Deciphering novel chemotherapy and its impact on dentistry

The provision of dental extractions in patients with established or a history of medication-related osteonecrosis of the jaw

Patients with existing or a history of medication-related osteonecrosis of the jaw (MRONJ) are considered to be at a higher risk of further developing MRONJ, particularly if dental extractions are necessary. It is assumed that their underlying risk factors predispose them to developing MRONJ and they are allocated into an 'elevated risk group'. There is no evidence to quantify this risk level; however, it has led to an avoidance of dental extractions in this cohort. However, avoidance of dental extractions is not a realistic treatment option to prevent MRONJ and there is emerging evidence that inflammatory dental disease, such as peri-apical pathology or periodontal disease, can trigger the pathogenesis of MRONJ. The current case series retrospectively reviewed 28 patients with existing or a history of MRONJ who underwent dental extractions (n = 65) via our departmental protocol, which includes elective circumferential socket alveoplasty and primary closure. Our outcomes show that MRONJ did not develop at the new extraction site, with a post-operative review period of at least six months. These results provide promising evidence that dental extractions can be performed in this group of patients with <1% risk of developing MRONJ at the new surgical site, if appropriate measures are undertaken.

An institutional protocol including socket alveoplasty and primary closure following dental extractions for patients with an elevated risk of developing medication-related osteonecrosis of the jaw

Background The purpose of this study was to evaluate the outcomes of alveoplasty and primary closure following dental extractions in patients with an elevated medication-related osteonecrosis of the jaw (MRONJ) risk.Study design A retrospective review of 46 patients with an elevated MRONJ risk was conducted. This included a total of 124 teeth extracted, due to unrestorable caries (n = 46; 37%) and peri-apical pathology (n = 44; 35%).Results Our results showed 0% (n = 0) of patients in our cohort developed MRONJ post-operatively. Most patients were being treated with intravenous zoledronic acid for breast cancer (n = 23; 50%), with an average of 15 doses (range 1-72).Conclusions This study supports the use of alveoplasty and primary closure for patients with an elevated MRONJ risk. The authors highlight the importance of pre-operative cone beam computed tomography imaging, optimisation of immune status, post-operative prophylactic antibiotics, and the delay of bone modifying agents recommencement as influential factors in mitigating risk and favouring successful outcomes.

What is the impact of biologics on the management of the oral surgery patient?

The use of biologics in medicine is on the rise. As dental professionals, it is becoming increasingly important that we are aware of this class of medications and the theoretical risks that they pose specific to the oral cavity to ensure safe delivery of dental treatment. This paper discusses some of these risks and recommendations to follow to manage patients undergoing oral surgery specifically.

Complications and treatment errors in periodontal therapy in medically compromised patients

Patients who are medically compromised may be at an increased risk of complications and treatment errors following periodontal therapy. A review of the evidence on the topic is presented, in relation to the type of complication reported, of periodontal treatment, and of patients' medical status. Further, a framework for risk assessment and appropriate treatment modifications is introduced, with the aim of facilitating the management of patients with existing comorbidities and reducing the incidence of treatment complications.

The presenting dental status of solid tumours with bone metastases requiring bone-targeting agents - part 4: miscellaneous cancers

This article discusses relevant information for the dental sector regarding metastatic cancers beyond breast and prostate cancer. Typically, tumour sites such as lung, renal, colorectal, gastrointestinal, thyroid, hepatic and pancreatic cancers are increasingly being referred for bone-targeting agents upon evidence of bone metastases.The current article explores the presenting dental status of these tumour groups on the background of survival outcomes. In addition, the article provides insight towards the complexity in achieving 'dental fitness' and whether 'dental stability' could be an alternative to consider via palliative dentistry in certain cases.

The presenting dental status of solid tumours with bone metastases requiring bone-targeting agents - part 3: prostate cancer

Introduction Metastatic prostate cancer (MPC) patients due to receive bone-targeting agents (BTAs) are expected to undertake a dental assessment before commencing. The aim of this study was to determine the dental status of this tumour group and understand the challenges the dental practitioner faces in attempting to achieve 'dental fitness'.Materials and methods Data were retrospectively collected from a dedicated pre-BTA dental assessment clinic and analysed for MPC. Statistical analysis and observational data were used to compare patient and tumour demographics.Results A total of 111 patients were included in this cohort, with the majority of patients presenting with only bone metastases (BM) and no additional metastatic sites. On average, MPC patients presented with 19.3 teeth and were below the threshold for functional dentition. The 75-84-year-old age group had the worst horizontal bone loss score and subsequently lose six teeth over a decade (p = 0.001). In addition, all MPC tumour sub-categories showed favourable survival rates.Conclusion MPC patients have a high dental burden on presentation, likely associated with their age. Favourable survival prospects and the cumulation of BTAs and dental disease would suggest a heightened risk of medication-related osteonecrosis of the jaw in this group compared to many other tumour sites.

The presenting dental status of solid tumours with bone metastases requiring bone-targeting agents - part 1: an overview

Introduction Dental pre-assessment before bone-targeting agents (BTA) in oncology patients is a well-recognised practice; yet, guidance on this has typically been unable to differentiate between the intricacies of varying oncology groups. This study assesses the presenting dental status of oncology patients with bone metastases (BM) due to commence BTA, to determine whether differences exist with varying tumour groups.Materials and methods Data were retrospectively collected from a dedicated pre-BTA dental assessment clinic. Statistical analysis and observational data were used to compare patient and tumour demographics as well as to their peers via the Adult Dental Health Survey.Results A total of 492 patients with a solid tumour diagnosis and BM requiring BTA were included in this retrospective study. Demographics such as sex, age, smoking status and tumour site were all significant for the number of teeth present (p = 0.000). Furthermore, survival data post-BTA identified prostate, breast and thyroid groups surviving over 12 months following dental assessment (p <0.000). In contrast, the remaining groups such as lung, colorectal and gastrointestinal had poorer outcomes (p <0.000).Conclusion Pre-BTA dental assessment should consider and incorporate additional patient and tumour demographics to allow for a tailored and personalised dental treatment plan. Application of this principle would look to optimise oral function while considering tumour prognosis to avoid over- or under-prescribing pre-BTA dental treatment.

The incidence of medication-related osteonecrosis of the jaw following tooth extraction in patients prescribed oral bisphosphonates

Aims To determine the incidence of medication-related osteonecrosis of the jaw in patients prescribed oral bisphosphonate medication following dental extraction in a dedicated clinic within the Department of Oral Surgery of King's College Hospital. The effect of factors such as sex, duration of therapy, medical comorbidities and site of extraction, which have previously been reported to significantly affect the risk of developing osteonecrosis of the jaw, was also examined.Materials and methods Data were gathered from the dental records of patients who had extractions over an eight-year period and were included in this retrospective study. Patients with previous or current exposure to intravenous bisphosphonates, denosumab, novel-targeted chemotherapies used in the oncology setting or radiotherapy to the head and neck were excluded from this study.Results The incidence of medication-related osteonecrosis of the jaw following tooth extraction in this group of 652 was 0.8%. A significantly increased risk of developing medication-related osteonecrosis of the jaw was evident in patients prescribed oral bisphosphonates for four years or more (p = 0.02), with an incidence in this group of 1.6%.Conclusion This study demonstrates that, following dental extraction, patients who are prescribed oral bisphosphonates are at risk of developing medication-related osteonecrosis of the jaw and that this risk increases significantly when the patient has been taking the bisphosphonate for four years or more.

Cancer Patients at Risk for Medication-Related Osteonecrosis of the Jaw. A Case and Control Study Analyzing Predictors of MRONJ Onset

The goal of this investigation was to identify potential risk factors to predict the onset of medication-related osteonecrosis of the jaw (MRONJ). Through the identification of the multiple variables positively associated to MRONJ, we aim to write a paradigm for integrated MRONJ risk assessment built on the combined analysis of systemic and local risk factors. The characteristics of a cohort of cancer patients treated with zoledronic acid and/or denosumab were investigated; beyond the set of proven risk factors a new potential one, the intake of new molecules for cancer therapy, was addressed. Registered data were included in univariate and multivariate logistic regression analysis in order to individuate significant independent predictors of MRONJ; a propensity score-matching method was performed adjusting by age and sex. Univariate logistic regression analysis showed a significant effect of the parameters number of doses of zoledronic acid and/or denosumab (OR = 1.03; 95% CI = 1.01–1.05; p = 0.008) and chemotherapy (OR = 0.35; 95% CI = 0.17–0.71; p = 0.008). The multiple logistic regression model showed that breast, multiple myeloma, and prostate cancer involved a significantly higher risk compared to lung cancer; a significant effect of the combined variables number of doses of zoledronic acid and/or denosumab (OR = 1.03; 95% CI = 1.01–1.06); p-value = 0.03) and exposure to novel molecule treatment (OR = 34.74; 95% CI = 1.39–868.11; p-value = 0.03) was observed. The results suggest that a risk assessment paradigm is needed for personalized prevention strategies in the light of patient-centered care.