recently heard Sal Roggerio talk at the AAOMS implant meeting. Because the serum CTX is a systemic measurement, it may not correlate with what happens in the jaws, therefore it may not be predictive of implant healing. He was not recommending the test proir to implant placement, but recommended a drug holidy prior to implant surgery and good informed consent. Marx was using serum CTX as a marker for recovery in those patients with Oral Bisphosphonate induced osteonecrosis of the jaws.

• Dr. Mehdi Jafari December 13th, 2007

  
  

  The cross-linked carboxyterminal telopeptide (ICTP) is released by matrix metalloproteinase (MMP) cleavage of type I collagen, and its levels reflect MMP-mediated soft tissue degradation. Cathepsin K-mediated osteoclastic bone resorption destroys ICTP antigenicity, but, both the carboxyterminal (CTx) and the aminoterminal (NTx) telopeptide of type I collagen are generated by cathepsin K-mediated bone collagen degradation. Although CTx and ICTP appear to provide identical information, more scrutiny reveals that these two markers, although based on the same principle of detecting type I collagen telopeptides, may provide valuable differential information. For instance, both CTx and NTx levels are very low in patients suffering from pycnodysostosis, which is caused by a deficient activity of cathepsin K, whereas ICTP levels are high. In postmenopausal women, anti-bone resorption therapy by hormone replacement reduces serum CTx levels, whereas ICTP levels do not change.In order to repair the damaged tissue , collagen synthesis is increased, leading to increased tissue levels of the C-terminal propeptide of type II collagen. By the way, CTX-II can be used to monitor therapy effects: In osteoporosis patients, elevated CTX-II levels suggest that bisphosphonates are degrading not nly the bone but the cartilage as well.

• 3rd molar slayer December 18th, 2007

  
  

  for the ctx to be accurate you order it “morning fasting” serum c-telopeptide.

• Mohamed Omar December 20th, 2007

  
  

  can any one send to me a recent paper about the CTx and BJBON,as I need more informatiom about that subject.
  Thanks.

• anon January 7th, 2008

  
  

  I have read that CTX levels should be 151 or higher in order to place dental implants. Is this accurate? Can I order this test or do I have to refer this to the patients’s physician to order it? How reliable is this test? I have several patients who have been taking bisphosphonates who need implants and I need to assess their risk levels. Thanks for any responses.

• Brad Bynum January 8th, 2008

  
  

  You can get Marx’s Book from Quintessence

  Oral & Intravenous Bisphosphonate-Induced Osteonecrosis of the Jaws by Robert E. Marx, DDS

  ISBN-13:978-0-86715-462-7

  My interpretation of his book is, if the patient has been on Bis Phosphonates for less than 3 years and have no medical risk factors, you are probably safe with an informed consent on implants. On patients who have been on BP for more than 3 years he says oral surgery may be done with the numbers below, but he does not say is safe to do implants with CTX above 150; (I could have misinterpreted what he means however)

  CTX 150 minimal to no risk

  For patients on Fosamax for more than 3 years, at least 3 month “holiday” from Fosamax then CTX must be above 150. Keep patient off Fosamax for 3 months after healing. Then well documented informed consent. My attorney says you or your staff also must explain the informed consent not just have the patient sign it. The patient has to tell you they understood what you explained to them. In other words, the first question in the deposition will be,”Ms. Jones, Did Dr. Implant or one of his staff members go over this informed consent with you or did they just ask you to sign it?”

• tim dpnley January 8th, 2008

  
  

  where can I find the asbmr statement? It is not readily available at their web site.

• anon OMS January 8th, 2008

  
  

  Addionally, my own thought here is that BP drugs should be really be discontinued in close consultation w/ physician who is prescribing them -otherwise, it seems to me that you are opening yourself up for liability from the other end (eg; pt breaks hip following your d/c’ing of BPs)

  I do think its the right thing to do for pts taking who have been taking these drugs for +3 years, just do it in concert w/ the MD. Since its at least a 3 month window, there is certainly time to consult…

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