Oral Surgery

The extraction of third molars is the most common surgical procedure in dentistry. It is therefore critical for the pediatric dentist to understand the standard of care for the treatment of the impacted third molars. There are multiple reasons for extracting a third molar; however, the primary reason for the extraction of an impacted third molar is to limit the progression of periodontal disease. The extraction of third molars in the young patient, however, is not necessarily deemed as preventive

If it is advantageous to extract third molars, the timing of this procedure should be such that it is performed with the intent to optimize health and minimize potential risks and complications. Optimal bone healing with improvement of intrabony defects on second molars adjacent to third molars has been shown to occur when surgery is performed in individuals younger than 25 years of age

Elie M. Ferneini, Jeffrey D. Bennett, in McDonald and Avery’s Dentistry for the Child and Adolescent (Tenth Edition), 2016

Prevention Strategies for Patients with Osteoporosis or Other Benign Bone Disease
The treating physician should inform all patients receiving bisphosphonates for osteoporosis and Paget disease that ONJ is a potential side effect of bisphosphonate therapy. However, it is equally important to reassure patients that the risk of developing BRONJ is very low, ranging between 1/10,000 and 1/250,000, and that the benefits of antiresorptive therapy in patients at high risk for fractures outweigh the low risk of BRONJ. Treating physicians should educate their patients about the signs and symptoms of ONJ (Table 81.2) and the risk factors for developing ONJ (Table 81.5). Patients taking bisphosphonates should be encouraged to maintain good oral hygiene, to have regular dental visits and proper dental care. They should be instructed to inform their dentist that they are taking a bisphosphonate and urged to report any oral problems to their dentist and physician. Because the risk of developing BRONJ is so low and appears to be related to longer duration of bisphosphonate exposure, it is not necessary to recommend a dental examination before beginning bisphosphonate therapy for osteoporosis or to alter otherwise routine dental management. However, if appropriate dental resources are available and the patient’s financial circumstances permit, it is also not unreasonable for patients to have a dental evaluation before or soon after initiating bisphosphonates, so that any necessary dental procedures can be completed either before or early in the course of treatment.

For patients on long-term bisphosphonate therapy for osteoporosis (empirically defined as > 3 years), several precautions are advised. Active dental disease should be treated despite the low risk of developing ONJ, because allowing caries, severe periodontal disease and periapical abscesses to remain untreated can lead to a requirement for more extensive therapy and these conditions are themselves risk factors for ONJ [10]. Periodontal disease should be managed without surgery, if possible. Any necessary surgery should be aimed primarily at reducing or eliminating periodontal disease. Dental implants are not contraindicated, but informed consent is recommended and should be documented. Endodontic treatment (root canal) is preferable to dental extraction when possible. While some dentists suggest stopping bisphosphonates temporarily before invasive dental procedures until healing is documented, there is no evidence that this practice improves dental outcomes. Given the long residence of bisphosphonates in the skeleton, temporary discontinuation of bisphosphonates is unlikely either to affect the risk of developing ONJ or to have an adverse effect upon the patient’s osteoporosis. Although it has been suggested that low serum C-telopeptide of type I collagen (CTX, a bone resorption marker) levels may identify patients at risk for ONJ [81–83], the clinical utility of this approach is questionable given that virtually all patients on a bisphosphonate will have reduced serum CTX levels [84].

Prevention Strategies for Patients with Malignant Bone Disease
The treating physician should inform all patients that bisphosphonates clearly prevent skeletal complications of malignancy, improve quality of life, and prolong survival but that ONJ is a potential side effect of bisphosphonate therapy. They should also inform the patients that although the estimated incidence of BRONJ in patients with malignancy varies widely (from <1% to as high as 18.6%), most studies suggest it is quite low, in the region of 2% to 3% for multiple myeloma and approximately 1% for breast cancer, at least in the US [21,24]. Whenever possible, patients should have a dental evaluation before starting IV bisphosphonates for bone metastases. Dental evaluations should continue throughout the course of bisphosphonate therapy at 6- to 12-month intervals, or as dictated by the clinical and dental status of the patient. If the patient’s oncological condition permits a delay in initiating bisphosphonate therapy, any necessary invasive dental procedures should be performed and healing completed before starting treatment with a bisphosphonate [12]. Otherwise, bisphosphonate therapy should be instituted concomitantly with dental therapy with careful follow-up to ensure complete healing of the surgical site. Elective dentoalveolar surgical procedures (such as implant placement, tori reduction, and extraction of asymptomatic teeth) are not recommended. If possible, symptomatic teeth that would otherwise require extraction should receive nonsurgical endodontic or periodontal therapy and should be left in place. Only if the tooth is excessively mobile and presents an aspiration risk should it be extracted. Periapical or periodontal surgery is not recommended. If symptomatic teeth are located within an area of bone that is already exposed and necrotic, extraction should be considered because it is unlikely that it will exacerbate the established necrotic process.

Management of Established Osteonecrosis of the Jaw
As it may not be possible to eradicate ONJ once established, reducing the risk of developing ONJ should be a central focus of the management strategy for patients receiving bisphosphonates any indication.

Some experts suggest stopping bisphosphonates in patients with established ONJ while others believe that discontinuation of bisphosphonates is unlikely to affect ONJ outcomes. However, the indication for which the patient is receiving bisphosphonates should be taken into consideration. If the patient has aggressive skeletal metastatic disease, bisphosphonate treatment may be continued. In contrast, if the patient is receiving therapy for prevention of metastases rather than for established metastases, bisphosphonate treatment may be discontinued. Temporary discontinuation may have minimal effects on osteoporosis management, particularly if the patient has received a full 5-year course of treatment.

Clinical management of established ONJ differs according to the stage of the disease [78]. Stage 1 ONJ (asymptomatic exposed bone without significant inflammation or infection) requires only oral antibiotic rinses (such as 0.12% chlorhexidine digluconate) and close clinical follow-up. Stage 2 disease (exposed necrotic bone with pain and infection) should be managed with pain control, oral antibiotic rinses, and systemic antibiotic therapy. Stage 3 disease (exposed necrotic bone with pain and infection plus fracture, extraoral fistula, or osteolysis) is typically refractory to antibiotics and may require surgical intervention, with segmental jaw resection, may be considered to control pain and infection.
Elizabeth Shane1, … David Burr3, in Osteoporosis (Fourth Edition), 2013

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