Epidemiological study of alendronate-related osteonecrosis of the jaw in the southeast of Scotland.

We aimed to establish the incidence of alendronate-related osteonecrosis of the jaw (ONJ) in the southeast of Scotland, and to assess the effect of corticosteroids on it. We studied a prospective case series of patients between June 2004 and March 2012 separated into steroid and non-steroid groups. There were 34 cases of alendronate-related ONJ and 78732 drug patient years (DPY) of alendronate, making the overall occurrence 43.1 cases/100000 DPY. There were 12 patients in the steroid group (mean (range) age 68.2 (48-87) years) making 42.5 cases/100000 DPY, and 22 in the non-steroid group (mean (range) age 76.2 (63-91) years) making 119.6 cases/100000 DPY. The mean (range) age at presentation of alendronate-related ONJ was significantly lower in the steroid group (68.2 (48-87) compared with 76.2 (63-91) years, p=0.019) as was the duration of exposure to alendronate before it developed (28.9 (6-120) compared with 61.3 (13-168) months, p=0.03). The overall incidence seems to be higher in the southeast of Scotland than elsewhere. Concurrent use of corticosteroids is not associated with an increased incidence of alendronate-related ONJ, but it seems to reduce the duration of exposure before it develops. Age is likely to be a confounding factor.

Summary of: a study of 225 patients on bisphosphonates presenting to the bisphosphonate clinic at King's College Hospital.

AIM: The aim of this retrospective study was to examine the outcome of patients referred to a dedicated clinic for dental extractions while they were prescribed either oral or intra-venous (IV) bisphosphonates (BPs). The following parameters were assessed: mode of BP administration, indication for BP prescription, incidence of BRONJ, concomitant risk factors for development of bisphosphonate-related osteonecrosis of the jaws (BRONJ) and demographic details. MATERIAL AND METHODS: The clinical records of 225 patients who underwent dental extraction while receiving oral or intravenous bisphosphonates were reviewed. Their clinical outcome, specifically the development of BRONJ was determined. RESULTS: Of the 225 patients, 202 were prescribed oral and 23 IV BPs. 34.8% (8/23) of patients prescribed IV BPs developed BRONJ following dental extraction, which was a significantly (p <0.001) higher proportion than that of the oral BP group, which was 2.5% (5/202 patients). 12.3% (8/65) patients taking BPs with steroids were at a significantly increased risk of a BRONJ (p <0.003). 12.3% (7/57) males developed a BRONJ compared with 3.6% (6/168) females where p = 0.015. All of the patients who developed a BRONJ as a result of oral BP prescription had been taking this medication for three years or more. CONCLUSION: In our patient cohort the risk of developing a BRONJ following dental extractions was greatest in those patients receiving IV BPs and those on oral BPs with concomitant steroid medication.

An epidemiological study of alendronate-related osteonecrosis of the jaws. A case series from the south-east of Scotland with attention given to case definition and prevalence.

A close case study series of alendronate-associated osteonecrosis of the jaws (AONJ) is presented. A consistency of case definition with a minimal reporting requirement was attempted as recommended by the task force of the American Society for Bone and Mineral Research. A hierarchy of evidence focussing on 7 categories of interest was included for each case. A further 7 categories were added by the authors and completed where possible. The patients were drawn from a discrete population of 900,000 from the south-east of Scotland. The prescribing of drugs to this population was monitored by a government agency, the Information Services Office of the National Health Service of Scotland. The daily or weekly standard doses of alendronate prescribed to this population were recorded, thus allowing a calculation of the drug patient years (DPYs). The number of cases of AONJ, when computed against the cumulative year-on-year DPYs for alendronate, suggests an incidence of AONJ per DPYs of <0.004% for age-related or hormone-related osteoporosis. This increased to >0.1% when alendronate was prescribed as a prophylaxis against glucocorticosteroid-induced osteoporosis.

Coronectomy of a third molar with cyst lining enucleation in the management of a dentigerous cyst.

UNLABELLED: A dentigerous cyst was treated with enucleation and coronectomy of the associated tooth to minimize the risk of inferior alveolar nerve damage, resulting from direct surgical trauma or indirectly from intra-operative or post-operative jaw fracture. Radiographic monitoring over 33 months confirmed migration of the roots through healed bone and progressive obliteration of the residual pulp canal chamber. These observations are not associated with failure of the technique but are, in fact, commonly observed in successful cases of coronectomy. A brief discussion of the risks versus benefits of this treatment modality is presented with reference to the literature available. CLINICAL RELEVANCE: In selected cases, coronectomy with cyst enucleation as a one stage procedure may reduce the risk of perioperative nerve damage.

Lingual mucosal ulceration with mandibular sequestration.

UNLABELLED: Lingual mucosal ulceration with mandibular sequestration is a condition that presents most commonly in the lower molar region and may be influenced by a variety of local and systemic factors. Three such cases are reported, two involving a history of recent dental extraction and one of seemingly spontaneous onset with the possibility of an underlying association with bisphosphonate therapy. An overview of the surgical and non-surgical management strategies for such cases is described. CLINICAL RELEVANCE: This condition presents most commonly following extraction of mandibular molar teeth. Patients may require referral to secondary care for further management if failing to respond to local non-surgical measures or in the presence of underlying systemic factors.

Dental procedures can be undertaken without alteration of oral anticoagulant regimen.

DATA SOURCES: Medline provided the primary data source with references from identified articles being reviewed for additional studies. The Cochrane Collaboration database was also searched and a search performed of cited references. STUDY SELECTION: Clinical studies, in English, examining perioperative management of patients receiving long-term oral anticoagulant (OAC) therapy were selected. DATA EXTRACTION AND SYNTHESIS: Data were extracted regarding management strategy, thrombo-embolic events and bleeding complications, and type of surgical or invasive procedure. Event rates were reported as number of patients experiencing the event divided by number of patients at risk. Binomial and Poisson distributions were used to calculate 95% confidence intervals (CI). RESULTS: A total of 31 reports were identified and concluded to be of generally poor quality. For studies reporting thrombo-embolic events, 29 events occurred in 1868 patients (1.6%; 95% CI, 1.0-2.1) of which seven were strokes (0.4%; 95% CI, 0.0-0.7). Major bleeding while receiving OAC was reported to be rare for dental procedures (occurring in four out of 2014 individuals), arthrocentesis (in none out of 32), cataract surgery (none out of 203), and upper endoscopy or colonoscopy with or without biopsy (no occurrences in 111 patients). For the other invasive and surgical procedures reviewed, OAC needs to be withheld and a suitable personalised perioperative management strategy instigated. A guideline, based on the limited evidence available, for the perioperative management of anticoagulation for procedures requiring discontinuation of OAC is presented. CONCLUSIONS: Certain surgical or invasive procedures can be undertaken in patients who are taking OAC therapy without alteration of their regimen. For procedures requiring discontinuation of OAC, personalised management strategies are required. More rigorous studies are needed to better inform this debate.