Proposal for a preventive protocol for medication-related osteonecrosis of the jaw.

BACKGROUND: Medication-related osteonecrosis of the jaw (MRONJ) is a severe adverse reaction experienced by some patients exposed to certain drugs (antiresorptives such as bisphosphonates or denosumab, and antiangiogenic drugs). From a review of the literature it appears that there is no uniform criterion when selecting preventive measures; these vary according to author. Likewise, the measures recommended are usually general, so that in few cases they result in specific actions to be applied depending on the different variables involved such as the type of drug used, the duration of its application, the underlying pathology, the presence or absence of risk factors, etc. The aim of this study has been to design a preventive protocol which can be easily applied in any clinic or by any dental care service. MATERIAL AND METHODS: We undertook an exhaustive literature review to find any articles related to the topic of study, namely, preventive measures for medication-related osteonecrosis of the jaw, on the one hand generically and on the other focusing on dental implant treatment. The most part the criteria of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed. From 3946 items, we selected a total of 21 items. RESULTS: From the analysis of the selected articles, several protocols have been developed that are easy to apply in a dental clinic.: Protocol 1. Before starting treatment with antiresorptives (Patients who are going to be treated for osteoporosis / Patients who are going to be treated for cancer). Protocol 2. Once treatment is initiated with antiresorptives (Patients being treated for osteoporosis / Patients being treated for cancer). CONCLUSIONS: The application of these protocols requires an interdisciplinary team which can handle the various treatments and apply the measures contained in them. Along with a team of well-educated and trained dentists, it is equally important to maintain contact with the medical team involved in the treatment of the underlying pathology, especially rheumatologists, oncologists, internists and gynaecologists. All the above requires a great staff learning and organization effort, continuous training and coordination of the whole team involved in the preventive management of these patients.

Analysis of different therapeutic protocols for osteonecrosis of the jaw associated with oral and intravenous bisphosphonates.

INTRODUCTION: Chemotherapy-associated osteonecrosis of the jaw caused by bisphosphonates is an exposure of necrotic bone with more than eight weeks of evolution that is attributable to bisphosphonates and no prior radiation therapy. Its etiopathogenesis remains unknown, although there are two hypotheses that may explain it: the drug's mechanism of action, and the risk factors that can lead to osteonecrosis. There is a wide range of treatment options for managing chemotherapy-associated osteonecrosis of the jaw, from conservative treatments to surgical procedures of varying levels of invasiveness, which are sometimes supplemented with adjuvant therapies. OBJECTIVE: The objective of this article is to group the therapeutic options for osteonecrosis of the jaw (ONJ) into seven different protocols and to evaluate their effectiveness in relation to stage of ONJ. MATERIAL AND METHODS: A literature review was carried out in PubMed following the PRISMA criteria. A total of 47 were collected after compiling a series of variables that define ONJ, applied treatments, and the clinical results obtained. RESULTS AND DISCUSSION: The 47 articles selected have a low to average estimated risk of bias and are of moderate to good quality. According to the data obtained, Protocol 3 (conservative treatment, clinical and radiological follow-up, minimally invasive surgical treatment, and adjuvant therapies) is the most favorable approach for ONJ lesions caused by oral bisphosphonates. For lesions caused by intravenous bisphosphonates, Protocol 2 (conservative treatment, clinical and radiological follow-up, minimally invasive surgical treatment, and no adjuvant therapies) is the best approach. When comparing the different stages of ONJ, Protocol 1 (conservative treatment, clinical and radiological follow-up) promotes better healing of Stage 1 ONJ lesions caused by orally administered bisphosphonates, and Protocol 3 is recommended for Stage II. For ONJ lesions attributable to intravenous bisphosphonates, Protocol 7 (conservative treatment, clinical and radiological follow-up, and adjuvant therapies) provides the best results in Stage 0; in Stages I, II, and III, Protocol 1 gives better results.

Hydrodynamic ultrasonic maxillary sinus lift: review of a new technique and presentation of a clinical case.

OBJECTIVES: Placing implants in the posterior maxillary area has the drawback of working with scarce, poor quality bone in a significant percentage of cases. Numerous advanced surgical techniques have been developed to overcome the difficulties associated with these limitations. Subsequent to reports on the elevation of the maxillary sinus through the lateral approach, there were reports on the use of the crestal approach, which is less aggressive but requires a minimal amount of bone. Furthermore, it is more sensitive to operator technique, as the integrity of the sinus membrane is checked indirectly. The aim of this paper is to review the technical literature on minimally invasive sinus lift and compare the advantages of different techniques with Intralift™, a new technique. STUDY DESIGN: The present study is a review of techniques used to perform minimally invasive sinus lift published in Cochrane, Embase and Medline over the past ten years and the description of the crestal sinus lift technique based on minimally invasive piezosurgery, with the example of a case report. RESULTS: Only eight articles were found on minimally invasive techniques for sinus lift. The main advantage of this new technique, Intralift, is that it does not require a minimum amount of crestal bone (indeed, the smaller the width of the crestal bone, the better this technique is performed). The possibility of damage to the sinus membrane is minimised by using ultrasound based hydrodynamic pressure to lift it, while applying a very non-aggressive crestal approach. CONCLUSIONS: We believe that this technique is an advance in the search for less traumatic and aggressive techniques, which is the hallmark of current surgery.

Empleo racional de la coronectomía en la extracción de terceros molares incluidos / Rational application of coronectomy when treating lower impacted third molar

Los terceros molares son los dientes que, con más frecuencia, sufrenel fracaso de su erupción y quedan incluidos o retenidos dentro de los maxilares.Un gran porcentaje de nuestros pacientes presentan los cordales incluidosy, de ellos, una parte importante se acompaña de patología que hace aconsejablesu tratamiento quirúrgico. La técnica de la coronectomía aplicada altercer molar incluido fue descrita por primera vez por Ecuyer y Debien en 1984como la eliminación parcial de dicho diente, dejando deliberadamente partede su raíz en el interior de la mandíbula. Fue propuesta para evitar la lesión delnervio dentario inferior (NDI) en aquéllos casos en los que existía una íntimarelación entre ambas estructuras anatómicas. Aunque el objetivo de la técnicaes muy claro, no está libre de controversia, ya que el cirujano debe valorarla posibilidad de una complicación infecciosa de origen pulpar. Presentamosun caso clínico exitoso de esta técnica, junto al análisis de la postura ante latécnica de los distintos autores, así como sus ventajas e inconvenientes(AU)

Third molars are the teeth that most frequently fail toerupt and remain impacted or retained inside the bone. A largepercentage of our patients have impacted wisdom teeth and manyof these patients also have pathologies that require surgicaltreatment. Applied coronectomy technique of the impacted thirdmolar was first described by Ecuyer and Debien in 1984. Thedescribed it as partial elimination of the tooth in question, deliberatelyleaving part of the root inside the bone. This was proposed to avoidinjuring the inferior dental nerve in cases where there was a closerelationship between the two anatomical structures. Although theobjective of the procedure is very clear, it is still controversial.Therefore, the surgeon should evaluate the possibility of an infectiouscomplication of pulpar origin. We present the successful clinical casethat uses this technique, as well as an analysis of the distinct authors’opinions this technique and its advantages and disadvantages(AU)

Randomized, double-blind study on effectiveness of intra-alveolar chlorhexidine gel in reducing the incidence of alveolar osteitis in mandibular third molar surgery.

Chlorhexidine (CHX) mouthwash is a good prophylactic agent for postextraction alveolar osteitis (AO), a very common complication. Recently, a bio-adhesive gel to deliver the active substance, CHX, has been introduced. The intra-alveolar positioning of the bio-adhesive gel allows more direct and prolonged action of CHX, which could be useful in the prevention of AO following extraction of impacted third molars. Presented here is a double-blind, randomised and parallel-group study evaluating the efficacy of the bio-adhesive 0.2% CHX gel (n=53) applied once within the alveolus during third molar surgery, compared to placebo gel only (n=50), in reducing the incidence of impacted third-molar postextraction AO. A 63.33% reduction in the occurrence of AO (P=0.019) was observed in the experimental group. In the control group, the occurrence of AO was 30% compared to 11% in the experimental group. Bio-adhesive 0.2% CHX gel, applied only once within the alveolus site at the time of surgery, may reduce the incidence of AO following removal of impacted third molars.

[Prevalence of dental caries in a 6-year old population from San Fernando (Cádiz)]. / Prevalencia de la caries dental en la población de 6 años de San Fernando (Cádiz).

AIM: The aim of this survey was to know the dental caries prevalence and severity in the 6 years old population from San Fernando (Cádiz). DESIGN: This is a cross sectional survey. EMPLACEMENT: We studied every schoolchildren at this age (100%) from the 27 city schools, in 1993. PARTICIPANTS: We studied 1439 schoolchildren of this age. This is one of the ages recommended by WHO in this class of surveys. INTERVENTIONS: We made an oral exploration following the WHO recommendations in this type of surveys. RESULTS: Dental caries prevalence reached 79% at this age. Dental decay index were; df-t index was 3.19; DMF-T was 0.68 and filling index was 11.2%. CONCLUSIONS: Our results of caries prevalence and epidemiological dental index, are higher in comparison with the results of other studies, which shows the severity of the dental decay problem in San Fernando. We still need educational and preventive programs in order to decrease dental caries prevalence and severity.