Ocrelizumab: External Resorption and Implant Treatment?

How did you arrive at that diagnosis? however, when in doubt it is advisable to refer.

I'm not sure there is any basis for fearing osteonecrosis as is the case with bisphosphonates, but I personally would worry about infection. 1. if she is asymptomatic treatment can wait. 2. extraction followed by a fixed bridge is an option. 3. if you go for an implant, I would do it in close consultation with her MD. Good luck thanks for being cautious.

How about endodontic treatment on the affected premolar followed by reduction below the osseous crest and allow the root to remain ? Follow this up with a 3 unit bridge to restore function

Consider reflecting a flap (will require some osseous recontouring/ostectomy)) to gain access to the external resorption and attempting restoration....does not appear to have pulpal involvement.... good luck!

As stated I would guard against infection with an appropriate pre- treatment regimen of antibiotics as well

I would say that Jerry is on the right track here. As long as there is no pulpal involvement, restoration is imperative. In our office, we use a glass ionomer restorative ( remember the old miracle mix?) after completely cleaning the defect. I had a classmate who once was Oral Path chairman at univ of Oklahoma who alerted me to this approach over 25 years ago. Not sure why it works and not sure if they ever reported any research on this, but it has been very successful in my practice with many patients.

This case should be restorable at least in the short term but possibly long term. I would suggest you talk to your best local endodontist colleague who should be familiar with up to date treatment options for external resorption.

I work with a great Endodontist and Periodontist. Nonetheless, when I contact them about such cases they usually punt and suggest extraction. I emailed one of them about this particular case and never received a reply. I appreciate all the comments, especially Jerry, John and Doc B. I appreciate you sharing your views and experience.

I have treated 10-12 similar cases via crown lengthening to gain access and a resin modified glass ionomer (Fuji II LC) or if the field is messy amalgam. Of the ones I have treated going back 10 years I recall only one failure.

Check the ctx telomerase levels.If it is less than 150 then treatment or extraction has very low risk of developing into MRONJ.However take an added step and Go ahead with doing a drug holiday for 4 months.Till that time let ur endodontist do some temp treatment. After 4 months extract the tooth. Good luck Dr indraniil Roy Oral and maxillofacial surgeon

I retired from my practice after practicing for 47 years, I am of the opinion that Dr.B's miracle mix will be a solution to this.

Looks like an impressive restorative material....here's a description of what it is: Miracle Mix by GC America is a crown and core build-up material that utilizes a unique, metal-reinforced formula of glass ionomer cement with 100% fine silver alloy powder. This composition makes Miracle Mix a reliable core material for long-lasting build-ups, block-outs, and repairs. Its strong direct bond eliminates the need for undercuts, while the fluoride release reduces the risk for secondary decay. Does not chip or flake when trimming Chemical bonding 4 minutes set to finish Does not stain or discolor teeth No-mess capsules or powder liquid

Agree with most of the above comments. I see no reason for a rush to extraction, nor why this should not be restorable. A flap with a little crown-lengthening might be needed and Miracle mix would probably work best, although Ti-Core Grey is also absolutely excellent for this (used it with great success in such cases), and plain old amalgam is fine as well, if operative field bleeding is uncontrollable. If you want to be surgically conservative you could also use the classical approach of a distal Class II prep to gain access to the resorption through the proximal box. Endo may also be warranted, depending on whether excavation leads to nerve exposure and/or post-op symptomatology. Implant is the very last thing I would consider, having exhausted all other possible options (including extraction and bridge, as a last-ditch option). My 34 years of practice can't dictate otherwise. And replace your current endodontist and periodontist. It's unprofessional to "punt" -- it smacks of lazyness or lack of experience. If a specialist never even replied to my e-mail re: a case, I wouldn't give him the time of day any more, as I would feel he doesn't deserve my referral. And congrats for being cautious. It's best to always err on the side of kindness.

If there is any risk of osteonecrosis I would avoid an extraction. Although the lesion is radiographically subcrestal it still may be restorable. I would determine endodontic need first (probably) a pulp test,pa and caries control. I would place a lab fabricated inlay-with a good impression an aggressive cord packing your sure to have a smooth sealed margin. I try to avoid canine abutments for posterior fpd’s for several reasons.....ps there’s distal decay on #19 and mesial calculus on #14-good luck

Thanks for sharing your case. I am certainly not an expert in the use of the following drugs I will discuss, I wanted to share my thoughts as I do not feel your current patient is at high risk for development of MRONJ. I am not certain you can make a direct correlation of developing MRONJ to the Ocrelizumab infusions in your other two patients who you stated had developed it, nor do I think it is a significant risk factor in this case. Three monoclonal antibodies are recognized by the Food and Drug Administration as leading to MRONJ: denosumab, bevacizumab, and sunitinib. While these are monoclonal antibodies, as is Ocrelizumab, their mechanism of action is quite different than Ocrelizumab in that these three drugs directly either inhibit angiogenesis or the maturation of pre-osteoclasts into osteoclasts. These two mechanisms of action have been proposed as possible causative factors in the development of MRONJ. Ocrelizumab selectively targets the CD20-positive B-cells by binding to the surface proteins of the cells and protecting the nerve cells from mediated damage caused by CD20-positive B lymphoma cell lines in patients with MS. While there is certainly some cytotoxic and immunosuppressive effect with this medication, its primary mechanism of action at least theoretically should not be a large risk factor in the development of MRONJ; at least as we understand MRONJ today. I would not be significantly concerned about doing an extraction on the patient in terms of risk of MRONJ. If the tooth is restorable (I am an OMFS but was a general dentist for five years before residency and used Miracle Mix many times to repair resorption), attempting to keep it is fine, but I would not be overly concerned about extracting it if that is deemed its fate. If the site appears to have normal healing after the extraction, then I would feel comfortable placing an implant in this patient. Ocrelizumab does not have a direct effect on osteoclasts or angiogenesis, so I would anticipate things would heal pretty normally. If the healing was poor or markedly delayed, then avoiding further surgery and doing a bridge might be a more reasonable option. Again, don’t consider myself to be an expert, but wanted to share my thoughts.

Dear Doctor Avoid doing implantation for 2 reasons 1_Possibilty oc infectiob and poor healing of bone and soft tissue around implant.