Review of current literature and implications of RANKL inhibitors for oral health care providers.

Bisphosphonates (BPs) were the first class of drugs commonly used to prevent skeletal-related events (SRE) in patients with osteoporosis, multiple myeloma (MM), or solid tumors with metastases to bone. A new alternative class of agents, receptor activator of nuclear factor kappa-B ligand (RANKL) inhibitors, are now available for use in these indications and have the potential to replace intravenous BPs. This paper presents a review of the current literature on denosumab and its association with osteonecrosis of the jaw (ONJ). Denosumab is a RANKL inhibitor that has recently been approved for the prevention of SRE for the same indications as BPs except for MM. Although the overall frequency of denosumab-related ONJ may be similar or higher than estimates of the occurrence rate of bisphosphonate-related ONJ, evidence continues to support appropriate planning and preventive care can reduce the likelihood of adverse effects, including osteonecrosis.

The effects of osteoclast modifiers on the oral cavity: a review for prescribers.

PURPOSE OF REVIEW: Osteonecrosis of the jaw associated with therapeutic osteoclast modifiers is a rare but serious event. The consequences of osteonecrosis can be devastating despite current treatment. With the increase in diversity of agents and significant increase in the prevalence of osteoclast modifiers prescribed by oncologists understanding diagnosis and management of osteoclast modifiers-related osteonecrosis of the jaws (OMRONJ) is necessary. The risk of osteonecrosis when osteoclast modifiers are used for management of osteoporosis is much less than osteoclast modifiers used in the oncology setting. A basic understanding of the oral exam and current management will lead to more effective communication and more effective prevention of devastating OMRONJ. RECENT FINDINGS: An indistinguishable rate of ONJ seen with new therapeutic agents is becoming apparent and relevant preventive therapy and counseling of the patient is indicated. Currently there is no comprehensive clinical guideline that unifies oncologists and oral health providers in the prevention and management of OMRONJ. SUMMARY: Communication and proper planning with each patient's provider is the most effective strategy to prevent OMRONJ. A team composed of an oncologist, oral and maxillofacial surgeon and dentist competent in managing this condition is necessary. An understanding of the cause and development of OMRONJ can give the prescriber an improved perspective to communicate with oral health professional colleagues. Current guidelines emphasize the need for dental management prior to the use of osteoclast modifiers for the prevention and management of osteonecrosis of the jaw.

Surgical treatment of snoring & obstructive sleep apnoea.

Obstructive sleep apnoea (OSA) syndrome is a potentially serious disorder affecting millions of people around the world. Many of these individuals are undiagnosed while those who are diagnosed, often exhibit poor compliance with nightly use of continuous positive airway pressure (CPAP), a very effective nonsurgical treatment. Various surgical procedures have been proposed to manage and, in some cases, treat OSA. In this article we review methods used to assess the sites of obstruction and a number of surgical procedures designed to address OSA. Effective surgical management of OSA depends upon developing a complete database and determining different levels of obstruction, which may include nasal, nasopharyngeal, oropharyngeal, and hypopharyngeal/retrolingual, or a combination of these sites. A systematic approach to clinical evaluation, treatment planning and surgical management is recommended and is likely to result in more predictable outcomes. Surgical treatment may involve various procedures that are performed in different stages depending on the patient's sites of obstruction. The most commonly performed procedures include nasal reconstruction, uvulopalatopharyngoplasty (UPPP), advancement genioplasty, mandibular osteotomy with genioglossus advancement, and hyoid myotomy and suspension. In more severe cases, maxillomandibular advancement (MMA) with advancement genioplasty may be indicated. Even after appropriate surgical treatment, some patients may demonstrate continued obstruction with associated symptoms. Published indications for surgical treatment include an elevated respiratory disturbance index (RDI) with excessive daytime somnolence (EDS), oxygen desaturations below 90 per cent, medical co-morbidities including hypertension and arrhythmias, anatomic abnormalities of the upper airway and failure of medical treatment. The success of surgery in OSA is generally measured by achieving a (RDI) of less than 5, improvement of oxygen nadir to 90 per cent or more with no desaturations below 90 per cent and quality of life improvements with elimination or significant reduction of OSA symptoms. From a practical point of view, achieving these goals may be extremely difficult without patients' cooperation, most notably in the realm of weight loss and maintenance of a healthy lifestyle.