Case series of 589 tooth extractions in patients under bisphosphonates therapy. Proposal of a clinical protocol supported by Nd:YAG low-level laser therapy

Abstract

Objective: Trauma during dental surgery is a predisposing factor for bisphosphonates (BP)-related osteonecrosis of the jaws (BRONJ). However, about 40% of cases of BRONJ are not related to dental invasive procedures, being probably associated to endodontic or periodontal infections. Extraction of non-treatable teeth is considered a reliable choice, to improve symptoms and to reduce the risk of BRONJ. Here we report our experience of tooth extractions in patients under oral or intravenous BP therapy. Study Design: Two-hundred and seventeen patients (38 males, 179 females; mean age 68.72 ± 11.26 years, range 30 to 83 years) under BP therapy received 589 tooth extractions at the Unit of Oral Medicine, Pathology and Laser-assisted Surgery of the University of Parma, Italy, between June 2006 and December 2010. Ninety five patients were under BP therapy for oncological disease (multiple myeloma (MM): 23; bone metastases (BM): 72) and 122 patients for non oncological diseases: 119 osteoporosis (OP), 2 rheumatoid arthritis (RA) and 1 Paget’s disease (PD). The mean duration of BP was of 35 months. Antibiotic treatment was administered three days before and 2 weeks after tooth extractions. Patients were additionally treated with low level laser therapy (LLLT) through Nd:YAG laser (1064 nm – power 1.25 W; frequency 15 Hz; fibre diameter: 320 ?m), 5 application of 1 minute each. Patients were evaluated 3 days and once a week for 2 months after the extractions and every time they received LLLT. Mean follow-up was 15 months (ranging from 4 to 31 months). Results: In a total of 589 extractions (285 mandibular, 304 maxillary) performed, a minimal bone exposure was observed in 5 cases, treated with Er:YAG laser vaporization and than healed. Conclusions: Our experience supports the hypothesis that the association of antibiotic treatment and LLLT can be effective in preventing ONJ after tooth extractions in patients under BPT. Key words:Nd:YAG laser, low level laser therapy, tooth extractions, bisphosphonates, jaws osteonecrosis.

The effect of laser therapy on the expression of osteocalcin and osteopontin after tooth extraction in rats treated with zoledronate and dexamethasone

“…The laser light was used in a nonfocused way with a scanning method, 2 mm from the tissue, in five applications of 1 min each (power density 268.8 W/cm 2 , fluence 14.37 J/ cm 2 ). These parameters were selected on the basis of our clinical experience on the use of laser therapy in management of patients affected by or at risk for MRONJ [10,21]. Rats received the irradiation immediately after tooth extraction and then, under general anaesthesia, at days 2, 4, and 6 after surgery.…”

“…Two years later, Vescovi et al published a case series of 589 tooth extractions in patients under BP therapy using a clinical protocol supported by Nd:YAG laser therapy and concluded that it was effective in preventing BRONJ [10].…”

A Strategy against the Osteonecrosis of the Jaw Associated with Nitrogen-Containing Bisphosphonates (N-BPs): Attempts to Replace N-BPs with the Non-N-BP Etidronate

“…[19][20][21][22][23][24] The studies cited for (i) to (iv) in Table 4 are all case reports and have not been confirmed. In contrast, the effectiveness of teriparatide therapy (v) has been reported repeatedly.…”

“…She received several kinds of antimicrobials, but her BRONJ symptoms did not improve. Within two months of the start of the first Eti-RT, separation of sequestrum was observed, and so extraction 20.2±11.9 (7.6±5.0) 29±26 # Months after the first examination (and after the start of Eti-RT). * Sequestrum was separated before Eti-RT.…”

Underlying Mechanisms and Therapeutic Strategies for Bisphosphonate-Related Osteonecrosis of the Jaw (BRONJ)

“…59,[73][74][75][76][77][78][79] The studies cited for (i) to (iv) in Table 3 are all case reports and have not been confirmed. In contrast, the effectiveness of teriparatide therapy (v) has been repeatedly reported.…”