Download Endodontic Treatment of a Patient on Intravenous Bisphosphonate

Endodontic Treatment of a Patient on Intravenous Bisphosphonate Therapy
IUSD Department of Graduate Endodontics
S. CHRISTENSEN * M. VAIL
Initial Presentation
A 74 year old male with a four year history of IV bisphosphonate (Aredia) therapy
for multiple myeloma presented to the Graduate Endodontic Clinic due to the risk of
Bisphosphonate Related Osteonecrosis of the Jaws (BRONJ). I.U. Oral Surgery and
Graduate Prosthodontics requested root canal therapy of several compromised teeth.
Initial examination revealed several missing teeth (1-5, 9, 15-20 and 32) with gross
decay and coronal fractures present on most of the remaining dentition (Fig. 1).
Teeth numbers 13, 28 and 30 had previous root canal therapy. Teeth #’s 12 and 14
presented as root tips with ulcerated, periradicular hyperplasic gingival tissue noted.
The patient had no complaint of overt pain, however tooth #30 was percussion
sensitive. The mucosa appeared dry, with no pooled saliva noted during
examination.
Treatment planning
Primary root canal therapy or retreatment was planned for the maxillary dentition in
preparation for a maxillary complete over-denture. Maxillary teeth were to be
decoronated and sealed with glass ionomer prior to fabrication of a maxillary overdenture. Treatment planning of the mandibular dentition included retreatment of
tooth #30 and fabrication of a removable partial denture. Root canal therapy for the
remaining dentition would be completed in the event of pulpal exposure.
Treatment
Root canal therapy was initiated with the primary focus of eliminating existing
infection prior to prosthetic restoration. Over the course of 7 months and 10
appointments, root canal therapy and decoronation procedures were completed on a
total of 13 teeth including a retreatment and perforation repair of tooth #30 (Fig. 2).
In all cases, whether root tips or intact dentition, standard treatment protocols for
orthograde root canal therapy was adhered to and included: rubber dam isolation;
copious irrigation with 6% Sodium Hypochlorite (Clorox, USA), 0.12%
Chlorohexidine (3M, Germany), and 17% EDTA (Vista, USA); hand and rotary
instrumentation; and sealed Resilon (Pentron, USA) obturation. A post-space, per
Graduate Prosthodontics request, was completed prior to coronal seal with Photac Fil
(3M, Germany) in all cases. Care was taken to limit instrumentation and obturation
within the canal to avoid unnecessary stimulation or trauma to the periodontium;
thus, limiting the possibility of subsequent complication consistent with BRONJ.
Due to decay and unrestorability, mandibular teeth were decoronated and a
removable partial over-denture was fabricated.
Follow-up
In each subsequent appointment, all previously completed root canals were assessed
clinically and radiographically for signs of healing and development of periapical
pathosis. Periapical sclerotic bone was noted on the distal root of #30 within 6 weeks
of completion of root canal therapy. Tooth #30 remained mildly symptomatic with
improving periapical status and eventual resolution of all symptoms within 4 months
post-operatively. No other significant complications in regards to osseous healing
were noted. On March 5, 2009 an upper complete over-denture and lower RPD
were delivered. As of March 26, 2009 the patient is functioning without pain.
A
B
E
C
D
F
G
Figure 1: Preoperative periapical radiographs: A 6-8. B:6-8, 10. C:11-13. D: 13-14.
E: 29-31. F: 23-27. G: 26-28.
A
B
E
C
D
F
Figure 2: Completed root canal therapies: A: 6-8. B: 8, 10. C:10-13. D:12-14.
E: 31, ReTx, MTA repair 30. F: 26-28
Pathogenesis
Bisphosphonate medications are known to inhibit osteoclasts and possibly interfere
with angiogenesis, precisely the reasons why they are indicated in some cancer
treatments.2 Unfortunately, these mechanisms are also the reason for the
development of BRONJ. Normally there exists a delicate balance between
osteoblasts and osteoclasts in remodeling normal bone and repairing microfractures. However, if osteoclastic function declines, as with patients on
bisphosphonates, the lifespan of afflicted osteocytes are diminished, creating
vulnerable bone. Moreover, one of the highest natural rates of active remodeling
occurs in the jaw allowing for incorporation of very high levels of bisphosphonates.
Clinical Presentation
BRONJ is often characterized by jaw pain, exposed bone, irregular soft tissue,
swelling, loosening of teeth and persistent infection with or without purulence (Fig.
3). These symptoms are often due to secondary infection of necrotic bone, not the
pathologic bone itself.1,3 The American Association of Oral and Maxillofacial
Surgeons suggests that positive diagnosis of BRONJ can only be made once three
criteria are fulfilled. 1) current or previous treatment with bisphosphonates; 2)
exposed or necrotic bone in the maxillofacial region lasting for more than 8 weeks
and; 3) no history of radiation therapy of the jaw.
Incidence
Current estimates indicate the prevalence of BRONJ is 6-10% in patients taking
aminobisphosphonates.
Ninty-four percent of BRONJ cases involve IV
formulations of bisphosophonate (pamidronate/Aredia and zoledronic acid/Zometa).
Of those patients on bisphosphonates for the treatment of multiple myeloma, 85%
will develop BRONJ.
References
1.AAOMS. Position Paper on Bisphosphonate-Related Osteonecrosis of the Jaws. American Association of Oral and Maxillofacial Surgeons 2006.
2.Berenson JR, Lipton A. Pharmacology and clinical efficacy of bisphosphonates. Current Opinion Oncology 1998;10(6):566-71.
3.Berenson JR, Lipton A. Use of bisphosphonates in patients with metastatic bone disease. Oncology (Williston Park) 1998;12(11):1573-9; discussion 79-81.
4.Hortobagyi GN, Piccart-Gebhart MJ. Current management of advanced breast cancer. Semin Oncol 1996;23(5 Suppl 11):1-5.
5.Hortobagyi GN, Theriault RL, Porter L, Blayney D, Lipton A, Sinoff C, et al. Efficacy of pamidronate in reducing skeletal complications in patients with breast cancer and
lytic bone metastases. Protocol 19 Aredia Breast Cancer Study Group. N Engl J Med 1996;335(24):1785-91.
6.Major P, Lortholary A, Hon J, Abdi E, Mills G, Menssen HD, et al. Zoledronic acid is superior to pamidronate in the treatment of hypercalcemia of malignancy: a pooled
analysis of two randomized, controlled clinical trials. J Clin Oncol 2001;19(2):558-67.
7.Major PP, Coleman RE. Zoledronic acid in the treatment of hypercalcemia of malignancy: results of the international clinical development program. Seminar Oncology
2001;28(2 Suppl 6):17-24.
8.Nussbaum SR, Younger J, Vandepol CJ, Gagel RF, Zubler MA, Chapman R, et al. Single-dose intravenous therapy with pamidronate for the treatment of hypercalcemia of
malignancy: comparison of 30-, 60-, and 90-mg dosages. Am J Med 1993;95(3):297-304.
9.Saad F, Gleason DM, Murray R, Tchekmedyian S, Venner P, Lacombe L, et al. A randomized, placebo-controlled trial of zoledronic acid in patients with hormonerefractory metastatic prostate carcinoma. J Natl Cancer Inst 2002;94(19):1458-68.
10.Saad F, Gleason DM, Murray R, Tchekmedyian S, Venner P, Lacombe L, et al. Long-term efficacy of zoledronic acid for the prevention of skeletal complications in
patients with metastatic hormone-refractory prostate cancer. J Natl Cancer Inst 2004;96(11):879-82.
Introduction
Intravenous second generation aminobisphosphonates (i.e. Aredia) are increasingly
considered in the effective treatment and management of cancer-related conditions.
These conditions include, but are not limited to the hypercalcemia associated with
malignancy, osseous-related pathosis associated with metastatic disease in the
context of solid tumors, prostate and lung cancer, as well as the management of lytic
osseous lesions commonly seen in multiple myeloma, chondroblastoma and
osteoblastoma. Bisphosphonates have also been shown to be effective in reducing
current hypercalcemia and stabilizing bony pathosis and preventing pathological
fractures. Bisphosphonate therapy has limited improvement on the overall survival
rates for the patients being treated. The greatest impact is seen in the vast
improvement for the quality of life of those taking bisphosphonates.1,2,4-8 Disruption
of the physiological repair mechanisms of osseous tissue due to bisphosphonate
therapy can lead to necrotic bone formation in response to bony injury. This
condition known as Bisphosphonate-Related Osteonecrosis of the Jaw (BRONJ)
adversely affects the quality of life and produces significant morbidity in afflicted
patients. The condition is often seen following extraction, implant placement,
periapical surgery and periodontal surgery involving osseous injury.1
Table 1: Staging and Treatment
Figure 3: BRONJ clinical photo
courtesy Dr. H. Phelps, Denver VA.
Treatment
The primary treatment focus is prevention. Elimination of dental infections and
preemptive surgical procedures including exodontia must be considered prior to
drug use. Oral hygiene and optimal periodontal health will also reduce future risks.
Routine dental therapy can be provided with few contraindications in patients
currently on bisphosphonates. If medication use exceeds 3 years consider a drug
holiday prior to invasive treatment. If BRONJ has been diagnosed the staging of the
pathosis will dictate treatment (Table 1).