This Quarterly update looks back on an issue that remains important for your patients and touches on two topics that are new and somewhat controversial in oral surgery. The old issue deals with the continuing debate over the indications for third-molar extractions, a topic that has taken on new and more important significance now that several large national insurance carriers are refusing to reimburse your patients for the removal of “asymptomatic” third molars. The second deals with the controversial subject of placing dental implants in patients who have taken bisphosphonates. Lastly I have included an article dealing with the use of statins to arrest the loss of alveolar bone secondary to extractions and periodontal disease. This is a very timely article and exposes us to a completely new and novel approach to an age old problem of alveolar bone stabilization after surgical intervention or bacterial contamination.
The indications for third-molar extraction
Dr. Lee’s Note –
In this article the author simplifies the categorization of implants into three groups. Group A are symptomatic and disease is present. Extraction is usually the treatment of choice, but an argument can be made for treatment options if they are possible. Dentists make this algorithmic decision process with each case and refer those patients who they believe need to be operated. Interestingly, insurance carriers are more frequently disagreeing with the necessity for extractions. Aetna and Blue Cross and Blue Shield have gone so far as to mandate radiographic evidence of pathology before they will cover surgery. The lack of eruption space is not an indication for surgery anymore. Neither is periodontal pocketing unless it can be verified on a radiographic image. As far as third molars in Group D: Symptoms and Disease Absent- there are no exceptions in spite of the fact that data from the 6,793 participants in the 2011 Atherosclerosis Risk In Communities Study revealed that fewer than 2% of participants with a retained visible third molar were free of coronal caries and periodontal pathology.
Effect of Dental Implants on Bisphosphonate-Related Osteonecrosis of the Jaws
Dr. Lee’s Note –
This article contradicts the past position of the AAOMS whose guidelines have suggested in cases of oral administration of BPs, dental implants can be safely inserted if the patient has been undergoing this treatment for less than 3 years. In other articles, authors have sited beneficial effects of oral BPs on Osseo integration and peri-implant bone healing. This article, while small in sample size and not adjusted for clinical co-morbidities, i.e. poor prosthetics etc., did cast some doubt on what has been preached as gospel concerning the benign nature of the placement of dental implants in patients who have received IV and oral bisphosphonates for less than 4 years. In this study, the authors found an accelerated and greater risk of developing osteonecrosis when implantation was performed after the start of or during BP therapy. This seems true for oral as well as IV bisphosphonate therapy. This is disconcerting, since several BP medications have been approved for use in osteopenia and osteoporosis resulting in an increase in our patient population. It appears that there is a link between bisphosphonate therapy and osteonecrosis of the jaw when dental implants are placed during or at the conclusion of administration of the drug. Drug route and duration of the dose were not factors. While a drug holiday of 3 months prior to the placement of implants, and 3 months after has been advocated by some, the evidence to support this treatment timeline is lacking, but still recommended.
Statins and Alveolar Bone Resorption: A Narrative Review of Preclinical and Clinical Studies
Dr. Lee’s Note –
This 21 study review opens up a whole new avenue for therapy to control bone loss associated with periodontal disease and the extraction of teeth. Statins have been used for a number of years to stabilize the condyle in orthodontic patients with temporomandibular joint disease. Its mechanism of action has been known for years, working as an inhibitor of osteoclastic activity and as a stimulant of bone morphogenic protein. It is exciting to see it used in this new role and, based upon cumulative research, it is only a matter of time until we see it used clinically to minimize bone loss in dento-alveolar surgery and periodontal disease.