• Dentistry,  Oral Bisphosphonates

    Oral Bisphosphonates: Study – Absolute Risk for Femur Fracture Low with Bisphosphonates

    I have written a number of pieces about the problems associated with bisphosphonates and osteonecrosis of the jaw. My latest post is here.

    Now, there is a new study published in the New England Journal of Medicine which sheds new light on the advantages vs. risks of taking these drugs.

    Almost 78% of all Swedish women aged 55 years and older who sustained an atypical femur fracture in 2008 had taken bisphosphonates, but the absolute risk for such breaks is small enough to justify prescribing the drugs, according to a study published in the May 5 issue of the New England Journal of Medicine (NEJM).

    For patients taking bisphosphonates, the age-adjusted relative risk for an atypical femur fracture — a clean, horizontal break spreading from the lateral side and occurring with minimal or no trauma — was 47.3%, the study reported. The crude incidence of the fractures was 0.09 per 10,000 patient-years among women who had never taken the drug compared with 5.5 among those who had ever taken it.

    These results “should be reassuring for bisphosphonate users,” write lead author Jörg Schilcher, MD, from the Department of Experimental and Clinical Medicine, Faculty of Health Science, Linköping University, Linköping, Sweden, and colleagues. “With a correct indication, the benefits of fracture prevention…will greatly outweigh the risk of atypical femoral fracture.”

    So, in other words, the benefits of preventing fractures by taking the medications outweigh the risk of an atypical leg (femur) fracture.

    So, how does this apply to dentistry?

    With more and more patients taking these drugs to prevent osteoporosis, and for longer periods of time, dentists will have to be scrupulous in their medical histories. Osteonecrosis of the jaw, while rare, is a known and serious complication.

    An undisplaced femoral fatigue fracture associated with bishosphonate treatment. NIH photo

    This study echoes the paper published in February in the Journal of the American Medical Association which I cited a few months ago. The AMA paper is here.

    Experts interviewed by Medscape Medical News call the study definitive because researchers not only studied a massive number of participants — all 1.5 million women in Sweden who were aged 55 years or older in 2008 — but also reviewed the x-rays of nearly all those who had particular kinds of femur fractures.

    “It’s the largest and most comprehensive study of this issue that I’ve seen,” said Sundeep Khosla, MD, president of the American Society for Bone and Mineral Research (ASBMR) and a professor of medicine and physiology at the Mayo Clinic in Rochester, Minnesota.

    The study’s conclusions echo those in other recent studies on the worrisome fractures and the bone-building drugs for osteoporosis. An article published in February in the Journal of the American Medical Association, for example, reported that long-term use of bisphosphonates boosted the risk for these fractures, but those authors noted that the absolute risk for fracture is low and is outweighed by the benefits of the therapy.

    And, what about drug holidays – especially since the risk of fracture declines rapidly after drug withdrawal?

    Because it is not clear how long patients with osteoporosis can be safely treated with bisphosphonates, the ASBMR recommends that clinicians consider discontinuing them after 5 years. At that point, many physicians give their patients a “drug holiday” for 1 or 2 years and then resume the therapy. Dr. Shane said that the rapid decline in fracture risk after drug withdrawal helps justify a holiday.

    “Now there seems to be evidence that giving patients intermittent drug holidays is appropriate to do,” she said. Dr. Khosla agreed, saying the decrease in fracture risk provides “reassurance that a [drug holiday] is good clinical practice.”

    Again for dentists, it will be esepcially important to monitor our patients for when they are on or off the medications. Since dental visits may be episodic, and in older patients only in case of an emergency e,g. tooth extraction, proper dental/medical records are mandatory. Appropriate consultation with the patient’s physician is indicated. Treatment plans for dental examination and/or treatment either prior to initial treatment or before resumption of treatment with these drugs would be beneficial to patients.

    I will look forward to additional studies on the risk of dental complications using a drug holiday approach – with resumption of drug use.

    In the meantime, Flap urges caution for patients taking ORAL Bisphosphonate medications. And,please patients update your health history and tell your dentist if you are using these drugs.

    Previous:

    Revisiting Bisphosphonates and Femur Fractures

    Oral Bisphosphonates Associated with a SLIGHTLY Elevated Risk of Developing Osteonecrosis of the Jaw?

    New Dentistry Cause for Alarm for Patients Who Use Bisphosphonates – Fosamax, Actonel, Boniva?

    Dentistry
    Today: Bisphosphonates: Zometa (zoledronic acid) & Aredia
    (pamidronate disodium) Associated with Osteonecrosis of Jaw – REDUX

    Bisphosphonates: Zometa (zoledronic acid) & Aredia (pamidronate dis odium) Associated with Osteonecrosis of Jaw

  • Dentistry,  Oral Bisphosphonates

    Revisiting Bisphosphonates and Femur Fractures

    I have written a number of pieces about the problems associated with bisphosphonates and osteonecrosis of the jaw. Now, there is this piece about some additional problems with these drugs.

    Nearly six years ago in this column, I discussed what was then a little-known problem associated with long-term use of bisphosphonates, the valuable drugs that protect against fractures caused by bone loss. The drugs, among them Fosamax, Actonel and Boniva, can slow bone loss, increase bone density and cut fracture rates in half in women with established osteoporosis.

    Reports had begun to emerge that some women taking bisphosphonates for many years suffered an unusual fracture of the femur, the long bone of the thigh. There was little or no trauma; in most cases the women were simply standing or walking when the femur snapped in half. In some, breaks occurred in both thighs, and many of the fractures were unusually slow to heal.

    Experts think the fractures happened because of the way the drugs work: by slowing the rate of bone remodeling, the normal process by which injured bone heals. As a result, microfractures that occur through normal wear and tear are not repaired. Although bone density may be normal, the bone can become brittle and crack under minor stress.

    In the years since, hundreds of cases of atypical femur fractures have been reported among women and some men taking bisphosphonates for five or more years. A number of studies have tried to assess the risk, and last fall the Food and Drug Administration issued a “safety announcement” and required that the drugs’ labels warn physicians and patients to be alert for this potential complication.

    So, with all of the problems associated with these drugs and the realized benefit, do the risks outweigh the benefits? The latest study was published in JAMA on February 23rd.

    “Compared to the number of fractures prevented,” she said, “the actual risk of a subtrochanteric femur fracture is small” — 1 case in 1,000 in the sixth year of therapy and 2.2 cases in 1,000 the seventh year.

    And, in another report in the The New England Journal of Medicine.

    A report published last year in The New England Journal of Medicine found no increase in atypical femur fractures, but that study did not include enough patients taking bisphosphonates for many years to produce a reliable result. Preliminary data from a much larger study has indicated that the risk of atypical femur fractures increased from 2 cases a year per 100,000 users after two years of bisphosphonate therapy to 78 cases a year per 100,000 after eight years on the drug.

    One more study:

    In a report from a 27-member task force of the American Society for Bone and Mineral Research (published online in September in The Journal of Bone and Mineral Research), the experts noted that the way bisphosphonates work can reduce the “toughness” of bones. “It is highly likely that case reports and case series of atypical femur fractures will continue to accumulate,” the task force wrote, noting that another 47 cases had been reported since their analysis was prepared. Many cases are not reported, and in an unknown number of cases physicians may not recognize the fractures as atypical.

    The task force called for an international registry of cases, including details that could help define who is most at risk.

    So, what should a patient and a dentist do?

    Certainly, be aware of the inherent risks of the bisphosphonates and be sensitive to the need, particularly if you are not at a high fracture risk.

    Initial excitement about bone-protecting drugs led to prescriptions for millions of women who were not necessarily at high fracture risk, and many experts now urge a thorough evaluation before a bisphosphonate is prescribed. In addition to bone density test results, the evaluation should take into account a patient’s smoking and drinking habits, thinness, family history of osteoporosis, previous osteoporotic fractures, drug prescriptions and weight-bearing exercise regimen. An online evaluation tool developed by the World Health Organization is at www.shef.ac.uk/FRAX, though some experts have criticized it as incomplete.

    The task force said a decision to treat should be “based on an assessment of benefits and risks,” and added, “patients who are deemed to be at low risk of osteoporotic-related fractures should not be started on bisphosphonates.”

    Even those with osteoporosis in the spine but little or no problem in their hips, the experts concluded, should consider alternative remedies.

    Osteonecrosis of the jaw is NOT a minor complication and the dentist in consult with the patient and patient’s physician must evaluate the risks, prior to dental surgery.

    The femur of Dr. Jennifer Schneider of Tucson, an internist who after seven years on Fosamax suffered a nontraumatic femur fracture that took two years to heal

    Dr. Schneider invites patients who have had such a fracture to write her at jennifer@jenniferschneider.com

    Previous:

    Oral Bisphosphonates Associated with a SLIGHTLY Elevated Risk of Developing Osteonecrosis of the Jaw?

    New Dentistry Cause for Alarm for Patients Who Use Bisphosphonates – Fosamax, Actonel, Boniva?

    Dentistry Today: Bisphosphonates: Zometa (zoledronic acid) & Aredia (pamidronate disodium) Associated with Osteonecrosis of Jaw – REDUX

    Bisphosphonates: Zometa (zoledronic acid) & Aredia (pamidronate dis odium) Associated with Osteonecrosis of Jaw

  • Dentistry

    Video: Kerr Corporation Launches SonicFill Dental Composite

    Dr. Ron Jackson demonstrates the new SonicFill material

    Kerr Corporation has introduced a new easy to use dental restorative composite resin, SonicFill.

    From the press release:

    Kerr Corporation, a leading manufacturer of technology for dental procedures has announced the launch of SonicFill, a first-of-its-kind, time-saving composite system that enables clinicians to perform posterior restorations with an easy-to-use, single-step, bulk fill technology that requires no additional composite capping layer.  Dentists utilizing SonicFill can go from placement to polished in less than 3 minutes on cavities up to 5mm.

    Kerr’s proprietary sonic activation within SonicFill’s delivery system dramatically lowers the viscosity of the composite during placement, providing superior adaptation. The SonicFill composite then immediately returns to a non-slumping, highly sculptable state that is easy to carve without being sticky.  Outstanding mechanical properties, including superior strength, low shrinkage and high depth of cure, allow it to be placed in bulk increments up to 5mm so that dentists can use it with confidence in posterior restorations.

    “We finally have a practical, efficient technique for placing posterior composites in one single, esthetic, bulk fill increment,” said Ron Jackson, DDS of Middleburg, VA. “SonicFill is a game changer.”

    “It’s truly rewarding to be able to offer the SonicFill system to the dental community because it is such a decidedly different and unique composite system that can dramatically save clinicians time,” said James Lobsenz, Kerr’s Product Manager. “And not only is SonicFill a tremendous time-saver, it has also proven, in a variety of third party clinical studies, to meet or exceed performance criteria when compared with either bulk fill flowables or traditional composites placed in layers.  The initial feedback we’re receiving from the clinician community is extremely enthusiastic – we are excited to be making the system available and feel SonicFill will change the way composites are done and ultimately the way clinicians do dentistry”.

    I haven’t used the material yet, but I look forward to doing so.

    One of the main time consuming elements in posterior composite restorations is the tedious layering that must be accomplished because of slumping of the bulk-fill material.

    Watching the video, one would have to agree at the ease of use of this material and the time saving.

    Here is a longer video that more extensively describes the system with the sonic nature of the handpiece delivery system.

  • Dentistry,  The Daily Extraction

    The Daily Extraction: Four Lower Anterior Teeth

    Dr. Tommy Murph extracts lower anterior teeth 24 – 27

    Again, Dr. Tommy Murph makes short work of these lower anterior teeth, using the 301 elevator and 151 forcep. Patients will, also, understand when the dentist says he will call you back and that he is with a patient, he may be very well be busy.

    Here is the pre-operative radiograph (x-ray):

    And, a pre-operative photo of the teeth:

    Enjoy your Daily Extraction.

    Dr. Murph is a South Carolina dentist who practices general dentistry who really excels in extracting teeth. For patients in the Myrtle Beach area, I can heartily recommend Tommy as YOUR dentist.

    For dentists, Dr. Murph has a number of resources for you in extracting teeth, including one on one courses in his office.

    Dr. Murph’s website is here and his extraction manuals are here on e-Bay.

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    The Daily Extraction Archive

  • Dentistry,  Dr. Tommy Murph,  The Daily Extraction

    The Daily Extraction: Lower Decayed Molar With A Complication – A Broken Instrument

    Dr. Tommy Murph extracts tooth #31 and has a complication – a broken elevator

    Dr. Murph is able to elevate this molar pretty quickly but the tip of his 301 elevator fractures off. He finishes the extraction with the #23 forcep and then goes after the broken instrument tip with a magnetized instrument.

    Here is the pre-operative photo of the tooth:

    And, the pre-operative radiograph (x-ray):

    Here are the magnetized instruments in Dr. Murph’s armamentarium:

    Plus, the instrument he uses to magnetize them:

    It is important for all exodontists to have either magnetized instruments or a magnetizer on hand in case an instrument or surgical bur should break. As you can see in the video above, it can be very difficult to visualize the instrument tip in a field of blood.

    Enjoy your Daily Extraction.

    Dr. Murph is a South Carolina dentist who practices general dentistry who really excels in extracting teeth. For patients in the Myrtle Beach area, I can heartily recommend Tommy as YOUR dentist.

    For dentists, Dr. Murph has a number of resources for you in extracting teeth, including one on one courses in his office.

    Dr. Murph’s website is here and his extraction manuals are here on e-Bay.

    Previous:

    The Daily Extraction Archive

  • Dentistry,  Dr. Tommy Murph

    The Daily Extraction: Upper Decayed Anteriors

    Dr. Tommy Murph extracts teeth numbers 6, 8, 9 and 10 with a 301 elevator and 151 forcep

    Dr Murph goes right after these carious maxillary anterior teeth. Note how he works the 301 elevator and uses the forcep without breaking the very decayed remaining crown.

    Here is the pre-operative radiograph (x-ray):

    Enjoy your Daily Extraction.

    Dr. Murph is a South Carolina dentist who practices general dentistry who really excels in extracting teeth. For patients in the Myrtle Beach area, I can heartily recommend Tommy as YOUR dentist.

    For dentists, Dr. Murph has a number of resources for you in extracting teeth, including one on one courses in his office.

    Dr. Murph’s website is here and his extraction manuals are here on e-Bay.

    Previous:

    The Daily Extraction Archive