NMDA Journal Summer 2020

New Mexico Dental Journal, Summer 2020 16 Foremost of these are the bisphosphonates which are commonly prescribed to post- menopausal females to treat osteoporosis. Some patients taking these medications developed osteonecrosis following surgical treatment. This condition was called bisphos- phonate induced osteonecrosis of the jaw (BRONJ) and although it occurred rarely, it can be a debilitating condition which is difficult to treat. Bisphosphonates work by preventing osteoclast function which is necessary for bone remodeling which must take place for osseointegration to occur and could also affect implant prognosis once an implant has osseointegrated. In 2014, the American Association of Oral and Maxillofacial Surgeons (AAOMS) released their most recent position paper on Medication Related Osteonecrosis of the Jaw (MRONJ). The position paper is available on the AAMOS website. This paper included other antiresorp- tives and antiangiogenic agents as medica- tions that could cause MRONJ formerly called BRONJ. The incidence of MRONJ is much higher in patients receiving IV antiresorptives (1–10%) than those taking oral antiresorptives (<1%). Therefore the route of administration of these medications must be considered during patient selection and addressed during informed consent. The guidelines issued by the AAOMS in this position paper are as fol- lows: 1. For patients taking oral bisphosphonates for less than four years and with no clinical risk factors implant surgery is not contrain- dicated; 2. For patients taking oral bisphosphonates for less than four years and who have also taken corticosteroids or antiangiogenic medications concomitantly; the prescriber should be contacted to approve discontin- uation of the oral bisphosphonate for two months prior to the procedure and the drug should not be restarted until osseous healing has occurred; 3. For patients taking oral bisphosphonates for more than four years with or without concomitant medications; the provider should be contacted to approve of the discontinuation of the oral bisphospho- nate for two months prior to the procedure and that the drug not be restarted until osseous healing has occurred; 4. For patients considering taking IV antire- sorptives the recommendation is to have dental health optimized prior to initiating antiresorptive treatment. For all of the above recommendations, the patient must be informed of the risk of develop- ing osteonecrosis and of the possibility of long term implant failure due to themedication. Other medications that have been found to have an effect on osseointegration include Selective Serotonin Reuptake inhibitors, Pro- ton Pump Inhibitors and Non-Steroidal Anti- Inflammatory agents. Selective serotonin reuptake inhibitors are the most commonly prescribed medications for the treatment of depression. Wu found that patients taking these drugs had twice the inci- dence of implant failure than patients who were not taking them. SSRI’s inhibit osteo- blasts and have been shown to cause decreased bone density, decreased bone for- mation and patients taking this medication have shown an increased incidence of hip fracture. In a 20 year study at the Mayo clinic involving 5,400 subjects, Carr found that there was a 60% greater failure rate for patients who had a history of taking Zoloft . This is especially significant in implant dentistry as many patients taking bisphosphonates are also taking antidepressants. Proton pump inhibitors are commonly pre- scribed for GERD. Thesemedications are avail- able over the counter. They have been shown to inhibit osteoclasts andWu found that patients taking thesemedications have been shown to have twice the rate of implant failure. Non-steroidal anti-inflammatory agents are the primary medication that dentists pre- scribe for the relief of post- operative pain. NSAID’s are also commonly prescribed for the treatment of chronic pain for conditions such as arthritis. Goodman found that bone forma- tion is suppressed by NSAID’s which contain a COX-2 inhibitor which could lead to delayed bone ingrowth and fracture healing. Gersten- field found both COX-1 and COX-2 inhibitors decreased bone healing in vivo. O’Connor found that ibuprofen delayed bone healing although the effect of Rofexicob was worse. Goodman also found that the effects of COX-2 inhibitors on bone were less profound if administered over a short period of time. So short-term treatment for acute pain may not be a concern for implant osseointegration. Bergenstock found no negative effects on fracture healing from a 10-day course of acet- aminophen. Rutkowski recommends limiting the use of NSAID’s to a 3–5-day course follow- ing surgery, then switching to acetaminophen with or without a narcotic if further pain relief is needed. He also recommends a drug holi- day or increasing healing time for patients taking long termNSAID’s. Dental history can help us determine the etiol- ogy of tooth loss, the value the patient has placed on dentistry in the past, and the patient’s attitudes and beliefs concerning den- tal care. It is important to pay particular atten- tion to the patients past dental experiences and to evaluate what steps may be taken to relieve dental anxiety. It is also important to evaluate the reason for the loss of teeth as well as the degree of ownership that the patient has for the loss of teeth. The factors that caused tooth loss should be addressed prior to implant placement and a patient who takes no respon- sibility for tooth loss may be a poor candidate froma riskmanagement perspective. Radiography is an essential part of an examina- tion and the use of computed axial tomogra- phy (CT) or cone beamcomputed tomography (CBCT) provides distinct advantages over tradi- tional periapical or panoramic radiographs in the evaluation of implant sites. Panorex and periapical radiographs can be used to evaluate implant sites, but their use is limited due tomag- nification, distortion, and the two dimensional nature of the image. CT andCBCT images pro- vide for a three-dimensional evaluation of implant site without magnification. CBCT images expose patients to less radiation than CT images and also offer the option of limited fields of view (FOV) which can further reduce radiation exposure for the patient. It is important for the doctor to take the time to identifywhat the patient desires to achievewith dental treatment and to get a feeling for the patient's expectations.  continued from page 15