Clinical Scenario

A 68‐year‐old woman presents for an emergency dental appointment complaining of pain and mild swelling in the upper left quadrant. Her symptoms commenced 48 hours earlier and the pain is exacerbated by eating/pressure in the area, but not affected by cold/heat. Sleep is not disturbed.

Structured Learning

1. What bone changes in this patient’s orthopantomogram may be associated with osteoporosis/risedronate treatment?
   • The trabecular bone of the maxilla and mandible has a granular appearance
   • Generalised loss of alveolar bone (periodontal disease also a cause)
   • Paradoxically, the mandibular cortical bone is wider than expected, possibly the result of administering antiresorptive agents
2. You also note that the pulpal chambers appear to be obliterated. Is this likely to be related to the osteoporosis?
   • No, not related directly to the osteoporosis
   • The patient is taking calcium supplements – it has been suggested that pulp obliteration is more common in patients with hypercalcaemia
   • It may be advisable to liaise with the patient’s medical practitioner to review her serum calcium level
3. You determine that the retained roots of #27 are the cause of her present discomfort and require extraction. The patient agrees to this but refuses all other treatment as she is worried about the cost. Why is she at particular risk if the rest of the teeth are left untreated?
   

   

   • Timely and regular intervention coupled with preventive advice is essential to avoid the risk of further tooth loss and hence reduce the risk of developing medication‐related osteonecrosis of the jaw (MRONJ) associated with risedronate
   • The #16 and #18 retained roots, as well as #28, may also become symptomatic and require removal
   • She has further caries and periodontal disease; left untreated, the prognosis of these teeth will worsen, resulting in further dental extractions
4. What risk factors does this patient have for developing MRONJ? (see Chapter 16.2)
   • Related to the antiresorptive drug: although risedronate is a relatively low‐potency antiresorptive drug, the patient has been taking it for an extended time (>4 years)
   • Related to local factors: the patient has an infectious process in relation to #27, periodontal disease and invasive dental procedures need to be performed
5. What factors are considered important in assessing the risk of managing this patient?
   • Social
     • Lack of motivation (only visits the dentist for acute episodes of dental discomfort)
     • Acceptable treatment plan for the patient is determined by her limited financial resources
   • Medical
     • Risk of MRONJ related to the prolonged use of risedronate (see Chapter 16.2)
     • Potential increased bleeding tendency and risk of hypertensive crisis due to high blood pressure (see Chapter 8.1)
     • Drug interactions with antihypertensive drugs and hypolipidaemic agents
   • Dental
     • Poor oral health and motivation to keep the teeth/gums healthy (brushes her teeth irregularly)
     • Requires urgent treatment of dental abscess and the elimination of its cause (#27)
     • Risk of delayed alveolar bone healing
     • Risk of MRONJ
     • Prone to periodontal disease and premature edentulism
     • If a rehabilitation with removable prosthesis is performed (limited financial resources), alveolar ridge resorption may result in an increased risk of movement/trauma from the denture, which in turn increases the risk of MRONJ
6. You decide to prescribe a course of antibiotics and painkillers in view of the acute pain/swelling associated with the roots of #27. What potential drug interactions will determine which drugs you select?
   • Non‐steroidal anti‐inflammatory drugs, including selective COX‐2 inhibitors, attenuate the effect of some antihypertensives such as angiotensin‐converting enzyme inhibitors (e.g. enalapril)
   • Macrolide antibiotics interfere with the metabolism of simvastatin, increasing the risk of rhabdomyolysis and hepatotoxicity
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