Prevention, Diagnosis,
and Management of
Oral Surgery
Complications
June 28, 2015
David Salehani, D.D.S., M.D.
Private Practice, West Hollywood, CA
UCLA Reagan Medical Center
Faculty at UCLA School of Dental Medicine
Complications of Dentoalveolar
Surgery


Proper treatment planning and sound surgical
principles should lower the incidence of
complications.
Incidence of complications associated with the
removal of third molars, the most common
dentoalveolar surgical procedure, is 7 to 10.8
percent. 2, 3
Complications of Dentoalveolar
Surgery

Think ahead and have all proper instruments
and medications available.
Proper surgical suction
 Hemostatic agents (gelfoam, collaplug, etc.)
 Sutures
 Surgical blades
 Surgical handpiece

Complications of Dentoalveolar
Surgery
Complications of Dentoalveolar
Surgery

To avoid complications:
Have all necessary radiographs for proper
diagnosis.
 Always have an unobstructed view and access in
the presence of adequate light, proper soft tissue
reflection, and adequate suction.

Complications of Dentoalveolar
Surgery

Local anesthetics complications:


Rare
A more common adverse sequela: hematoma



PSA: rapid posterior buccal swelling
Pterygoid venous plexus: slower development
Treatment:



Direct pressure to the area
Cold packs for 24 hrs
Then heat to facilitate reabsorption
Complications of Dentoalveolar
Surgery

Local anesthetics complications: (Cont’d)

More serious situation: IA artery hematoma
Can compromise the airway
 Tx is directed at maintaining an airway, followed by
local or systemic interventions if required.

Complications of Dentoalveolar
Surgery

Local anesthetics
complications:

Facial ecchymosis and
discoloration:
Complications of Dentoalveolar
Surgery

Local anesthetics complications: (Cont’d)

Inadvertent posterior injection into the parotid
capsule:

Facial nerve palsy:


Reassure patient of the transient nature
Gauze patch over the affected eye
Facial Nerve Palsy:
Facial Nerve Palsy:
Complications of Dentoalveolar
Surgery

Local anesthetics complications: (Cont’d)

Fracture of the needle within the tissues
No attempt to palpate the needle
 Radiographs to orient the location in three planes

Complications of Dentoalveolar
Surgery

Local anesthetics complications: (Cont’d)
It is reported that the needles do not frequently migrate
through soft tissues to vital structures.
 However, an attempt to retrieve the needle may be made
to alleviate patient anxiety regarding subsequent injury
 Weigh the risks and benefits of surgical exploration
 Refer to a surgeon

Complications of Dentoalveolar
Surgery

Local anesthetics complications: (Cont’d)

Nerve trauma:







Rare
Most common: IAN (1 in 400,000 to 1 in 750,000 cases)
Epineural hematoma
Direct needle trauma
Avoid excessive firm needle contact with the bone to prevent a
needle barb.
Toxicity of local anesthetic
Reported that if spontaneous recovery has not been achieved within
21 days, the odds of its return are approximately 33%.
Complications of Dentoalveolar
Surgery

Neurologic complications:










Sensory nerve damage
Usually associated with third molar surgery
Typically IAN
Less frequently lingual nerve
Rarely long buccal nerve
0.6% to 5% of third molar cases
Spontaneous recovery in 96% of IAN cases
Spontaneous recovery in 87% of lingual nerve cases
Mostly in the first 6-8 weeks, remaining within 9 months
Total recovery after 9 months is rare.
Complications of Dentoalveolar
Surgery


Neurologic complications: (Cont’d)
Patient Age:

Higher morbidity in patients older than 25 years
Complications of Dentoalveolar
Surgery

Neurologic complications: (Cont’d)

Pre-op radiologic exam: (Panorex)

Cortical outline and location of the canal
Complications of Dentoalveolar
Surgery

Paresthesia is
one of the
leading causes of
liability against
OMFS and has
been among the
top four in
dollars awarded.
Complications of Dentoalveolar
Surgery

Injuries to the lingual nerve:
1% of lower third molar extractions
 Most difficult for patients to accept because of
altered taste sensation and reduced chance of
recovery.
 The lingual nerve may course over onto the
retromolar pad.
 It can be traumatized by incisions, retractions, flap
elevation, tooth and follicle removal, and suturing.

Complications of Dentoalveolar
Surgery

Injuries to the lingual nerve:
Unlike with IAN damage, reducing the incidence
of lingual nerve injury is related to surgical
technique.
 If indicated , mandibular third molar suturing
should be limited to the superficial tissues of the
lingual flap to reduce trauma to the lingual nerve.

Complications of Dentoalveolar
Surgery

Injuries to the lingual nerve: (Cont’d)

The return of sensation with the first 4 weeks:

Neuropraxia, excellent px
Symptoms of recovery manifesting at 1 to 3
months indicate a less certain px
 Failure to exhibit recovery sypmtoms for 12 or
more weeks indicates neurotmesis, poor px for
spontaneous recovery

Complications of Dentoalveolar
Surgery

Injuries to adjacent teeth and structures:

Iatrogenic luxation of adjacent tooth:
Assess the mobility of the tooth
 Reposition the tooth
 Take out of traumatic occlusion
 Stabilize for 10-14 days

Complications of Dentoalveolar
Surgery

Injuries to adjacent teeth and structures:
The use of exuberant force when extracting teeth is
unnecessary.
 Force must always be applied in a controlled
manner, using surgical finesse.
 The most common damage: fracture of the crown
or the existing restoration (mostly with elevators
while luxating)

Complications of Dentoalveolar
Surgery

Injuries to adjacent teeth and structures
(Cont’d):
During luxation with the elevator
 Consider carious teeth or large restorations of
adjacent teeth pre-op as potential risks.
 Discuss with the patient as part of the informed
consent form pre-op.

Complications of Dentoalveolar
Surgery

Inadvertent removal of the wrong tooth:
Attention to detail (Time-Out)
 Atraumatic removal of a wrong tooth: (if
immediately identified)

Reimplant and stabilize
 All other extractions should be delayed 4 to 6 weeks to
allow assessment and prognosis of the reimplanted tooth

Complications of Dentoalveolar
Surgery

Injuries to the opposing dentition:
Result of excessive traction forces and sudden
release of the tooth
 Can cause chipped or fractured tooth
 Minimize tractional forces, use proper elevation
 Inform the patient

Complications of Dentoalveolar
Surgery

Pain and swelling:




Associated with all surgical procedures
Normal physiologic responses to surgical treatment
However, this does not preclude the surgeon from taking all
necessary actions to lessen their severity.
Factors that may increase these complications:




Excessive operating time
Poor management of soft tissue
Inappropriate use of irrigation
Ignoring other basic surgical principles
Complications of Dentoalveolar
Surgery

Swelling:




Steroid therapy should have maximal anti-inflammatory
effects and minimal glucocorticoid and mineralocorticoid
activity.
Two steroids, dexamethasone and betamethasone are the
most popular.
Pre-op IV steroids and post-op oral steroids have the
greatest effect in decreasing swelling.
The use of ice, which is a routine recommendation, was not
demonstrated to be a considerable factor in decreasing
post-op swelling.
Complications of Dentoalveolar
Surgery

Pain:
An inevitable sequela of dentoalveolar surgery
 Peak pain: early post-op period 3-5 hrs after
surgery
 Study: 97% of patients suffered their highest level
of pain on the day of surgery

Complications of Dentoalveolar
Surgery

Pain (Cont’d):




Associated with increased concentration of prostaglandins
Prostaglandin antagonists such as NSAIDs would be the
most effective means of pain management.
Use longer-acting local anesthetics
Proper surgical technique:




Reflection of flaps
Management of soft tissue
Copious irrigation when using drills
Use of controlled forces
Complications of Dentoalveolar
Surgery

Temporomandibular joint injury:





If mandible is placed in an open position for extended
periods, certain degree of force will be transmitted to the
TMJ.
Use bite blocks, support the mandible.
Most successfully managed by conservative measures (soft
diet, moist heat, jaw rest, muscle relaxants, NSAIDs, and
on rare occasions splint therapy.
Further work-up: if symptoms persist beyond two weeks
Discuss as part of the informed consent
Complications of Dentoalveolar
Surgery

Displacement of teeth into anatomical spaces:
 Can occur with excessive force
 Use:
Adequate access and visualization
 Controlled force
 Removal of sufficient bone
 Placement of finger or instruments as distal stop

Complications of Dentoalveolar
Surgery

Displacement into infratemporal fossa:
Distoangular maxillary third molar
 Excessive force, poor visualization, lack of distal
stop

First locate the tooth (lateral and PA cephs)
Possible locations:
1) infratemporal fossa
2) maxillary sinus
3) in the mouth /aspirated/ throat pack

Complications of Dentoalveolar
Surgery

Displacement into infratemporal fossa:
Attempt to recover
 Extend incision distally for better access and
visualization
 Subperiosteal dissection to avoid the pterygoid
venous plexus

Visualize the tooth: place a curette behind the tooth to
retrieve
 Unable to visualize the tooth: close incision, notify the
patient, antibiotics for one week or longer

Complications of Dentoalveolar
Surgery

Displacement into infratemporal fossa:

Attempt to recover (Cont’d)
Complete exam on follow-up: check for infection and
limitation of function
 At this point refer to specialist.

Complications of Dentoalveolar
Surgery

Displacement into submandibular space:
Less common
 More common in third molar region
 The most common factor: excessive apical force
while attempting removal of mandibular molar
roots.

Complications of Dentoalveolar
Surgery

Displacement into submandibular space:

In the event the root or tooth is lost from the visual
field:
Initial attempt: palpation of the lingual aspect of the
mandible
 If identified, attempt to guide it back into the surgical
field
 Attempt to locate fails: closure, antibiotics, refer to
specialist.

Complications of Dentoalveolar
Surgery

Foreign Body Aspiration:





Any dentoalveolar surgery or dental procedure is associated
with the risk of foreign body aspiration.
The risk is increased with the use of sedation or GA.
The clinical presentation is usually, but not always,
associated with coughing or gagging.
In this case the patient should be allowed to attempt to
expel the object.
Premature intervention may hinder the patient and actually
facilitate aspiration.
Complications of Dentoalveolar
Surgery

Foreign body aspiration:
Use throat/pharyngeal drape
 Have suction available
 Instruct the patient not to swallow before you start

Complications of Dentoalveolar
Surgery

Foreign Body Aspiration: (Cont’d)
If true airway obstruction occurs, a BLS protocol
should be in place, which may include the
Heimlich maneuver, back blows, or abdominal
thrusts.
 No acute respiratory distress:

Refer patient for immediate chest and abdominal
radiographs.
 If the foreign body is determined to have entered the GI
tract, it is usually of little consequence, as it will
generally pass with no ill effects.

Complications of Dentoalveolar
Surgery

Foreign Body Aspiration: (Cont’d)

If displaced in trachea or bronchial tree
Pt requires admission to the hospital for its retrieval
 Consult a physician to perform bronchoscopy
 Keep in a monitored setting after retrieval
 IV antibiotics to cover oral flora and prevent aspiration
pneumonia
 Once patient is stabilized and follow up chest x-rays are
negative , the pt may be discharged and followed on an
outpatient basis.

Complications of Dentoalveolar
Surgery

Hemorrhage:
Refer to PMH regarding bleeding d/o’s
 If bleeding persists post-op

Reassure, instruct direct gauze pressure
 Persistent bleeding  examine the patient

Complications of Dentoalveolar
Surgery


Exam for persistent bleeding:
Review PMH



Patient's status
Remove gauze gently, not to disturb the clot
Active bleeding vs. oozing

Oozing:




Direct gauze pressure 30-45 min
Oozing continues: local anesthesia (block preferably), remove clot?, place
hemostatic agent, suture (figure-of-eight), direct pressure, observe
Consider electrocautery on wound margins (conservative)
If oozing continues, treat as active bleeding
Complications of Dentoalveolar
Surgery


Active bleeding:
Is it due to anticoagulants, bleeding d/o’s, liver
disease, chronic antibiotics?
First approach conservatively as above
 If active bleeding persists:


REFER to specialist or ER (call PMD, ER, or specialist
to report)
Complications of Dentoalveolar
Surgery

Alveolar Osteitis (dry socket):



Etx:








Incidence following the routine extraction of erupted teeth: 1-3 %
Impacted mandibular third molars: 1-65 %
Oral contraceptives
Smoking
Difficulty of extraction
Experience of the surgeon
Bacterial contamination
Poor OH, pericoronitis, gingivitis??
Exact pathophysiology remains unclear.
Possibly due to breakdown of the normal clot
Alveolar Osteitis

Symptoms:




Presents fourth to fifth day post-op
Constant moderate to severe pain
Foul taste and odor
May be differentiated from a post-op infection:




Absence of fever
No localized edema
No lymphadenopathy
No erythema
Alveolar Osteitis

Treatment:
Conservative
 Primary goal: relieve pain during the healing phase
 Curettage of the socket is not necessary.
 Gentle saline irrigation
 Dry-socket dressing
 Change dressing everyday or every other day until
the pain subsides

Alveolar Osteitis

Numerous studies have examined measures to
prevent alveolar osteitis:
Preop PCN? Mixed results
 Interestingly metronidazole given prophylactically
decreases the incidence of dry socket, indicating a
possible role of anaerobic bacteria.
 Topical tetracycline placed in the extraction site by
itself or with Gelfoam has been shown to decrease
the incidence of dry socket.

Alveolar Osteitis


Resolves 3-5 days, sometimes 10-14 days
post-op
If symptoms persist longer, look for other
causes of persistent pain:

DDX:
Osteomyelitis or post-op infection
 Fracture
 Drug dependence?
 Adjacent teeth?

Alveolar Osteitis

Persistent pain:

Thinking osteomyelitis?




Dry socket dressing doesn’t relieve pain
Panorex: new radiolucency
Clinically: purulent drainage, swelling, severe pain
Tx:



Refer to specialist
Debridement to bleeding bone
Long-term antibiotics (oral or IV)
Osteomyelitis
Complications of Dentoalveolar
Surgery

Soft tissue complications:

Most commonly a result of failing to protect the
soft tissue

Most frequent: tearing of the mucosal flap
Unintentional penetration of the soft tissues
 Soft tissue burns and abrasions

Complications of Dentoalveolar
Surgery

Injuries to adjacent osseous tissues:
 Atraumatic exodontia requires the expansion of alveolar
bone
 Inadvertent use of excessive force often results in fracture
of the maxilla or mandible.
 The most common areas for traumatic bony fractures are
the buccal cortical plate of the canines, premolars, and
molars; the floor of the maxillary sinus, tuberosity, and the
buccal cortical plate of mandibular incisors and canines.
Complications of Dentoalveolar
Surgery

Injuries to adjacent osseous tissues:
Prevention:

1)
2)
-
Thorough clinical and radiographic evaluation
Patient’s age and associated osseous elasticity
High risk:
-
Consider a surgical extraction technique
Provides more controlled bone removal, sectioning of roots,
and direct visualization of the degree of alveolar expansion
during luxation and elevation.
Complications of Dentoalveolar
Surgery

Injuries to adjacent osseous tissues:
Use finger support on alveolar process
 Bone that is knowingly fractured and removed
with the delivery of the tooth should not be
replaced.
 Smooth out the sharp bony edges with bone file
 Reposition the soft tissue
 Mandible fracture: atrophic mandible, impacted
third molar, significant odontogenic pathology, use
of excessive force

Complications of Dentoalveolar
Surgery

Maxillary sinus complication:

Pre-op radiograph:
Pneumatized maxillary sinus
 Chronic or acute periapical infection
 Periapical pathology
 Extruded endo fill
 Adjacent edentulous spaces
 Traumatic extraction

Complications of Dentoalveolar
Surgery

Maxillary sinus complication:
A small 1-4 mm sinus perforation is often covered
by the post-op blood clot and usually heals without
complications.
 Can use hemostatic agents
 Larger perforations, 5 mm or greater, requires
more aggressive action.

Complications of Dentoalveolar
Surgery

Maxillary sinus perforation:
An attempt should be made to attain primary
closure
 May need a buccal flap
 Post-op sinus precautions, antibiotics, nasal
decongestant, and antihistamine
 No nose blowing for 3 weeks
 Sneeze or cough with mouth open (3 weeks)

Closure of Fistulous Tract
Complications of Dentoalveolar
Surgery

Displacement of root tips into the maxillary sinus:



Decision to leave the root tip:



Take a radiograph to confirm
Rule out displacement under the palatal or buccal soft
tissue
Root tip between 1-3 mm
No infection/ pathology
Decision to remove:


Root tip> 2mm
Demonstrates evidence of infection or pathology
Complications of Dentoalveolar
Surgery

Displacement of root tips into the maxillary
sinus:

Attempts to retrieve:
Conservative first (suction and proper lighting)
 Access through the socket
 Caldwell-Luc procedure

Sinus Perforation:


Pre-op consultation, informed consent
Document in detail








Explained risks pre-op
Consent read and signed
Size of perforation
Any radiographs
What was performed
Post-op instructions
Meds prescribed
Follow-up appt
Complications of Dentoalveolar
Surgery



Complications in dentoalveolar surgery are to
be expected.
Timely dx and tx are important parts of
comprehensive surgical management.
Avoiding complications is best achieved by
designing an appropriate treatment plan, using
sound surgical techniques, and obtaining
thorough written informed consent.
Odontogenic Infections

Objectives:
Understand the microbiology of odontogenic
infections
 Understand the signs, symptoms and findings in
patients with odontogenic infections
 Review the various pathways of spread with
odontogenic infections
 Understand the medical and surgical management
of odontogenic infections

Odontogenic Infections

Source of the bacteria that cause most
odontogenic infections:
Mostly indigenous bacteria that normally live on
or in the host.
 These bacteria gain access to deeper tissues and
cause infection.

Odontogenic Infections


Which species of bacteria cause odontogenic
infections?
Almost all odontogenic infections are caused by
multiple bacteria (an average of five species)





Mostly gram-negative rods (fusobacteria, bacteroides)
Some are gram-positive cocci (streptococci and
peptostreptococci)
25% are aerobic, mostly gram-positive cocci
About 60% are anaerobic bacteria
Fusobactrium spp. is associated with severe
infections.
Odontogenic Infections

What is Gram staining?

Each specimen obtained from a patient with an infectious
process initially should be stained.




Staining
Decolorizing
Restaining with a different stain
Then categorize the organisms into four groups based on
their stain retention and morphology:




G+ cocci
G- cocci
G+ rods
G- rods
Odontogenic Infections

What is the clinical significance of gram stain?

Because gram staining can be completed within a
few minutes, it usually narrows the list of likely
causative organisms immediately, whereas culture
and sensitivity testing and biochemical
identification may take 1-5 days to complete.
Odontogenic Infections

Progression of odontogenic infections;
Early infection is often initiated by high-virulence
aerobic organisms (commonly streptococci), which
cause cellulitis.
 Followed by mixed aerobic and anaerobic
infections.
 Abscess stage: anaerobic bacteria predominate
 Eventually exclusively anaerobic.

Odontogenic Infections

What is cellulitis?
Warm, diffuse, erythematous, indurated, and
painful swelling of the tissue in an infected area.
 Easy to treat, but can also be severe and life
threatening.
 Antibiotics and removal of the cause are usually
sufficient.
 Surgical incision and drainage are indicated if no
improvement is seen in 2-3 days, or if evidence of
purulent collection is identified.

Odontogenic Infections

What is an abscess?
A pocket of tissue containing necrotic tissue,
bacterial colonies, and dead white cells.
 May or may not be fluctuant.
 The patient is often febrile at this stage.

Odontogenic Infections
CELLULITIS
ABSCESS
Acute
Chronic
Pain
Severe and generalized
Localized
Size
Large
Small
Diffuse borders
Well circumscribed
Doughy to indurated
Fluctuant
No
Yes
Degree of
seriousness
Greater
Less
Bacteria
Aerobic
Anaerobic
Duration
Localization
Palpation
Presence of pus
Odontogenic Infections

Signs of infection:
Swelling
 Erythema
 Heat
 Pain
 Fever
 Purulent drainage

Odontogenic Infections

Signs and symptoms of serious orofacial infections:









Airway compromise
Fever
Fatigue
Malaise
Dehydration
Trismus
Dysphagia
Odynophagia
Drooling
Pathways of Odontogenic Infection
Submandibular Abscess
Sublingual Abscess
Buccal Space Abscess
Lateral Pharyngeal Space Abscess
Odontogenic Infections

Factors that influence the spread of
odontogenic infections:
Thickness of bone adjacent to the offending tooth
 Position of muscle attachment in relation to root
tip
 Virulence of the organism
 Status of patient’s immune system

Pathways of Odontogenic Infection
- Pulp necrosis results from deep decay in tooth,
(inflammatory reaction)
 Usual cause of odontogenic infection: necrosis of
tooth pulp and bacterial invasion through the pulp
chamber into deeper tissues
 Further progression leads to medullary space
infection
 More commonly, get fistulous tracts through alveolar
bone
 Fistulous tract may penetrate oral mucosa or facial
skin
Odontogenic Infections

Principles of therapy for odontogenic infections:




Determining the severity of infection
Cellulitis vs. abscess
Status of host’s immune system
Treatment:






Removing the source of infection
Incision and drainage
Antibiotics
Analgesics
Fluids
Nutritional support
Odontogenic Infections

Different methods of drainage:
Endodontic treatment
 Extraction of the offending tooth
 Incision and drainage of soft tissue collection

Odontogenic Infections

Surgical principles of incision and drainage:
Prior to incision, obtain fluid for culture +
sensitivity
 Incision in healthy skin or mucosa

Cosmetically and functionally acceptable place
 Blunt dissection


Placement of a drain

Drain removal
Odontogenic Infections

Antimicrobial spectrum of the most common
antibiotics used in treatments for oral and
maxillofacial infections:

Penicillin:






Streptococcus (except group D)
Staphylococcus(non-beta-lactamase producing)
Treponema
Actinomyces
Oral anaerobes
Oxacillin and dicloxicillin:

Beta-lactamase-producing staphylococci
Criteria For Immediate Treatment







Dysphonia
Dyspnea (airway embarrassment)
Dysphagia
High fever
Medically compromised patient
Location of infection
Rapidly progressing cellulitis
Odontogenic Infections

Amoxicillin:

Same as penicillin plus:




E. coli
H. Influenza
Proteus Mirabilis
Amoxicillin plus clavulanate:

Above plus:





Klebsiella
Staph. Aureus
Staph epidermidis
Enterocci
gonococci
Odontogenic Infections

Cephalexin:






Streptococcus (except group D)
Staphylococcus
E. coli
P. mirabilis
Klebsiella
Erythromycin:






Streptococcus
Staphylococcus
Mycoplasma
H. influenza
Legionella
Oral anaerobes
Odontogenic Infections

Clindamycin:
Streptococcus
 Staphylococcus
 Actinomyces
 Bacteroides fragilis
 Oral anaerobes


Metronidazole:

Oral anaerobes
Odontogenic Infections

Antibiotic of choice:

Empiric therapy:


Allergic to penicillin:


Penicillin or penicillin plus metronidazole, if the patient
is not allergic to these and not immunocompromised.
Clindamycin is an excellent alternative
Definitive antibiotic treatment should be based
on culture and sensitivity.
Odontogenic Infections

Indications for prophylactic antibiotics:
To prevent local wound infection
 To prevent metastatic wound infection (SBE,
prosthetic joints)

Odontogenic Infections

Indications for prophylactic antibiotics to
prevent local wound infection:
Procedures associated with a high incidence of
infection
 When infections may have grave consequences.
 Immunocompromised patient
 Long surgical procedure
 Surgical procedure with high degree of
contamination

Odontogenic Infections

Possible causes of failure of antibiotic therapy:
Inadequate surgical treatment
 Depressed host defenses
 Presence of foreign body
 Problems associated with use of antibiotics:

patient compliance,
 inadequate dose,
 antibiotic-related infection,
 use of wrong antibiotics.

Odontogenic Infections

What to look for at the follow-up
appointment?
Response to treatment
 Recurrence of infection
 Presence of allergic reactions
 Toxicity reactions to antibiotics
 Secondary infection (e.g. Candida)

Odontogenic Infections

Pseudomembranous colitis:

A toxin reaction associated with the use of an
antibiotic that causes alteration of colonic flora
leading to the overgrowth of Clostridium difficile.
Profuse watery diarrhea that may be bloody
 Cramping
 Abdominal pain
 Fever
 Leukocytosis

Odontogenic Infections


Risk factors associated with
pseudomembranous colitis are related to the
type of antibiotic and patient-related factors.
Type of antibiotics:
Clindamycin (originally thought to be the main
antibiotic, only one third of cases)
 Ampicillin (one third)
 Cephalosporins (one third)

Odontogenic Infections

Patient-related factors for pseudomembranous
colitis:
Previous GI procedures
 Medically compromised patients
 Advanced age
 Female gender
 Inflammatory bowel disease
 Cancer chemotherapy
 Renal disease

Odontogenic Infections

Diagnosis of pseudomembranous colitis:




Signs and symptoms
Culture
Sigmoidoscopy to confirm the dx
Treatment:




Discontinue the causative antibiotics
Use alternate antibiotic if necessary
Restoration of fluid and electrolytes balance
Anticlostridia antibiotics (oral vancomycin or
metronidazole)
Antibiotics For Odontogenic
Infections:

Penicillin (Pfizerpen, Pen-Vee K, Beepen-VK)



Drug of choice; effective against most aerobes and
anaerobes.
Bactericidal against sensitive organisms when adequate
concentrations are reached and most effective during the
stage of active multiplication. Inadequate concentrations
may produce only bacteriostatic effects.
Penicillin V (phenoxymethyl penicillin) is administered
orally, whereas aqueous penicillin G is administered IV or
IM.
Pen Vee K

Adult Dose:


Pediatric Dose:


Probenecid can increase effects of penicillin; coadministration of
tetracyclines can decrease effects of penicillin
Pregnancy:


Documented hypersensitivity
Interactions:


Penicillin V: 15-62.5 mg/kg/d PO divided q4-8h
Contraindication:


Penicillin V: 250-500 mg PO q6h
B - Usually safe but benefits must outweigh the risks.
Precautions:

Caution in impaired renal function
Antibiotics For Odontogenic
Infections:

Amoxicillin and clavulanate (Augmentin):





Amoxicillin inhibits bacterial cell wall synthesis by binding
to penicillin-binding proteins. Addition of clavulanate
inhibits beta-lactamase-producing bacteria.
Good alternative antibiotic for patients allergic or intolerant
to the macrolide class. Is usually well tolerated and
provides good coverage to most infectious agents.
The half-life of oral dosage form is 1-1.3 h.
For children aged 3 mo or older, base dosing protocol on
amoxicillin content.
Because of different amoxicillin/ clavulanic acid ratios in
250-mg tab (250/125) vs. 250-mg chewable tab (250/62.5),
do not use 250-mg tab until child weighs >40 kg.
Augmentin

Adult dose:


500 mg PO tid for 7-10 d
Pediatric Dose<3 months: 125 mg/5mL PO susp; 30
mg/kg/d (based on amoxicillin component) PO
divided bid for 7-10 d
>3 months: if using 200 mg/5 mL or 400 mg/5 mL
susp, 45 mg/kg/d PO q12h; if using 125 mg/5 mL or
250 mg/5 mL susp, 40 mg/kg/d PO q8h for 7-10 d
>40 kg: Administer as in adults
Augmentin

Contraindications:


Interactions:



Documented hypersensitivity
Coadministration with warfarin or heparin increases risk of
bleeding;
Pregnancy B - Usually safe but benefits must
outweigh the risks.
Precautions:

Adjust dose in renal impairment; diarrhea may occur;
cross-allergy may occur with other beta-lactams and
cephalosporins
Antibiotics For Odontogenic
Infections:

Clindamycin (Cleocin):
Considered by many as first-line therapy because
of emergent penicillin resistance.
 Excellent activity against oral aerobes and
anaerobes; penetrates bone and abscess cavities,
but its use is limited because of the danger of
inducing pseudomembranous colitis;
 Use in patients who are allergic to penicillin.

Clindamycin

Adult Dose:


Pediatric Dose:


erythromycin may antagonize effects of clindamycin; antidiarrheals may delay
absorption of clindamycin
Pregnancy B:


Documented hypersensitivity; regional enteritis; ulcerative colitis; hepatic impairment;
antibiotic-associated colitis
Interactions:


20-30 mg/kg/d PO divided q6h; not to exceed 1.8 g/d
Contraindications:


150-450 mg PO q6-8h; not to exceed 1.8 g/d
Usually safe but benefits must outweigh the risks.
Precautions

Adjust dose in severe hepatic dysfunction; no adjustment necessary in renal
insufficiency; associated with severe and possibly fatal colitis
Medication-Related
Osteonecrosis of the Jaw
www.aaoms.org
(health professional section, lower
right hand corner)
MRONJ



The Special Committee recommends changing the
nomenclature of bisphosphonate-related osteonecrosis
of the jaw (BRONJ).
The Committee favors the term medication-related
osteonecrosis of the jaw (MRONJ).
The change is justified to accommodate the growing
number of osteonecrosis cases involving the maxilla
and mandible associated with other antiresorptive
(denosumab) and antiangiogenic therapies.
Antiresorptive Preparations
Commonly Used in the U.S.
Primary
Indication
Nitrogen
Containing
Dose
Route
Alendronate
(Fosamax)
Osteoporosis
Yes
10 mg/day; 70
mg/wk
Oral
Residronate
(Actonel)
Osteoporosis
Yes
5 mg/day;
35mg/wk
Oral
Ibandronate
(Boniva)
Osteoporosis
Yes
2.5 mg/day;
150mg/ month
Oral
Pamidronate
(Aredia)
Bone metastasis
Yes
90 mg/ 3 wks
Intravenous
Zoledronate
(Zometa)
(Reclast)
Denosumab
(Xgeva)
(Prolia)
Bone metastasis
4 mg/ 3 wks
Yes
Osteopororsis
Bone metastasis
Osteoporosis
Intravenous
5mg/yr
NO
Humanized
monoclonal
Ab
120 mg/4 weeks
60mg/6 months
SQ
SQ
MRONJ





Oral bisphosphonates are approved for
treatment of:
Osteoporosis
Osteopenia
They are also used for a variety of less
common conditions such as Paget’s disease of
bone, and osteogenesis imperfecta.
The most common use, however, is for
osteopenia and osteoporosis.
MRONJ




Intravenous (IV) bisphosphonates (BPs) are
antiresorptive medications used to manage:
Cancer-related conditions including hypercalcemia of
malignancy,
Skeletal-related events (SRE) associated with bone
metastases in the context of solid tumors such as
breast cancer, prostate cancer and lung cancers, and
For management of lytic lesions in the setting of
multiple myeloma.
MRONJ

IV BPs once yearly infusion of zolendronate
(Reclast) and a parenteral formulation of
ibandronate (Boniva) administered every three
months, have FDA approval for management
of osteoporosis.
MRONJ

RANK ligand inhibitor (denosumab):



is an antiresorptive agent
fully humanized antibody against RANK ligand (RANK-L) and inhibits
osteoclast function and associated bone resorption.
When denosumab (Prolia) is administered subcutaneously every 6 months;

reduction in the risk of vertebral, non-vertebral, and hip fractures in
osteoporotic patients.

Denosumab (Xgeva) is also effective in reducing SRE related to metastatic
bone disease from solid tumors when administered monthly.

Denosumab therapy is not indicated for the treatment of multiple myeloma.
Interestingly, in contrast to bisphosphonates, RANK ligand inhibitors do
not bind to bone and their effects on bone remodeling are mostly
diminished within 6 months of treatment cessation.

MRONJ

Angiogenesis inhibitors:
interfere with the formation of new blood vessels.
 These novel medications have demonstrated
efficacy in the treatment of gastrointestinal tumors,
renal cell carcinomas, neuroendocrine tumors and
others.

MRONJ


Oral and maxillofacial surgeons first recognized and
reported cases of non-healing exposed bone in the
maxillofacial region in patients treated with IV
bisphosphonates.
In September 2004, Novartis, the manufacturer of the
IV bisphosphonates pamidronate (Aredia) and
zoledronic acid (Zometa), notified healthcare
professionals of additions to the labeling of these
products, which provided cautionary language related
to the development of osteonecrosis of the jaws.
MRONJ


This was followed in 2005 by a broader drug
class warning of this complication for all
bisphosphonates including the oral
preparations.
More recently, other antiresorptive agents and
novel anti-cancer drugs have been linked to the
development of jaw necrosis.
MRONJ

Patients may be considered to have MRONJ if
all of the following characteristics are present:
1. Current or previous treatment with antiresorptive or
antiangiogenic agents;
 2. Exposed bone or bone that can be probed through an
intraoral or extraoral fistula(e) in the maxillofacial
region that has persisted for more than eight weeks; and
 3. No history of radiation therapy to the jaws or obvious
metastatic disease to the jaws.

MRONJ

It is important to understand that patients at
risk for or with established MRONJ can also
present with other common clinical conditions
not to be confused with MRONJ.
MRONJ

Commonly misdiagnosed conditions may include, but are not
limited to:










alveolar osteitis,
sinusitis,
gingivitis/periodontitis,
caries,
periapical pathology,
fibro-osseous lesion,
sarcoma,
chronic sclerosing osteomyelitis, and
TMJ disorders.
It is also important to remember that ONJ occurs in patients
not exposed to antiresorptive or antiangiogenic agents.
Pathophysiology
A. Inhibition of osteoclastic bone resorption and
remodeling



Bisphosphonates (BP), and other antiresorptives such as
denosumab, inhibit osteoclast differentiation and function, and
increase apoptosis, all leading to decreased bone resorption
and remodeling.
Osteoclast differentiation and function plays a vital role in
bone healing and remodeling in all skeletal sites, but
osteonecrosis of the jaws only occurs primarily within the
alveolar bone of the maxilla and mandible.
An increased remodeling rate in the jaws may explain the
differential predisposition to ONJ compared to other bones in
the axial or appendicular skeleton.
Pathophysiology



B. Inflammation/Infection
Both systemic and local oral risk factors have
been implicated in ONJ.
From these clinical studies, several animal
models have been developed to demonstrate
that both inflammation or bacterial infection
and systemic antiresorptives are sufficient to
induce ONJ.
Pathophysiology




C. Inhibition of Angiogenesis
Angiogenesis is a process that involves growth,
migration and differentiation of endothelial cells to
form new blood vessels.
Angiogenesis favorably influences tumor growth and
also influences tumor invasion of vessels, resulting in
tumor metastasis.
Angiogenesis requires binding of signaling molecules
such as vascular endothelial growth factor (VEGF) to
receptors on the endothelial cells. This signaling
promotes new blood vessel growth.
Pathophysiology

Osteonecrosis is classically considered an
interruption in vascular supply or avascular
necrosis, and therefore, it is not surprising that
inhibition of angiogenesis is a leading
hypothesis in ONJ.
Risk Factors for MRONJ


A) Medication related risk factors:
1) MRONJ risk among cancer patients:
The risk for ONJ among cancer patients
enrolled in clinical trials and assigned to
placebo groups ranges from 0% to 0.019% (01.9 cases per 10,000 cancer patients)
 The risk of ONJ among cancer patients exposed
to zolendronate ranges between 50-100 times
higher than cancer patients treated with
placebo.

Risk Factors for MRONJ

2. MRONJ risk among osteoporosis patients
Most dentists and oral and maxillofacial surgeons
see patients in their practices who have been
exposed to antiresorptive therapy, eg oral BPs, for
management of osteoporosis.
 When evaluated by age, 5.1 million patients over
the age of 55 years received a prescription for a
bisphosphonate in year 2008.

Risk Factors for MRONJ

Based on the current review of data, the risk of
developing ONJ among osteoporotic patients
exposed to oral, IV BPs, or denosumab is real
but remains very low.
Risk Factors for MRONJ

3. Duration of medication therapy as a risk
factor for MRONJ:
Regardless of indications for therapy, the duration
of BP or antiresorptive therapy continues to be a
risk factor for developing ONJ.
 When compared to cancer patients receiving
antiresorptive treatment, the risk of ONJ for
patients with osteoporosis exposed to
antiresorptive medications is about 100 times
smaller.

Risk Factors for MRONJ

B) Local Factors:

1) Operative Treatments:
Dentoalveolar surgery is considered a major risk
factor for developing MRONJ.
 Most clinicians and patients want to know:
“Among patients exposed to antiresorptive
medications, what is the risk for developing ONJ
following tooth extraction (or other dentoalveolar
procedures such as implant placement or
periodontal procedures)?”

Risk Factors for MRONJ


The best current estimate for the risk of ONJ
among patients exposed to oral bisphosphonates
following tooth extraction is 0.5%.
Absent data, the committee considers the risk for
ONJ after dental implant placement and endodontic
or periodontal procedures that require exposure and
manipulation of bone to comparable to the risk
associated with tooth extraction.
Risk Factors for MRONJ

2. Anatomic factors:
MRONJ is more likely to appear in the mandible
(73%) than the maxilla (22.5%) but can appear in
both jaws (4.5%).
 Denture use was associated with an increased risk
for ONJ among cancer patients exposed to
zolendronate.

Risk Factors for MRONJ

C. Demographic and systemic factors and other
medication factors:



Age and sex are variably reported as risk factors for
MRONJ. The higher prevalence of this complication in the
female population is likely a reflection of the underlying
disease for which the agents are being prescribed (i.e.
osteoporosis, breast cancer).
Corticosteroids are associated with an increased risk for
MRONJ.
Co-morbid conditions among cancer patients:


include anemia (hemoglobin < 10g/dL) and diabetes.
Tobacco use has been inconsistently reported as a risk
factor for MRONJ.
Risk Factors for MRONJ

D. Genetic factors:

Collectively, studies suggest that a germ line
sensitivity to bisphosphonates may exist.
Risk Factors for MRONJ


In summary, the current literature reaffirms that the
risk of MRONJ is significantly greater in cancer
patients receiving antiresorptive therapy as compared
to treatment regimens for osteoporosis.
Moreover, the risk of MRONJ in osteoporosis
patients receiving antiresorptive therapy continues to
be very low regardless of drug type (bisphosphonates,
denosumab) or dosing schedule.
Management Strategies for Patients Treated
with Antiresorptives or Antiangiogenics

1. Prevention of MRONJ:


Early screening and initiation of appropriate dental
care
2. Cessation of at-risk medication therapy prior
to tooth extraction or other procedures, which
involve osseous injury (eg dental implant
placement, periodontal or apical endodontic
treatment): DRUG HOLIDAY??
Management Strategies for Patients Treated
with Antiresorptives or Antiangiogenics



Drug Holiday??
a. Antiresorptive Therapy for
Osteoporosis/Osteopenia :
Damm and Jones note that since 50% of serum BP
undergoes renal excretion the major reservoir of BP is
the osteoclast whose life span is 2 weeks. Thus the
majority of free BP within the serum would be
extremely low 2 months following the last dose of an
oral bisphosphonate and a 2-month drug free period
should be adequate prior to an invasive dental
procedure.
Management Strategies for Patients Treated
with Antiresorptives or Antiangiogenics


Drug Holiday??
b. Oncology Patients Receiving Monthly
Antiresorptive Therapy:

There are no data to support or refute the cessation
of antiangiogenic therapy in the prevention or
management of MRONJ and therefore continued
research in the area is indicated.
Management Strategies

A. Patients about to initiate intravenous
antiresorptive or antiangiogenic treatment for
cancer therapy :

The treatment objective: minimize the risk of developing
MRONJ.



Non-restorable teeth and those with a poor prognosis should be
extracted.
Other necessary elective dentoalveolar surgery should also be
completed at this time.
Based on experience with osteoradionecrosis, it appears
advisable that antiresorptive or antiangiogenic therapy should
be delayed, if systemic conditions permit, until the extraction
site has mucosalized (14-21 days) or until there is adequate
osseous healing.
Management Strategies

B. Patients about to initiate antiresorptive
treatment for osteoporosis:

At the initiation of treatment, patients should be
educated as to the potential risks of MRONJ as the
antiresorptive therapy is likely to exceed beyond 4
years treatment. The importance of optimizing
dental health throughout this treatment period and
beyond should be stressed.
Management Strategies

C. Asymptomatic patients receiving intravenous
bisphosphonates or antiangiogenic drugs for cancer :
 Maintaining good oral hygiene
 Procedures that involve direct osseous injury should be
avoided.
 Non-restorable teeth may be treated by removal of the
crown and endodontic treatment of the remaining roots.
 Placement of dental implants should be avoided in the
oncology patient receiving intravenous antiresorptive
therapy or antiangiogenic medications.
Endodontically Treated
IV Meds
Management Strategies

The risk of developing MRONJ associated
with oral bisphosphonates, while exceedingly
small, appears to increase when the duration of
therapy exceeds 4 years.
Management Strategies

The efficacy of utilizing a systemic marker of
bone turnover to assess the risk of developing
jaw necrosis in patients at risk has not been
validated. Therefore the use of systemic
markers of bone turnover as a measure of
MRONJ risk is not recommended although the
Committee supports continued research in this
area.
Management Strategies

For individuals who have taken an oral
bisphosphonate for less than four years and
have no clinical risk factors, no alteration or
delay in the planned surgery is necessary. This
includes any and all procedures common to
oral and maxillofacial surgeons, periodontists
and other dental providers.
Management Strategies

For those patients who have taken an oral
bisphosphonate for less than four years and
have also taken corticosteroids or
antiangiogenic medications concomitantly:

the prescribing provider should be contacted to
consider discontinuation of the oral
bisphosphonate (drug holiday) for at least two
months prior to oral surgery, if systemic conditions
permit.
Management Strategies

For those patients who have taken an oral
bisphosphonate for more than four years with
or without any concomitant medical therapy:

the prescribing provider should be contacted to
consider discontinuation of the antiresorptive
for two months prior to oral surgery, if systemic
conditions permit. The bisphosphonate should
not be restarted until osseous healing has
occurred.
Staging and Treatment Strategies

At risk category:


No apparent necrotic bone in patients who have
been treated with either oral or IV bisphosphonates
Management:
No treatment indicated
 Patient education

Staging and Treatment Strategies

Stage 0:
No clinical evidence of necrotic bone,
 But non-specific clinical findings

radiographic changes
 and symptoms


Systemic management, including the use of
pain medication and antibiotics
Staging and Treatment
Strategies

Stage 1:
Exposed and necrotic bone,
 or fistula that probes to bone,
- in patients who are asymptomatic and have no evidence of
infection

Management:
 Antimicrobial mouthrinse
 Clinical follow-up on a quarterly basis
 Patient education and review of indications for
continued bisphosphonate therapy
Staging and Treatment
Strategies

Stage 2:



Exposed and necrotic bone,
or fistula that probes to bone,
associated with infection as evidenced by pain and erythema in the
region of the exposed bone with or without purulent drainage.
Management:
 Symptomatic treatment with oral antibiotics
 Oral antibacterial mouth rinse
 Pain control
 Debridement to relieve soft tissue irritation and
 infection control
Staging and Treatment
Strategies



Stage 3:
Exposed and necrotic bone,
or a fistula that probes to bone in patients with pain,
infection, and one or more of the following:

exposed and necrotic bone extending beyond the region of
alveolar bone,(i.e., inferior border and ramus in the
mandible, maxillary sinus and zygoma in the maxilla)
resulting in pathologic fracture, extra-oral fistula, oral
antral/oral nasal communication, or osteolysis extending to
the inferior border of the mandible of sinus floor
Staging and Treatment
Strategies

Stage 3 management:
Antibacterial mouth rinse
 Antibiotic therapy and pain control
 Surgical debridement/resection for longer term
palliation of infection and pain

Management Strategies

Regardless of the disease stage, mobile
segments of bony sequestrum should be
removed without exposing uninvolved bone.
The extraction of symptomatic teeth within
exposed, necrotic bone should be considered
since it is unlikely that the extraction will
exacerbate the established necrotic process.
Oral BP
Oral BP
After Debridement
IV BP
April 2013
IV BP
IV BP
August 2013
IV BP
After Debridement