TriangleOMS Newsletter David M. Lambert, DDS, PA
October 2006 Volume 1, Number 4
In This Issue · Bisphosphonate Osteonecrosis Revisited · Antibiotic Resistance · Editorial · Important Dates Bisphosphonate Osteonecrosis of the Jaws Triangle OMS Referral Resource Site Read several articles about BON from the literature Contact Us www.TriangleOMS.com dmldds@TriangleOMS.com	Bisphosphonate Osteonecrosis Revisited The ADA recently published a position paper regarding bisphosphonate osteonecrosis (BON). Their recommendations parallel the recommendations made by Dr. Robert Marx and others. Despite the emergence of information regarding BON, it has been our experience there continues to be great confusion as regards who specifically is at risk within the local community. Risk for BON is multifactorial but perhaps the 2 most influential factors are 1) trauma and 2) the indication and therefore the associated route of administration of bisphosphonate agent. The risk of BON is significantly greater when the more potent agents are administered IV (Aredia/Pamidronate) for patients with metastatic bone cancer than when administered orally (Fosamax/Alendronate) for patients with bone density issues (post-menopausal females, spinal compression fractures, etc). The approaches to patient management therefore greatly differs depending upon the indication for bisphosphonate use. Suffice it to say, patients receiving IV bisphosphonates must be treated very carefully with prevention of BON being the utmost concern since once the process has been initiated there is no cure. Invasive procedures (i.e. surgery) must be avoided at all costs. Pre-treatment bisphosphonate oral screening/clearance has therefore been recommended. Because the risk of BON is much less with oral bisphosphonates, patients may undergo more routine procedures (restorative procedures, cleanings, endodontics, etc), and even surgery, with less concern. Keeping in mind trauma (i.e. surgery) is often the initiating factor, however, our approach is nevertheless to inform and include the risk BON in the informed consent process. Antibiotic Resistance Despite decades of use and the emergence of new agents, Penicillin is still the empiric drug of first choice for odontogenic oral and maxillofacial infections. However, we are witnessing a significant increase in the resistance of infections to Penicillin. This can be manifest in many ways, but increased time to clinical effect and/or decreased maximum effect are commonly observed in our practice. Infections which commonly include anaerobic bacteria (infections due to periodontitis, pericoronitis, or endodontic infections) are notoriously resistant to Penicillin – due to the production of penicillinase by these organisms. Previous administration with the same antibiotic for the same problem will tend to select resistant strains and thus increase the likelihood for poor clinical response when re-challanged (read Darwin – Origin of Species…). If your patient does not appear to be responding to Penicillin, first consider the addition of Metronidazole (Flagyl). Alternatively, changing Penicillin to Augmentin (amoxicillin/clavulanate) should provide effective coverage, with a decrease in symptoms within 24-48 hours – but perhaps this drug should be reserved for more severe infections or for immune compromised patients. For penicillin-allergic patients, consider the use of clindamycin, or ciprofloxacin. A first generation cephalosporin, such as Keflex (cephalexin) or Ceclor (cefaclor) will not provide adequate antimicrobial coverage; nor will Erythromycin (also remember GI intolerance and plethora of drug interactions). Lastly, never forget the ramifications of disease processes which affect immune status; i.e. diabetes mellitus, renal dysfunction, transplant patients, etc – and how they may effect clinical outcome. Editorial My intent here is not to wax political – but I’m really having trouble understanding something – can somebody please help me? You see, I’m having a bit of a problem understanding why there is a proposal to open a new dental school at East Carolina University. Let me see if I understand this…if there is a perceived need for a new dental school, then it must be because there is also a perceived lack of manpower or access to care in certain geographic areas. If this is true, then before embarking upon such a costly proposition, might not politically minded individuals wisely consider alternative measures first – like maybe… Promote an open climate of professional licensure in NC? Provide or increase tuition/tax incentives to practitioners to practice in underserved areas? Increase the size of classes at the UNC Dental School? None of these alternatives have been initiated. To make matters worse, this proposal is still being pursued despite… The high cost of building a new dental school will be firmly placed on the backs of taxpayers of NC Comparing the economics of medical practice to dental practice is irrelevant and a carrot. Successful assimilation of medical trainees into the local community is based upon ample opportunities with managed care (HMO’s, PPO’s, etc) organizations – an environment the polar opposite from traditional fee-for-service based dental practice. Suggestions that dental practitioners would follow the medical model therefore are misrepresentations. States which have more than 1 dental school (Kentucky, Michigan, Pennsylvania, etc) have historically consistent discussions about closing one school States which have pursued the opening of another dental school with the premise of easing access to care problems have increased provider density in already overserved areas. This provides fertile turf for the entrenchment of dental managed care plans. There is already a dirth of personnel to fill academic positions throughout the country Interestingly enough, the NCDS – despite decades of promoting “high quality care” for NC citizenry thru fostering restrictive professional licensing – is remarkably reticent on this issue. Somebody much wiser than I once said “if something doesn’t make sense, chances are there’s politics involved”. Looks more like the tail wagging the dog… Well, my 0.02, for what it’s worth. If you’re scratching your head like me, consider signing the online petition at: www.ipetitions.com/petition/no_new_school/ Important Dates October 4 – 6, 2006: AAOMS Annual Meeting in San Diego, Ca November 23-24, 2006: Thanksgiving Holiday December 25-26, 2006: Christmas Holiday January 1, 2007: New Year’s Holiday We support our partners in practice. We exist to serve you and your patients. We appreciate the opportunity to participate in your patients care.