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Maxillary infections, MRONJ medication-related osteonecrosis of the jaw…

- - - - Feeling of facial fullness
      - Pacient can refer cacostomia (bad smell of nasal secretion).
        => Usually accompanied by nasal obstruction and orosinusal or nasal purulent secretion
      - Pain in the orbital area
    - - There is no pain except in cases of exacerbation. Unilateral purulent secretion. Sensibility at infraorbital and supraorbital points.
      - Can be of dental origin in a 50% of cases.
- - - - NSAIDs analgesic; ibuprofen, dexketoprofen
      - dressing materials: Alvogyl 牙槽鎮痛軟膏
        
        one-step/ self-eliminating treatment -> rapidly alleviates pain
        
        easily adheres to the alveolus and assisted by the patients tongue movements, it gradually self eliminates
- - - - cheek swelling
      - discharge/ drainage
      - exposed bone
      - mobility of the affected teeth
      - in mandible, it's common paresthesia of the alveolar nerve
      - pain and inflammation
    - - initial phase of spontaneous pain
      - suppurative phase with a long discharge of pus
      - can appear as primary form or be secondary to an acute form.
      - low symptomatology while not obstruct the drainage of pus
  - - - clinical manifestations
        
        most cases is chronic, progresses and becomes more extensive and painful
        
        ulceration, with the exposure of necrotic bone l
        
        mandible (80%)
        
        advanced stages: bone sequestration, truisms, intense pain, swelling, cutaneous fibulas and pathological fractures
      - treatment
        
        second stage
        
        pain develops -> analgesics+antibiotics (amoxicillin / clavulanic acid and ciprofloxacin)
        
        pain and discomfort persists -> curettage or debridement
        
        third stage
        
        infection becomes continuous, the extent of osteolysis is considerable, pain proves intense, or fistulization and suppuration or fractures
        
        more radical ablation surgery
        
        early stage
        
        mucosal irritants should be suppressed (smoking, alcohol, dentures),
        
        oral hygiene should be optimized and 0.2% Chlorhexidine rinses/ irrigation of the lesion 3-4 times a day
      - dental consideration
        
        before RT through dental exploration is indicated
        
        repair should be limited to those teeth that are truly amenable to restoration and which have adequate chances for survival
        
        extractions should be made at least 2-3 weeks before RT -> retained teeth (longer)
        
        evaluating those teeth with a poor prognosis due to caries, periodontal disease, or with latent infections
    - - complication of bisphosphonate (BP) drug usage, characterized by transmucosal exposure of necrotic bone, often followed by infection and pain
      - MRONJ
        
        characteristics (if all are present may be considered to have MRONJ)
        
        current or previous treatment with antiresorptive or antiangiogenic agents
        
        exposed bone that can be probed through an intramural or extra oral fistula in the maxillofacial region that has persisted for more than 8 weeks
        
        no history of radiation therapy to the jaws or obvious metastatic disease to the jaws
        
        risk factors
        
        type of medication
        
        used for ostepenia/ osteoporosis
        
        used for malignancy
        
        duration of medication therapy
        
        operative treatment: dentoalveolar surgery is considered a major risk factor for developing MRONJ
        
        anatomic factors: appear in the mandible(73%), maxilla (22.5%), but can appear in both jaws (4.5%)
        
        concomitant oral disease: pre-existing inflammatory dental disease such as periodontal disease or periapical pathology
        
        demographic and systemic factors and other medication factors: higher prevalence in the female population
        
        antiresorptive medicaitons 抗骨吸收藥物
        
        Oral BPs: osteoporosis, osteopenia and Paget's disease.
        
        :fire:RANK ligand inhibitor (denosumab): reduces the risk of vertebral, non-vertebral and hip fractures in osteoporotic patients when administered sc every 6m (Prolia®) / interferes with bone resorption (Prolia®)
        
        bisphosphonates (BPs):
        
        IV: cancer-related conditions (malignant Hypercalcemia, bone metastasis, and multiple myeloma)
        
        they inhibit osteoclast function and angiogenesis
        
        Alendronate (Fosamax®)
        
        Pamidronate and Zolendronic acid
        
        Antiangiogenic medications: interfere with formation of new blood vessels. effective in GI tumors and renal cell carcinomas/ interfere with the formation of new blood vessels ( Bevacizumab, Sunitinib)
        
        Management
        
        prevention
        
        dental screening
        
        appropriate dental measures before initiating antiresorptive therapy reduce the risk of ONJ
        
        cessation of at-risk medication therapy prior to tooth extraction
        
        Antiresorptive Therapy for Osteoporosis/Osteopenia : patients receiving BP or denosumab less than 2y may continue antiresorptive therapy during invasive dental treatment. BP exposure (>4 years) discontinue oral bisphosphonates for 3 months prior to and 3 months following invasive dental surgery
        
        Oncology Patients Receiving Monthly Antiresorptive Therapy:increased risk of developing ONJ following tooth extraction and thus these procedures should be avoided if possible. if ONJ develops the oncologist may consider discontinuing antiresorptive therapy until soft tissue closure has occurred, depending on disease status.
      - dental considerations
        
        before
        
        oral BP: no special prevention
        
        IV BP: dental examination -> extraction 4-6 weeks before starting treatment
        
        during and after
        
        oral BP
        
        IV BP