Cesar Luchetti
Department of Implant Dentistry. National University of La Plata. Argentina
Treatment of bisphosphonates associated osteonecrosis is very difficult, and surgery may not be indicated because of the probability of aggravate the condition, as many authors have pointed out. However, sometimes there is not other option. In these cases, my protocol is as follow:
1- If is possible, I take samples for bacterial and mycological analysis. (If this is not possible in the preop, I do it during surgery)
2- Pre-medication according with the test results or empirically, amoxicillin 1 gr plus clavulanic acid and Metronidazol 500 mg, both one every 12 hours. If the patient is immuno-suppressed, which is very common, and has been taking antibiotics for long periods, I assume that he/she could has mycosis also, so I prescribe Fluconazol 150 mg/week.
3- During surgery, I do a VERY conservative resection of the necrotic bone, and carefully eliminate every sharpened part of it. Then I place a membrane made of autologous high concentrated platelet rich plasma. Finally, I manipulate the soft tissue to achieve a complete closure without tension.
You can not regenerate bone, but is possible to stop the progression this way.
Case 1:
Multiple Myeloma patient. 15 days after the first signs of osteonecrosis. Antibiotics were adjusted to bacteriological test results plus local use of clorhexidine 0,12 %. This was my first attempt. After a month without healing, in fact with a situation aggravating, I decide to do surgery. The before, during and after pics are below. This was my second surgery case. Also was the one with the faster resolution. I think that may be because of I treated it quickly.
Case 2:
Multiple Myeloma patient. 4 years after his first sign of osteonecrosis. These days the bisphosphonates associated osteonecrosis had not been described yet. I saw the patient about a year ago. My first approach was palliative, with antibiotics and oral rinses just to try to maintain the bone clean as much as possible. On November 2006, the patient was felling very uncomfortable with the situation and ask me to try something. I told him the risks. He accepts it. The pictures show the before and after. We can not rebuild bone, but al least we were able to achieve soft tissue closure. The area will be reconstructed with a removable prosthesis next month.
Multiple Myeloma patient. 4 years after his first sign of osteonecrosis. These days the bisphosphonates associated osteonecrosis had not been described yet. I saw the patient about a year ago. My first approach was palliative, with antibiotics and oral rinses just to try to maintain the bone clean as much as possible. On November 2006, the patient was felling very uncomfortable with the situation and ask me to try something. I told him the risks. He accepts it. The pictures show the before and after. We can not rebuild bone, but al least we were able to achieve soft tissue closure. The area will be reconstructed with a removable prosthesis next month.
Important note: This post is not trying to stimulate the surgery approach in bisphosphonates associated osteonecrosis. It just tries to stimulate debate. Surgery in these cases is very unpredictable and must be taken carefully. The results, as many authors have pointed out in the literature, could be worse than the preoperative situation.
I hope you have enjoyed it. I will try to post more about this subject in the near future.
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