Bisphosphonate-related osteonecrosis of the jaw: what we have learned.

Bisphosphonate related osteonecrosis of the jaws (BRONJ) is an entity that has become prevalent upon the dental and medical community for more than 10 years. This entity is unfortunate because both oral and intravenous nitrogen containing bisphosphonates have beneficial effects for patients for certain conditions. The exact pathology of BRONJ has yet to be determined, although many hypotheses have been put forth. Since its prevalence, a clinical staging system has been developed and radiological findings have been described. BRONJ can be prevented if oral healthcare is undertaken before the start of bisphosphonate therapy or after a short time from the start of their use. However, after BRONJ has developed in patients, a myriad of treatments have been proposed that may help these patients.

Treatment options for osteoporosis and decision making criteria: 2009.

Osteoporosis is recognized worldwide as a major public health problem since many decades ago, mainly due to the cost of treatment for related fragility fractures. Fortunately, WHO has provided new strategies for identifying populations with a high ten-year fracture risk, which together with increasingly sensitive diagnostic methods make it feasible for decision makers in this field to design cost effective fracture prevention strategies. These strategies are aimed at preventing falls and improving bone strength and therefore diminishing the prevalence and incidence of new or recurrent osteoporosis related fractures. Herein we review the content of these new strategies, and the medical treatments available, as well as their efficacy in the Mexican context. Several countries are now reporting a decreasing incidence and prevalence of osteoporosis related fractures, after 30 years of clinical and population-based interventions. Mexico has several effective anti-fracture drug treatments available. Such drugs can be classified according to the mechanism that makes them effective as: 1) antidestructive or anticatabolic, 2) bone forming or anabolic, and 3) those with both actions or mixed drugs. The authors argue that treatment strategies that use drugs to strengthen bone tissue must assure normal mineralization of the already formed, remnant bone tissue and/or the newly formed bone tissue in order to encourage biochemical outcomes like formation of mature hydroxyapatite crystals with complete biomechanical and biochemical properties and therefore long term benefits. The present review includes some perspectives that will surely enhance osteoporosis management in the near future and which will bring about a decrease in the impact of the problems in Mexico.

Do patients receive recommended treatment of osteoporosis following hip fracture in primary care?

BACKGROUND: Osteoporosis results in fractures and treatment of osteoporosis has been shown to reduce risk of fracture particularly in those who have had a history of fracture. METHODS: A prospective study was conducted using patients admitted to a hip fracture rehabilitation program at a large referral center to evaluate the use of treatments recommended for secondary prevention of osteoporotic fracture between September 1, 2001 and September 30, 2003. The frequency of medication use for the treatment of osteoporosis including estrogen replacement therapy, bisphosponates, calcitonin, calcium and vitamin D therapy was determined on admission, at 6 weeks post discharge and one year following discharge. All patients were discharged to the care of their family physician. All family physicians in the referral region received a copy of the Canadian Consensus recommendations for osteoporosis management 1-3 months prior to the study. RESULTS: During the study period, 174 patients were enrolled and 121 completed all assessments. Fifty-seven family physicians were identified as caring for 1 or more of the study patients. Only 7 patients had previous BMD, only 5 patients had previously been prescribed a bisphosponate and 14 patients were taking calcium and/or vitamin D. All patients were prescribed 2500 mg calcium, 400 IU vitamin D and 5 mg residronate daily during rehabilitation and at discharge.Following discharge, a significant improvement was seen in all clinical indices of functional mobility, including the functional independence measure (FIM), walking distance, fear of falling score (FFS), and the Berg balance score (BBS). At six weeks a significant (p < 0.01) decrease in calcium and vitamin D use was observed. All patients remained compliant with residronate therapy. At twelve months 71 patients remained on residronate (p < 0.01), 10 were now taking alternate bisphosphonate therapy and few were taking calcium and/or vitamin D (p < 0.001). FIM, FFS and Berg scores were significantly decreased from discharge (p < 0.001) while walking distance was unchanged. CONCLUSION: Few patients admitted for hip fracture had previously taken recommended osteoporosis therapy including bisphosphonates. While compliance with Canadian Consensus recommendations was observed at six weeks, this was not the case at twelve months post hip fracture rehabilitation. Interventions to improve not only the detection and treatment of osteoporosis but also the ongoing treatment and management post-fracture need to be developed and implemented.

Unmet needs and current and future approaches for osteoporotic patients at high risk of hip fracture.

This review provides a critical analysis of currently available approaches to increase bone mass, structure and strength through drug therapy and of possible direct intra-osseous interventions for the management of patients at imminent risk of hip fracture. PURPOSE: Osteoporotic hip fractures represent a particularly high burden in morbidity-, mortality- and health care-related costs. There are challenges and unmet needs in the early prevention of hip fractures, opening the perspective of new developments for the management of osteoporotic patients at imminent and/or at very high risk of hip fracture. Amongst them, preventive surgical intervention needs to be considered. METHODS: A European Society for Clinical and Economic Aspects of Osteoporosis, Osteoarthritis and Musculoskeletal Diseases (ESCEO)/International Osteoporosis Foundation (IOF) working group reviewed the presently available intervention modalities including preventive surgical options for hip fragility. This paper represents a summary of the discussions. RESULTS: Prevention of hip fracture is currently based on regular physical activity; prevention of falls; correction of nutritional deficiencies, including vitamin D repletion; and pharmacological intervention. However, efficacy of these various measures to reduce hip fractures is at most 50% and may need months or years before becoming effective. To face the challenges of early prevention of hip fractures for osteoporotic patients at imminent and/or at very high risk of hip fracture, preventive surgical intervention needs further investigation. CONCLUSION: Preventive surgical intervention needs to be appraised for osteoporotic patients at imminent and/or at very high risk of hip fracture.

Treatment options for osteoporosis and decision making criteria: 2009 / Alternativas de tratamiento para osteoporosis y criterios de decisión: 2009

Osteoporosis is recognized worldwide as a major public health problem since many decades ago, mainly due to the cost of treatment for related fragility fractures. Fortunately, WHO has provided new strategies for identifying populations with a high ten-year fracture risk, which together with increasingly sensitive diagnostic methods make it feasible for decision makers in this field to design cost effective fracture prevention strategies. These strategies are aimed at preventing falls and improving bone strength and therefore diminishing the prevalence and incidence of new or recurrent osteoporosis related fractures. Herein we review the content of these new strategies, and the medical treatments available, as well as their efficacy in the Mexican context. Several countries are now reporting a decreasing incidence and prevalence of osteoporosis related fractures, after 30 years of clinical and population-based interventions. Mexico has several effective anti-fracture drug treatments available. Such drugs can be classified according to the mechanism that makes them effective as: 1) antidestuctive or anticatabolic, 2) bone forming or anabolic, and 3) those with both actions or mixed drugs. The authors argue that treatment strategies that use drugs to strengthen bone tissue must assure normal mineralization of the already formed, remnant bone tissue and/or the newly formed bone tissue in order to encourage biochemical outcomes like formation of mature hydroxyapatite crystals with complete biomechanical and biochemical properties and therefore long term benefits. The present review includes some perspectives that will surely enhance osteoporosis management in the near future and which will bring about a decrease in the impact of the problems in Mexico.

La osteoporosis se reconoce mundialmente como un problema de salud pública desde hace muchas décadas, principalmente por el impacto global implícito en la atención de las fracturas que ocasiona. Afortunadamente, cada vez contamos con más y mejores estrategias desarrolladas por la OMS para identificar oportunamente a las personas en riesgo de sufrir una fractura; actualmente es posible definir este riesgo para los siguientes diez años. Lo cual, aunado a métodos cada vez más sensibles para establecer diagnósticos definitivos y opciones de tratamiento costo-eficaces para evitar caídas y disminuir significativamente la presentación de fracturas, permite a quien toma decisiones en este problema diseñar y poner en práctica planes de atención sustentados en la mejor evidencia científica, que son motivo de esta revisión. Varios países empiezan a informar un abatimiento del número de fracturas, después de haber establecido programas dirigidos a este fin desde hace 30 años. Contamos con medicamentos que han demostrado su eficacia para abatir la presentación de la primera fractura o de fracturas recurrentes de manera costo-eficiente, estos se pueden dividir para su estudio de acuerdo al mecanismo de acción que los vuelve eficaces. Así, aquellos que frenan la destrucción del tejido óseo se clasifican como anti-catabólicos, los que estimulan la formación de tejido óseo nuevo son anabólicos, los que tienen ambas acciones se conocen como de acción mixta. En todos los casos, el tejido remanente, previamente formado o en vías de destrucción, que se fortalecerá o el tejido de nueva formación, requieren medidas para garantizar que el proceso de mineralización suceda normalmente y se genere hidroxiapatita o un compuesto con características similares para que la eficiencia biomecánica del tejido realmente mejore a largo plazo. Esta revisión incluye algunas perspectivas que seguramente mejorarán nuestro manejo de la osteoporosis en el futuro inmediato y que...