Radiolucent periapical lesion in patient with osteoporosis: Recommendations for implant installation?
I have a 67 year old female patient with osteoporosis. Â I extracted #4 [maxillary right second premolar;15] due to a failed endodontic treatment and non-restorable root fracture 4 months prior. Â The tooth had an abscess and a very definite radiolucent periapical lesion visible on the pre-operative periapical radiograph. Â There was a significant buccal cortical plate defect following the extraction. I curretted the socket aggressively to remove infected material. Â I grafted with Bio-Oss and covered with a resorbable collagen membrane. Â I did not pack graft material in the very most periapical reaches of the extraction socket because I was concerned about penetrating the maxillary sinus. Â The medical history is significant for Metformin for well controlled diabetes and bisphosphonates for osteoporosis. Â She has been receiving IV Risedronate. Â I have postponed the implant installation for 6 weeks to see if the periapical ‘shadow’ disappears due to bone remodeling and continued healing. Â I am planning on installing a 10mm MIS SEVEN implant which will reach the area with the shadow.
1)Should I continue to wait and observe this shadow to see it will completely fill in with new bone?
2)Are there any special precautions I should take when I do the implant installation?
Any other recommendations would be appreciated.
Most current X-ray of the 15 site. Approx 4 months since exo + Bio-Oss
![]Most current X-ray of the 15 site. Approx 4 months since exo + Bio-Oss](https://osseonews.nyc3.cdn.digitaloceanspaces.com/wp-content/uploads/2012/10/Image012.jpg)
Infected 15 site before extraction and bone grafting
![]Infected 15 site before extraction and bone grafting](https://osseonews.nyc3.cdn.digitaloceanspaces.com/wp-content/uploads/2012/10/Image015.jpg)
22 Comments on Radiolucent periapical lesion in patient with osteoporosis: Recommendations for implant installation?
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behzad rahsepar
10/3/2012
There is no contraindication or special precautions. sometimes it takes 6 months for normal radiologic findings of the mature bone go a head.
Leal
10/3/2012
I don't agree.
My way of thought in oral surgery is: oral Risedronate: hmm...... more or less OK; IV Risedronate: hmmm... not OK.
The Xenograft you placed in (not that I have ANYTHING against it... I use it in some particular cases) is well known to be some part very slowly resorbable or non resorbable at all.
So with a potent osteoclast inhibitor like the Risedronate you will most likely (for sure) have a xenograft mass in place for the rest of that lady's life. So what can happen (worst case scenario)? 1st: implant will never integrate; 2nd Osteonecrosis.
I have only one question and one question only. In an old lady taking IV bisphosphonate and having diabetes why would you think about placing an implant? Why not placing a fixed bridge? It would probably last for 25 years (probably the patient's all life) and you would get rid of that amalgam.
Leal
10/3/2012
I will go further and say that even for that tooth extraction I would send a letter to her family doctor and ask for written consent to do a minor surgery. But that's just me.
Regards.
a
10/3/2012
I agree with Leal.
IV bisphosphonates higher risk of ONJ and implant not integrating. If patient really wants implant, maybe get CTX test first to check her level.
Also I agree with Bio-Oss. In patient with reduced bone-turnover (IV bixphosphonates) and a xenograft, very unlikely xenograft would be replaced with bone (if at all). In your case, I would only expect bone to fill in the apical area where you did not pack Bio-Oss.
Hope this helps :)
CRS
10/4/2012
Bio-oss never resorbs it stays there forever. I'd wait another two months see if BRONJ develops then make her a nice bridge. If you roll the dice and place an implant you need to have a very clear consent for the risk of BRONJ since the iv dose really raises the risk. Remember all you are looking at on the film is the bio-oss not healed bone. I agree with Leal good advice. You have three risk factors, 1. an infected site (retrograde peri-implantitis) 2. Iv bis-phos/osteoporosis 3.diabetes. I would have gotten the medical clearance PRIOR to extraction (CYA) How about a drug holiday with approval of MD? The first posting is inaccurate and foolish. Call the physician to keep him informed, and do the right thing for the patient.
sb oms
10/4/2012
99% of physicians know little to nothing about BRONJ. We are the ones who diagnose and treat disease, GP's and oral surgeons. When you are asking the MD if it's okay to take the tooth out- what good are you really doing here? Basically just a CYA move, nothing else. If you are unsure about whether it's okay to do a procedure, you shouldn't be doing it. Ask an expert. OMFS see and treat this condition. They (we) are the experts.
Regarding this case, if your patient can heal an extraction site, they can tolerate a dental implant (correctly done). Extraction socket healing puts a lot more demand on bone biology than a single strait forward dental implant.
That being said, what were you trying to accomplish with bio-oss in this extraction site?
Bio-oss is an excellent space maintainer, but it really never resorbs. Ridge augmentation - preservation under pontics is a great bio-oss use. Socket grafting-- not a good one. Regardless of what the rep says. You want bone around your implant - not bovine HA. Especially in this case where you were trying to regenerate an area of buccal plate.
I commend you on asking these questions. But lets think about this one-
You have a diabetic on Intravenous bisphophonates. While I'm sure you could do this correctly, I wouldn't. Refer it to someone who would stand better than you in the eyes of the medico-legal world if this went bad.
CRS
10/5/2012
No junior you are finding out the duration of the treatment, and the possibility of a drug holiday. You are also educating the md. All information is helpful. And yes I agree that a general dentist has no business treating this case, I've seen it time and time again with serious results. There are three big red flags in this case, it's already been done and I was tactfully trying to have the gp back out and refer the case. As an oral surgeon, I would not tackle this elective case just to put in an implant it's not the best option for the patient. I've done IV bisphosp. case extractions following the Marx/AAOMS protocol and guidelines, unfortunately this was not done and no preop consultation with an OMS or MD was done. So I'm agreeing with you but , your "expert" attitude is not helpful, no one really knows the outcome of these cases, the Bisphos has a long half-life! Sorry if I was too harsh, good comments.
Richard Hughes, DDS! FAAI
10/7/2012
Why on earth did you use BioOss? It only yields 23% bone. There are much better products available. What is her CTx test result?
CRS
10/7/2012
Actually it's not so crazy, if you think about it, if the patient doesn't have functioning osteoclasts, you are not relying on turnover of the product. Any way there aren't any studies that I know of. I'd still recommend the bridge!
Richard Hughes DDS FAAID
10/8/2012
I correct my self. BioOss does not yield bone. However, there is a fill in of bone ane a lot of fibrous connective tissue
greg steiner
10/8/2012
To CRS, Hughes and sb oms
You have presented a clear understanding of the graft material used and that is the best possible use of this forum. Bone grafts are possibly the least understood of any material we use in dentistry and for those few that do understand it is a great service to share your knowledge. Greg Steiner Steiner Laboratories
pcPerio
10/9/2012
As a periodontist with 30 years of surgical experience, I think we have several topics under discussion.
1. This woman is a poor surgical risk from a medical perspective. An implant is not the best option regardless of who places it.
2. Regardless of her medical history, you do not have good bone to place your implant. the material is irrelevant. Simply placing something in the socket will not give you good bone. It is a little more complex than that. The drugs she is taking certainly complicate things even more.
3. Medicolegal considerations are important, but what about the patient? If this was my family member I would want a different treatment approach.
4. ONJ is a very difficult thing to manage in anyone's hands There are no experts, it is unpredictable, period. I see no reason to risk complicating this person's life.
drD
10/9/2012
The medical diagnosis and drug therapy issues aside, if you were to go into this site with an osteotomy you will find granulation tissue. It may not have been properly curretted in the first place. Id give it ample time..again..medical issues aside
DrT
10/9/2012
The CTx is of questionable diagnostic value....check the literature.
DtT
gary omfs
10/10/2012
Quite right, I always wondered why people on this forum rely on it. It's worth nothing and won't save you from litigation. As for the family physician, surely he'll say no, what else?
Totally agree with leal.
Farhan Qureshi
10/9/2012
Every thing a side,please check vitality of tooth # 5
Baker k. Vinci
10/9/2012
Based on the literature I read, this is contraindicated care. A surgeon should have extracted the tooth, with little or no flap elevation and you certainly should not raise a large enough flap for a membrane. If the tooth was abcessed, there was little to discuss. Now there should be some discussion between the patient and the prescribing doctor, as to why they are utilizing iv bisphosphonates for osteoporosis. Most of the time, the cure is worse than the disease in these patients . I would have not used a graft/xeno and I would encourage a fixed partial. Bvinci
Baker k. Vinci
10/9/2012
Based on the literature I read, this is contraindicated care. A surgeon should have extracted the tooth, with little or no flap elevation and you certainly should not raise a large enough flap for a membrane. If the tooth was abcessed, there was little to discuss. Now there should be some discussion between the patient and the prescribing doctor, as to why they are utilizing iv bisphosphonates for osteoporosis. Most of the time, the cure is worse than the disease in these patients . I would have not used a graft and I would encourage a fixed partial. Bvinci
Sam Jain DMD
10/10/2012
Doc
Which country u r practicing in? Seems like you haven't heard the words ONJ or BRONJ. You got to know what IV bisphophonate therapy means for a dentist in the business of placing implants. And then not cleaning the socket properly for the fear if poking in the sinus and then using bio- OSS .....this is not being sincere.
Sam Jain DMD UCONN 2000
Center for Implant Dentistry
Fremont, CA
Baker k. Vinci
10/15/2012
I probably treat more "bronj" than most in my region and from my experience, I have never had a case in the first premolar region, with the exception of one, that involved the entire posterior maxilla. It had been watched for over a year, before getting to our office. My point is; the likely hood of getting the disease here, is low. Conservative extraction and if it grows bone( unlikely in this case) an implant can be placed after a 6-12 month holiday, if you must place an implant???? Bvinci
CRS
10/20/2012
This is a really good discussion on Bronj. Let's take another look at management of a buccal plate defect.It needs to be addressed with more than Bio-OSS and a resorbable membrane even without the Bisphosp. This case should have been referred to an oral surgeon, you did not follow the treatment protocol. I totally agree with Vinci. Hopefully you will learn from the discussion and I applaud your courage in posting the case, that's how we all learn!
Richard Hughes, DDS, FAAI
10/22/2012
I agree with CRS and BV, iv BP's are a serious red flag. BioOss does not resorb and most likely will not yield a sufficient site for implant survival. A FPD is a most viable and safe treatment plan for this site and circumstance.
