1. Contemporary Oral Surgery for the General Dentist Iowa Dental Assoc. May 4, 2008 J. Bruce Bavitz, DMD

2. Collect Data, Formulate Tx Plan History Follow-up questions Exam Lab tests History Follow-up questions Exam Lab tests

3. Consider “Protoplasm Biopsy” Prior to Doing Surgery Will they get numb and sit still?* Will they have a medical emergency?* Will they stop bleeding?* Will they resist infection?# Will they heal?# Will the operation “work”?# Will they get numb and sit still?* Will they have a medical emergency?* Will they stop bleeding?* Will they resist infection?# Will they heal?# Will the operation “work”?# *An intra-operative problem #A post-operative problem

4. Common Changes/Modifications from Normal Surgical Routine Antibiotic Pre-medication D/c anticoagulants Prior Radiation Therapy? Consider HBO Oral, Nitrous oxide, or IV sedation M.D. consult for tune up or “clearance” Allergy (penicillin, latex, sulfite etc) Abs + BCP…… Consider warning patient Delay Elective TX (Pregnancy, MI, CVA) Long acting or quickly metabolized local Limit epi to.04 mg for “cardiac” patients Insulin dose modification for major oral surgery Bisphosphonate subplots Antibiotic Pre-medication D/c anticoagulants Prior Radiation Therapy? Consider HBO Oral, Nitrous oxide, or IV sedation M.D. consult for tune up or “clearance” Allergy (penicillin, latex, sulfite etc) Abs + BCP…… Consider warning patient Delay Elective TX (Pregnancy, MI, CVA) Long acting or quickly metabolized local Limit epi to.04 mg for “cardiac” patients Insulin dose modification for major oral surgery Bisphosphonate subplots

6. Bisphosphonates… Present Thinking The IV forms (Aredia and Zometa) are by far the most problematic, and are typically prescribed for multiple myeloma and metastatic breast/prostate cancer. Currently available published incidence data for BRON are limited to retrospective studies with limited sample sizes. Based on these studies, estimates of the cumulative incidence of BRON range from 0.8%-12%. With increased recognition, duration of exposure, and follow-up, it is likely that the incidence will rise. The IV forms (Aredia and Zometa) are by far the most problematic, and are typically prescribed for multiple myeloma and metastatic breast/prostate cancer. Currently available published incidence data for BRON are limited to retrospective studies with limited sample sizes. Based on these studies, estimates of the cumulative incidence of BRON range from 0.8%-12%. With increased recognition, duration of exposure, and follow-up, it is likely that the incidence will rise.

7. Bisphosphonates… Present Thinking Oral agents (Fosamax, Actonel), often used for osteoporosis and osteopenia, may negatively influence post surgical bone healing, even years (decades) after stopping the drug. Incidence of BRON after oral use:.0007% (Merck) to.34% (following extractions Alastair Goss DDS, Australia). Oral agents (Fosamax, Actonel), often used for osteoporosis and osteopenia, may negatively influence post surgical bone healing, even years (decades) after stopping the drug. Incidence of BRON after oral use:.0007% (Merck) to.34% (following extractions Alastair Goss DDS, Australia).

8. The following other variables are thought to be risk factors for BRON: 1. Corticosteroid therapy 2. Diabetes 3. Smoking 4. Alcohol use 5. Poor oral hygiene 6. Chemotherapeutic drugs The following other variables are thought to be risk factors for BRON: 1. Corticosteroid therapy 2. Diabetes 3. Smoking 4. Alcohol use 5. Poor oral hygiene 6. Chemotherapeutic drugs

9. Serum-C- Terminal Telopeptide (CTX) High serum levels= more osteoclast activity (more collagen break down) A predictor of ORN Risk? CTX <100 pg/ml =high risk? CTX >150 = low risk? Take people off oral bisphosphonates, and delay elective surgery until CTX levels rise? Serum-C- Terminal Telopeptide (CTX) High serum levels= more osteoclast activity (more collagen break down) A predictor of ORN Risk? CTX <100 pg/ml =high risk? CTX >150 = low risk? Take people off oral bisphosphonates, and delay elective surgery until CTX levels rise? Future?

10. Oral Bisphosphonate-Induced Osteonecrosis: Risk Factors, Prediction of Risk Using Serum CTX Testing, Prevention, and Treatment RE Marx, JE Cillo Jr, and JJ Ulloa Journal of Oral and Maxillofacial Surgery Volume 65, Issue 12Journal of Oral and Maxillofacial Surgery Volume 65, Issue 12, December 2007 Journal of Oral and Maxillofacial Surgery Volume 65, Issue 12 CTX levels rise about 26pg a month, once drug is stopped….Usually 6 month “holiday” is sufficient CTX Testing Quest labs Morning, fasting Study ~ $175.00

11. Web Resources http://www.ada.org/prof/resources/to pics/osteonecrosis.asp http://www.ada.org/prof/resources/to pics/osteonecrosis.asp http://www.ada.org/prof/resources/to pics/osteonecrosis.asp http://www.ada.org/prof/resources/to pics/osteonecrosis.asp http://www.aaoms.org /docs/position_papers /osteonecrosis.pdf http://www.aaoms.org /docs/position_papers /osteonecrosis.pdf http://www.aaoms.org http://www.onjcme.com May 30 th, 2007 “Webinar”

12. Pragmatic Thoughts On oral Agent <3 years, probably “O.K.” On oral Agent <3 years, probably “O.K.” On IV agent < 3 months, probably “O.K.” On IV agent < 3 months, probably “O.K.” Consider upgraded consent forms on all patients, as well drug holiday Consider upgraded consent forms on all patients, as well drug holiday Do easiest surgical procedure first, watch and wait Do easiest surgical procedure first, watch and wait Avoid envelope pushing procedures like immediate implants Avoid envelope pushing procedures like immediate implants Keep eye on CTX data…is it valid or not? Keep eye on CTX data…is it valid or not?

14. The concept of metabolic equivalent or METS is in vogue. One MET is defined as 3.5 ml of 02/Kg/min. It essentially is a test of the patient’s ability to perform physical work. Some examples are: 1-4METS(eating, dressing, walking around house, dishwashing) 4-10METS(climbing stairs – 1 flight, walking level ground 6.4 km/hr, running short distance, game of golf) > 10METS(swimming, singles tennis, football) People with capacities of 4 METS or less are at high risk for medical complications with those who can perform 10 METS or more at very low risk. A person who is anxious with a BP 200/115 but can perform 10 METS of work would likely have no problems with a simple extraction.

15. Ready for Surgery? Treatment modifications employed Stress diagnosed and treated (sedation) Consent signed and witnessed Pre-op vitals taken Antiseptic rinse Proper imaging Treatment modifications employed Stress diagnosed and treated (sedation) Consent signed and witnessed Pre-op vitals taken Antiseptic rinse Proper imaging

16. Alveolar Bone Alveolar Bone Reconstruction – –Bone grafting with implants – –BMP/PRP – –Distraction osteogenesis Reconstruction – –Bone grafting with implants – –BMP/PRP – –Distraction osteogenesis Preservation –Save teeth –Careful extraction technique –Graft sockets? –Implants, immediate or conventional Preservation –Save teeth –Careful extraction technique –Graft sockets? –Implants, immediate or conventional

17. These teeth are non restorable and the patients are interested in implants. 1.How can I extract to preserve as much bone as possible? 2.Should I graft the socket? 3.If so, what material(s)? 4.Should I use a membrane? 5.What type of membrane? 6.Will insurance reimburse? 7.Is there an ADA code?

19. Poor Man’s Periotome Woodson Elevator

20. Don’t expand labial plate! No “Wimpy” Forceps No Labial Force