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Patient 👵🏼 (MRONJ (S&S (Pain, Soft tissue swelling and infection,…

- - - - Exposed bone
      - Duration>8weeks
      - Take drug
        
        Bisphosphonate
        
        Incidence
        
        Osteoporotic patient exposed to Oral BP
        
        Long-term
        
        0.1%
        
        greater than 4 years
        
        0.21%
        
        Osteoporotic patient exposed to IV BP
        
        3 years
        
        0.017%
        
        Antiangiogenic
        
        Impair healing capacity
        
        Capability to deal with infection and trauma :arrow_down:
        
        Surgery
        
        Tooth extraction
        
        monoclonal antibodies
        
        Denosumab
      - Without history of radiography at head and neck
  - - - Clinical
        
        No areas of bone necrosis
      - Tx.
        
        No Tx.
    - - Clinical
        
        No clinical +radiological symptoms
      - Tx.
        
        Expectant
    - - Clinical
        
        Bone exposure with necrosis bone
      - Tx.
        
        Chlorhexidine 0.12% +OH+Analgesics
    - - Clinical
        
        Bone exposure with necrosis bone + Infection + Pain + erythema
      - Tx.
        
        Chlorhexidine 0.12% +OH+Analgesics +Antibiotic
    - - Clinical
        
        Bone exposure with necrosis bone + Infection + Pain
        
        One or more of this sign
        
        Pathological Fx.
        
        Extraoral fistula
        
        Osteolysis
      - Tx.
        
        Chlorhexidine 0.12% +OH+Analgesics +Antibiotic + Surgical treatment
- - - - Small
      - Thin
    - - Low estrogen in women
      - Low testosterone in men
  - - - Normal : ≥ -1 S.D.
      - Osteropenia : -2.5 to -1 S.D.
      - Osteroporosis : < -2.5 S.D.
      - Severe osteroporosis : < -2.5 S.D. + ≥ 1 Fragility fracture
  - - - Bisphosphonates
        
        Mechanism
        
        Osteoclastic bone resoption ⬇️
        
        Inhibit angiogenesis
        
        Alendronate, Risedronate, Ibandronate, Zoledronate
        
        Indication
        
        Metastatic bone disease
        
        Breast
        
        Prostate
        
        Lung
        
        Paget's disease
        
        ADR ‼️
        
        MRONJ
        
        Nausea, vomiting
        
        Diarrhea
        
        Constipation
        
        Severe bone/ joint/ muscle pain
      - Estrogen
      - Selective estrogen receptor modulators
      - Calcitonin
        
        Binding calcitonin receptor of osteoclast
        
        Inhibit bone resorption
    - - Teriparatide (TPTD)
  - - - Postmenopausal osteoporosis
        
        Estrogen deficiency
      - Senile osteoporosis
        
        Degenerative osteoblast
    - - Drug 💊
        
        Anticancer drug, Immunosuppresive drug
      - Disease
        
        Malabsorption, Chronic liver disease
      - Others
- - - - Acetaminophen
      - NSAIDs : Diclofenac
        
        Mechanism : COX1 inhibitor
        
        ADR ‼️
        
        Peptic ulcer
        
        Coagulation disorder
        
        Stroke
        
        Acute myocardial infarction
- - - - Bisphosphonate
      - NSAID
      - Corticosteriod
    - - Cancer
      - Radiation
      - DM
      - AID
- - - - Menopause
        
        Estrogen :arrow_down:
        
        Osteoporosis
    - - Bone mass :arrow_down:
      - Destruction of cartilage
        
        Osteoarthritis
  - - - Periodontal disease
        
        Alcohol
        
        DM
        
        Smoking
      - Poor oral hygiene
    - - Drug induced
      - Age
    - - Drug induced, periodontal disease
- - - - Use less than 3 y.
        
        Do normal oral procedure
      - Use less than 3 y. + steroids
        
        Consult medicine stop
        bisphosphonate for 3 m.
      - Use more than 3 y.
        
        Stop bisphosphonate for 3 m.
    - - Oral administration
        
        Do normal oral procedure
      - Extraction if necessary
        
        0.12% chlorhexidine
      - Antibiotic prophylaxis
        
        Not prevent BRONJ
      - Root canal treatment
        
        Avoid extraction
      - Restorative
        
        Minimizing the impact on bone
      - Periodontal treatment
        
        Follow up
      - Implantation
        
        Inform before treatment
      - Orthodontics
        
        Inhibited tooth movement
    - - Ask patients about use of drugs, mode of administration
        
        Oral 💊
        
        IV 💉
        
        Longer half life, more risk
  - - - Nutrition
      - Exercise