Page 8 - GP Fall 2019

I saw the patient on June 13, 2019, a little patient had already developed active infec- References
over a year since the extraction, for another tion and osteomyelitis before the tooth was https://www.iofbonehealth.org/what-is-osteo-
follow-up examination. The extraction site extracted so we could not wait any longer. porosis
had still not healed, but was stable. I was https://osteoporosis.ca/wp-content/uploads/
concerned about an extension of the ne- There are two treatment options for this ONJ-Pamphlet-Mar16.pdf
crosis to tooth #30 (Figures 6-9). I do not patient: The first is surgery. This would https://www.aaoms.org/docs/govt_affairs/advo-
cacy_white_papers/mronj_position_paper.pdf
https://jada.ada.org/article/S0002-
8177(14)61831-6/fulltext

Dr. Philip A. Gentry is a
Fellow of the Academy
of General Dentistry and
has been in private prac-
tice in Arlington, Virginia
for 30 years. He is Clin-
Figure 6. Extraction site 1 year post-extraction. Figure 7. Osteonecrosis extending on lingual to ical Assistant Professor,
tooth #30, 1 year post-extraction. Dean’s Faculty, in the Advanced Educa-
tion in General Dentistry Department,
at the University of Maryland School of
Dentistry.

Figure 8. X-ray 1 year post-extraction. Figure 9. X-ray 1-year post extraction showing
osteonecrosis extending to tooth #30.
expect the extraction site for tooth #31 to require removing three inches of the right
ever heal. We will monitor the extension of posterior mandible along with four teeth
the osteonecrosis on tooth #30. The treat- and having the area grafted. This would be
ment of choice is to keep the area free of undesirable and risky given the health and
infection and wait it out. If the necrosis age of the patient, and should only be done
continues, we will wait until #30 becomes as a last resort.
loose and hopefully the tooth will just fall
out on its own. This is the most atraumatic The second treatment option would be to
solution. I would not recommend extract- manage the osteonecrosis with antibiotics.
ing tooth #30 unless it becomes infected. This seems to be working so far. He has no
Unfortunately, he has had a re-occurrence pain, and has been tolerating the antibiotic
of prostate cancer and is being treated for well. This is the treatment of choice. The
that, but without osteoporosis medication patient will take Augmentin 875Amox/
this time. 125Clav twice a day for the rest of his life.
We could have also used amoxicillin, and
Conclusion can switch to that if tolerance becomes an
This case is an example of drug-induced issue. He was also given a prescription for
osteonecrosis of the mandible caused by flagyl to take for ten days for any flare-ups
Xgeva. The patient was taking a high dose such as swelling, which he did have once.
(120 mg injections) of Xgeva over a long He was given an irrigation syringe to irri-
period of time, five years. Even though the gate the socket with water after eating and
half-life of Xgeva is 28 days, this patient at bedtime.
still developed osteonecrosis six months
(180 days) after his last injection. There- The patient will follow up with me every
fore, if an extraction or any procedure caus- three months and the oral surgeon regular-
ing trauma to the bone cannot be avoided, ly. Surgery will be indicated only if he has
I recommend waiting as long as possible; a pathologic jaw fracture or the infection is
two years would be ideal. In this case, the not able to be controlled with antibiotics.

www.nysagd.org l Fall 2019 l GP 8