What is the Risk of Developing Osteonecrosis Following Dental Extractions for Patients on Denosumab for Osteoporosis?

PURPOSE: Osteonecrosis of the jaws (ONJ) occurs in patients on antiresorptive drugs for osteoporosis with the risk with oral bisphosphonates being known to be of the order of 0.1 to 0.3% while the risk for patients on denosumab for osteoporosis is not known. The aim of this study was to determine the risk of developing ONJ in a consecutive series of patients on denosumab for osteoporosis having dental extractions. MATERIAL AND METHODS: A prospective cohort study of patients on denosumab for osteoporosis having dental extractions in the period January 1, 2017 and June 30, 2021 were compared to a control group not on antiresorptives. Detailed demographic records including length of time on antiresorptives and CTX values were obtained. Comparison to further define risk factors was made between those patients developing ONJ to those who didn't. RESULTS: The treatment group included 427 patients who were on denosumab for osteoporosis; they collectively underwent 561 episodes of dental treatment involving extractions for a total of 1081 extractions, with 10 developing ONJ (risk 2.3%). The control group consisted of 299 patients who were not taking denosumab; they collectively underwent 315 episodes of dental treatment for a total of 669 extractions, and none of them developed ONJ. There were significant differences in age and sex, but not medical comorbidities between the treatment and control groups. Within the treatment group, there were no significant differences in any of these characteristics between those who did, and those who didn't, develop ONJ. Within the treatment group, the number of extractions modified the risk of developing ONJ (odds ratio, 1.35; confidence interval, 1.1-1.7). Of the 76 patients who had extractions between 6 and 7 months after the last denosumab injection, none developed ONJ. CONCLUSIONS: The risk of ONJ in patients on denosumab for osteoporosis is a magnitude greater than for patients on the oral bisphosphonates 2.3% v 0 - 0.3%, which is 7.7 times more likely. Number of extractions and early resumption of the next dose of denosumab increases the risk of ONJ.

The New Zealand oral and maxillofacial surgeon workforce in 2017-18: characteristics, practice and prospects.

AIM: To describe and consider the findings of a workforce survey of New Zealand Oral and Maxillofacial Surgeons (OMS) which was conducted in 2017-18, and to compare those to findings from a similar survey undertaken in 2001. METHODS: A questionnaire was used to obtain information on the qualifications, sociodemographic characteristics and and practising circumstances of all practising OMS in New Zealand. Data were analysed using SPSS (version 24). After the computation of descriptive statistics, cross-tabulations were used to identify differences in proportions (with those tested for statistical significance using Chi-squared tests), and analysis of variance was used to examine differences in means. RESULTS: All 39 OMS took part. There were 17 medically qualified surgeons who also held a surgical fellowship, comprising just under half of the workforce. Overall, one in eight surgeons worked solely in the public sector, while just under one-quarter worked solely in private; the remainder worked in both sectors. Dentoalveolar procedures were by far the most common undertaken (with considerably more done by older surgeons than younger ones), followed by implants, the treatment of facial trauma, skin lesions and surgery for malignancy. Orthognathic surgery and dentoalveolar trauma procedures were the least commonly reported. Only two-thirds of surgeons participated in public on-call work. While 95% of surgeons were indeed satisfied with their work, the lowest rate was observed among those working solely in the public sector, where it was 80%; among those working exclusively in private, it was 100%. Between 2001 and 2017-18, the proportion of medically qualified surgeons rose from just over one-quarter to more than two-thirds. The proportion of surgeons working solely in private practice rose from one in seven to almost one-quarter. There were marked increases in the mean number of malignancies dealt with and implants provided. CONCLUSION: The findings highlight a number of problems-some long-standing, others emerging-in New Zealand's OMS system. Fewer surgeons are participating in public sector provision and there is stress on those who remain. Workforce planners should be aware that more resources need to be put into training surgeons who will take up hospital appointments and provide essential after-hours emergency services.

MicroRNA-204 regulates osteogenic induction in dental follicle cells.

The dental follicle is an ectomesenchymal tissue surrounding developing tooth germ that contains osteoblastic-lineage-committed stem/progenitor cells. MicroRNAs (miRNAs) are small non-coding RNAs that regulate gene expression during stem cell growth, proliferation, and differentiation. The aim of this study was to investigate the key regulators of miRNA during osteogenic differentiation in human dental follicle cells (hDFC). We analyzed miRNA expression profiles in hDFC during osteoblastic differentiation. Expression of miR-204 was decreased in hDFC during osteogenic induction on microarray analysis. Real-time and RT-PCR analysis also showed that the expression of miR-204 was decreased in all three hDFC during osteogenic differentiation. To investigate whether miR-204 has an effect on osteogenic differentiation, miR-204 was predicted to target alkaline phosphatase (ALP), secreted protein acidic and rich in cysteine (SPARC), and Runx2 in the in the 3'-UTRs by in silico analysis. When miR-204 was transfected into hDFC, the activity of ALP and protein levels of SPARC and Runx2 were decreased. mRNA levels of ALP, SPARC and Runx2 were also decreased by miR-204 transfection. Our data suggest that miR-204 negatively regulates the osteogenic differentiation of hDFC by targeting the bone-specific transcription factor Runx2, the mineralization maker ALP and the bone extracellular matrix protein SPARC.

Melanoma Metastatic to the Mandible: Symptoms Precede Imaging Findings.

BACKGROUND: Malignant melanoma is an aggressive and unpredictable cancer with the propensity for widespread metastasis. Whilst metastatic spread to the axial skeleton is relatively common, metastasis to the jaws is rarely reported and the optimal approach to investigation and management is yet to be defined. CASE PRESENTATION: A 58-year-old woman presented with dental pain, swelling and mental neuropathy on a background of an excised cutaneous melanoma. Early radiological investigations showed non-specific osteolysis despite strong clinical findings. It was not until later that magnetic resonance imaging showed changes consistent with metastatic disease. Dental extraction and biopsy confirmed the diagnosis of metastatic melanoma to the mandible. CONCLUSION: Metastatic melanoma to the mandible is a rare phenomenon which may arise many years following treatment of the cutaneous primary. This case demonstrates the difficulties in early diagnosis as symptoms preceded radiographic findings using high-resolution modalities. Earlier use of magnetic resonance imaging with or without the use of bone scintigraphy may provide the sensitivity required for early identification of metastatic disease in the mandible.

Relationship Between Intracapsular Fracture Patterns and Arthroscopic Findings.

PURPOSE: To observe the superior joint compartment (SJC) using ultrathin arthroscopy in intracapsular condylar fracture (ICF) of the temporomandibular joint, describe the changes, and evaluate the relations among fracture pattern, arthroscopic findings, and clinical outcome. PATIENTS AND METHODS: Twenty patients with 27 ICFs were the subject group. Thirteen patients had unilateral ICFs and 7 had bilateral ICF. The fracture patterns were classified into 9 categories, and all patients had arthroscopic examination of the traumatized joint at the time of definitive treatment. At 4 months after treatment of the injury, all patients had a secondary arthroscopy of the ICF joint. In all patients, range of motion (ROM) was measured as the interincisal distance (millimeters) at the first visit to 12 months after the first treatment, and the data were statistically evaluated. RESULTS: Intra-articular hyperemia, hypervascularity, and temporal bone damage were found, and 4 patients had disc perforations at the first examination. At the second arthroscopy 4 months later, normal healing occurred in 11 joints, all of which had minimally displaced fractures. Fifteen joints showed complete filling of the SJC, all of which had a displaced minor fragment from the fossa. Comparison of the effect of the presence versus absence of SJC fibrosis on ROM showed marked differences from 1 to 12 months. The effect of early versus delayed definitive treatment showed marked differences at 4 and 12 months. CONCLUSION: The intra-articular condition at 4 months after ICF as observed arthroscopically was related to the minor fragment position. If the minor fragment is nondisplaced, then it will heal to a normal state; however, if the minor fragment is displaced from the fossa, then the SJC shows disc damage and fibrosis. This could lead to fibrous ankylosis.

Endoscopically Assisted Intraoral Removal of an Ectopic Third Molar in the Mandibular Subcondylar Region.

The ectopic placement of mandibular third molars in the subcondylar region is an uncommon phenomenon. Most patients are asymptomatic but can present with acute infection or associated pathology necessitating surgical intervention. Surgical approaches have been described utilizing both extraoral and intraoral approaches to the region.This paper presents a clinical report of a patient presenting with acute fascial space infection arising from an ectopic third molar in the mandibular subcondylar region, managed with surgical removal via an endoscopically assisted intraoral approach.

Postoperative Bleeding Following Dental Extractions in Patients Anticoagulated With Warfarin.

PURPOSE: The practicing dentist must frequently advise on the risks involved with dental extractions in the patient taking an anticoagulant. This study assessed the risk of bleeding in a large heterogeneous cohort of patients on warfarin treated by practitioners in training (dental students and junior staff in a teaching hospital). MATERIALS AND METHODS: This was a retrospective case-and-control study of 439 patients on warfarin (1,022 extractions) and 439 matched controls (1,049 extractions). Patients with an international normalized ratio (INR) lower than 2.2 had no specific measures, those with an INR 2.2 to 4 received suturing and tranexamic acid mouthwash, and those with an INR higher than 4 did not undergo extraction. Bayesian methods were used to estimate posterior probabilities of bleeding. RESULTS: Of cases, 63% were men, 25% were older than 80 years, 40% had an INR lower than 2.2, and 9% had an INR higher than 3. Nine cases bled 0 to 10 days postoperatively, with 1 requiring admission and transfusion. Significant predictors of bleeding were INR and number of extractions (P < .001 for the 2 comparisons). There were no events of bleeding in controls or cases with an INR lower than 2.2 (95% credible interval [CrI] for difference, -0.7 to 1.6). The posterior mean of bleeding was 1% (CrI, 0.1-2.6) for an INR lower than 2.2, 2.3% (CrI, 0.9-4.5) for an INR of 2.2 to 3, and 8.4% (CrI, 3.5-15) for an INR higher than 3. CONCLUSION: Unselected patients taking an anticoagulant with an INR lower than 2.2 had a similar risk of bleeding as control patients. The risk was approximately 1 in 40 in those with an INR of 2.2 to 3, whereas the risk in patients with an INR higher than 3 was approximately 1 in 11.

The use of cone beam computed tomography in the postoperative assessment of orbital wall fracture reconstruction.

PURPOSE: Computed tomography (CT) is currently the standard in postoperative evaluation of orbital wall fracture reconstruction, but cone beam computed tomography (CBCT) offers potential advantages including reduced radiation dose and cost. The purpose of this study is to examine objectively the image quality of CBCT in the postoperative evaluation of orbital fracture reconstruction, its radiation dose, and cost compared with CT. MATERIALS AND METHODS: Four consecutive patients with orbital wall fractures in whom surgery was indicated underwent orbital reconstruction with radio-opaque grafts (bone, titanium-reinforced polyethylene, and titanium plate) and were assessed postoperatively with orbital CBCT. CBCT was evaluated for its ability to provide objective information regarding the adequacy of orbital reconstruction, radiation dose, and cost. RESULTS: In all patients, CBCT was feasible and provided hard tissue image quality comparable to CT with significantly reduced radiation dose and cost. However, it has poorer soft tissue resolution, which limits its ability to identify the extraocular muscles, their relationship to the reconstructive graft, and potential muscle entrapment. CONCLUSIONS: CBCT is a viable alternative to CT in the routine postoperative evaluation of orbital fracture reconstruction. However, in the patient who develops gaze restriction postoperatively, conventional CT is preferred over CBCT for its superior soft tissue resolution to exclude extraocular muscle entrapment.

A C-terminal crosslinking telopeptide test-based protocol for patients on oral bisphosphonates requiring extraction: a prospective single-center controlled study.

PURPOSE: Patients undergoing extraction are at risk for bisphosphonate-related osteonecrosis of the jaws (BRONJ). A C-terminal crosslinking telopeptide (CTX) level lower than 150 pg/mL has been suggested as a predictor of BRONJ risk. The authors aimed to increase the precision of estimates of the risk of BRONJ in osteoporosis after extraction and to assess value of CTX testing at extraction time in cases of BRONJ in a large prospective cohort. PATIENTS AND METHODS: All patients on oral bisphosphonates for osteoporosis referred for extractions over a period of 6.5 years were included in a standard protocol. Pre-extraction fasted CTX levels were obtained. All patients were followed until healing. If the CTX level was lower than 150 pg/mL, they were offered a drug holiday. If they declined, if the CTX level was above 150 pg/mL at baseline, or after the drug holiday, they had extractions performed under local anesthesia. Age-matched controls not on bisphosphonates were identified. RESULTS: Nine hundred fifty patients had 2,461 extractions. One hundred eighty-one patients had a CTX level lower than 150 pg/mL. Four patients developed BRONJ; all had a CTX level lower than 150 pg/mL. All were on alendronate. The case-control comparison approached significance (<150 pg/mL; P = .073). Alendronate was associated with a low CTX level (P < .05). A CTX level lower than 150 pg/mL had a sensitivity of 100% and specificity of 81%. Bayesian analysis yielded a population expected risk of BRONJ of 0.29% (95% confidence interval, 0.12-0.52); the expected risk was 0.42% for a CTX level lower than 150 pg/mL and 0.13% for a CTX level higher than 150 pg/mL. CONCLUSION: The risk of BRONJ for patients with osteoporosis on bisphosphonates having extractions is approximately 0.2%. A CTX level lower than 150 pg/mL is sensitive and is associated with an approximately 3-fold greater risk of BRONJ.

Immunoglobulin G4-related disease of the hard palate.

A 71-year-old woman presented with erythematous, nontender, bilateral hard palate nodules of 6-month duration. Biopsy showed collagenous sclerosis and a follicular lymphoplasmacytic infiltrate among the minor salivary glands. Immunoglobulin G (IgG) and IgG4 staining showed 280 IgG4(+) cells per high-power field and a ratio of IgG4(+) to IgG(+) cells of 0.8. The patient subsequently developed bilateral lacrimal gland and parotid gland enlargement associated with an increased serum IgG4 level of 3,031 mg/dL (≤ 135 mg/dL). Left lacrimal gland biopsy confirmed IgG4-related dacryoadenitis. The patient declined corticosteroid treatment for IgG4-related disease (IgG4-RD) and remained stable at 15 months after the first presentation. Spontaneous, partial resolution of the palatal lesion was observed during follow-up. IgG4-RD should be considered in the differential diagnosis of lymphoplasmacytic lesions of the hard palate.

Surgically-assisted rapid maxillary expansion of narrowed maxillae: a case-cohort study.

AIMS: The aim of this study was to investigate a consecutive cohort of surgically-assisted rapid maxillary expansion cases to determine the indications, results and relapse associated with the procedure. METHODS: The records of 21 cases of SARME treated by the Oral and Maxillofacial Surgery and Orthodontic units at the University of Adelaide were examined. Overall expansion and subsequent relapse were compared on study models and posteroanterior cephalometric radiographs against the variables of age, gender, surgeon, surgical technique, final occlusion and the retention period. Statistical analysis was performed on paired variables. RESULTS: Maximum expansion was gained across the intermolar width and the most relapse identified across the canines. Male patients showed statistically greater stability across the intercanine width. There were otherwise no significant relationships between the treatment variables, stability or relapse. CONCLUSIONS: SARME is a safe surgical technique for narrowed maxillae requiring intermolar expansion of 6 mm or more. Overexpansion of up to 60% is required to compensate for relapse.

Oral Lesion as the first Clinical Presentation in Sarcoidosis: A Case Report.

Sarcoidosis is a common multi-system disease characterized histolopathologically by the formation of non-caseating granulomas in the affected tissues. The oral involvement of sarcoidosis is relatively rare with less than 70 reported cases in literature while an oral lesion as the initial presenting sign is even less common. Oral lesions of sarcoidosis may mimic the lesions of other serious systemic diseases including Crohn's disease and tuberculosis as well as lesions localized to the orofacial region such as orofacial granulomatosis. This report presents a case of non-progressive sarcoidosis where the initial presenting symptom was a lesion in the buccal vestibule attached to the gingivae. A brief review of the pathology and clinical features is also presented.

The nature and frequency of bisphosphonate-associated osteonecrosis of the jaws in dental implant patients: a South Australian case series.

PURPOSE: To determine the number of bisphosphonate-associated cases of dental implant failure in South Australia. MATERIALS AND METHODS: All general and specialist dentists who place dental implants in South Australia were contacted and asked to provide information on the total number of implants placed over the decade to December 2007. Cases of bisphosphonate-associated implant failure were identified. RESULTS: All 46 practitioners involved in implant placement and the management of bisphosphonate-associated osteonecrosis of the jaws in South Australia were identified. Approximately 28,000 implants had been placed in 16,000 patients. We identified 7 cases of oral bisphosphonate-associated implant failure, with 3 cases of failure of osseointegration and 4 cases of successful implants losing integration after being placed on oral bisphosphonates. There were 5 women and 2 men, and the mean age was 65.7 years (range, 49-75 years). Only 1 was medically compromised, with steroids and diabetes. No cases of implant failure in intravenous bisphosphonate cases were identified. On the basis of the assumption that 5% of the patients were taking an oral bisphosphonate, 1 in 114 (0.89%) had implant failure. CONCLUSION: In patients taking oral bisphosphonates, a failure to integrate or subsequent loss of integration may occur when oral bisphosphonates are started after successful implant placement. The rate of failure is low, at less than 1%.

Clinical investigation of C-terminal cross-linking telopeptide test in prevention and management of bisphosphonate-associated osteonecrosis of the jaws.

PURPOSE: The aim of this study was to determine, in a clinical setting, the effectiveness of the C-terminal cross-linking telopeptide test (CTX) test in the prevention and management of osteonecrosis of the jaws (ONJ) in patients taking bisphosphonates. PATIENTS AND METHODS: A total of 348 patients underwent a fasted morning CTX test. Of these, 222 were patients at risk of ONJ who had been referred for extractions, 15 had ONJ, and 113 were controls. RESULTS: The 215 patients taking long-term oral bisphosphonates were older (71 +/- 11.6 years), were predominantly women with osteoporosis, and were medically compromised. The average CTX value was 238 +/- 144 pg/mL, with 98 having a value less than 200 pg/mL. One patient with a CTX value of 126 pg/mL developed ONJ after an extraction. Seven intravenous bisphosphonate patients underwent extractions with no cases of ONJ developing. The CTX value was 329 +/- 354, with 4 less than 200 pg/mL. Fifteen patients developed ONJ, 12 after extractions and 3 spontaneously. Of these, 7, who were still taking a bisphosphonate at presentation, had a CTX value of 116 pg/mL. A CTX value of less than 150 pg/mL did not correlate with the clinical risk factors of age, gender, comorbidities, bone disease, or bisphosphonate duration. A statistically significant difference in the CTX value was found for those taking alendronate compared with those taking risedronate (P < .0001). If the bisphosphonate was ceased, the CTX value increased at approximately 25 pg/mL per month. CONCLUSIONS: The CTX test is not predictive of the development of ONJ for an individual patient but does identify those in the "risk zone," which is a value of less than 150 pg/mL to 200 pg/mL. If medically appropriate, the bisphosphonate can be ceased so that the CTX value increases to bring the patient out of the "risk zone."

Penetrating injuries to the orbit despite safety equipment.

Penetrating injuries to the orbit are uncommon but may have catastrophic consequences ranging from blindness, cerebral damage to death. Apparently similar injuries but with a slight difference in the anatomic pathway may have minimal morbidity. Prevention by the use of full safety equipment is recommended. This case report shows that full safety equipment may not prevent injury.

A sheep model of intracapsular condylar fracture.

PURPOSE: An animal model of a condylar head fracture similar to a type B intracapsular fracture in humans was created. The effect of this model on mandibular function and morphological changes of temporomandibular joint (TMJ) structure was evaluated. MATERIALS AND METHODS: Ten sheep were divided into 3 groups, sacrificed at 1 week (2 sheep), 4 weeks (4 sheep), and 12 weeks (4 sheep) after surgery. The right side of the TMJ was considered the surgical group; the left side, the control group. The anterior and posterior attachments of the discs were cut, and an oblique vertical osteotomy was made from the lateral pole of the condyle to the medial side of the condylar neck. The condyle fragment was pushed together with the disc anteriorly, inferiorly, and medially. The lateral side of the condylar stump was sutured to the capsule to limit movement. Preoperative and postoperative body weight, maximum mouth opening, lateral excursions, and x-ray and computed tomography (CT) findings in the 3 surgical groups and the control group were recorded. The SPSS software program was used for all statistical analyses. RESULTS: There were no significant differences in weight loss and left lateral movement among the 3 surgical groups, but maximum mouth opening and the right lateral movement decreased significantly in the 4-week and 12-week surgical groups. X-rays demonstrated severe bone erosion and new bony outgrowth in the lateral side of the condylar stump and a narrowed, indistinct joint space in these 2 groups. Three-dimensional reconstruction of CT images showed changed contours of the condylar stump, condylar fragment and articular eminence in all 3 surgical groups. CONCLUSIONS: This study demonstrates progressive changes toward ankylosis and pathological changes in sheep TMJ over time consistent with what has been found in humans.

Nature and frequency of bisphosphonate-associated osteonecrosis of the jaws in Australia.

PURPOSE: The purpose of this study is to estimate the frequency and describe the clinical characteristics of patients diagnosed with bisphosphonate-associated osteonecrosis of the jaws (ONJ) in Australia. MATERIALS AND METHODS: Cases of ONJ were identified in 2004 and 2005 primarily by a postal survey of Australian Oral and Maxillofacial Surgeons (OMS) with additional cases from other dental specialists and the Commonwealth of Australia Adverse Drug Reaction Committee (ADRAC). The clinical characteristics were recorded. The frequency of ONJ cases was estimated from prescription and dental extraction data. Univariate and bivariate statistics were calculated. RESULTS: One hundred fifty-eight cases of ONJ were identified. These were primarily in patients with bone malignancy (72%) and the main trigger was dental extraction (73%). The reported number of cases varied between different Australian States with the highest frequency being reported in the States with the best integrated health systems. The frequency of ONJ in osteoporotic patients, mainly on weekly oral alendronate was 1 in 2,260 to 8,470 (0.01% to 0.04%) patients. If extractions were carried out, the calculated frequency was 1 in 296 to 1,130 cases (0.09% to 0.34%). The total dose of oral alendronate at the onset of ONJ was 9,060 (+/-7,269) mg. The frequency of ONJ for Paget's disease cases was 1 in 56 to 380 (0.26% to 1.8%). If extractions were carried out, the calculated frequency of ONJ was 1 in 7.4 to 48 (2.1% to 13.5%). The frequency of ONJ in bone malignancy cases, treated with mainly intravenous zoledronate or pamidronate was 1 in 87 to 114 (0.88% to 1.15%). If extractions were carried out, the calculated frequency of ONJ was 1 in 11 to 15 (6.67% to 9.1%) The total dose of pamidronate was 3,285 (+/-2,530) mg and zoledronate 62 (+/-54.28) mg at the onset of ONJ. The median time to onset of ONJ was 12 months for zoledronate, 24 months for pamidronate, and 24 months alendronate. CONCLUSIONS: Before the prescription of bisphosphonates for bone disease the patient should be made dentally fit so that the need for subsequent dental extractions is minimized. Appropriate informed consent for the risk of ONJ for different bisphosphonates, for osteoporosis, and malignancy both in general and in particular for dental extractions can be provided using this data.