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News Bulletin : ADA News Bulletin October 2010
17 OCTOBER 2010 Panadeine® Extra contains paracetamol 500 mg and codeine phosphate 15 mg. Use: For temporary relief from moderate to severe pain. Contraindications: Hypersensitivity to any ingredient in the product; children under 12 years. Precautions: CNS, respiratory depression; high doses, prolonged use; renal, hepatic impairment; poor CYP2D6 function; pregnancy & lactation. Adverse reactions: Dependence; Impairment of mental & physical abilities; nausea, vomiting, constipation; dizziness, drowsiness. Interactions: Anticoagulants; sedatives, tranquillisers; drugs affecting gastric emptying; chloramphenicol; hepatic enzyme inducers; CYP2D6 inhibitors. Dosage: Adults and children 12 years and over: 2 Caplets® every 4–6 hours orally with water; (maximum 8 caplets in 24hrs). Please review full Production Information (PI) before recommending. The full PI is available from GlaxoSmithKline Consumer Healthcare on request ( FREECALL 1800 028 533). Panadeine®, Caplet® and the Panadeine VibrationTM are trade marks of the GlaxoSmithKline group of companies. GlaxoSmithKline Consumer Healthcare. 82 Hughes Avenue, Ermington, NSW 2115. 1800 028 533. GLA0020/B/ADA Recommend the STRONGEST pain reliever available without a prescription. * *Based on codeine content per dose Fold GLA0020_ADA_297x210_v3.indd 1 19/2/10 12:24:36 PM committee report Patients with dentures need these to be carefully checked and either remade or relined as needed. Patients on long-term bisphosphonate therapy need regular dental monitoring. If their teeth become symptomatic and it is possible to treat the tooth endodontically rather than extract it, then endodontics is preferred. For patients with dental implants, these need to be carefully maintained, as bisphosphonate associated risk of loss of osseointegration of the implant has been reported to be approximately 1%. A balanced and informed explanation of the risk of ONJ needs to be given to patients who require an extraction and who are on an oral bisphosphonate to obtain their consent for the procedure. A fasting serum beta-CTX test may be performed to determine the degree of bone turnover suppression. Generally, the level increases at approximately 25 pg/month after cessation of bisphosphonate so this could be rechecked prior to extraction. Therapeutic Guidelines recommend a prophylactic dose of 2 g amoxicillin one hour prior to the extraction. Teeth should be extracted with the minimum of trauma, any exposed bone carefully removed and the socket sutured. Oral bisphosphonates can be commenced at approximately three to four weeks after the extraction or once there is primary mucosal coverage and commencement of socket healing. The key step for any patient who is on a bisphosphonate and requires dental treatment is that the patient’s dental and medical practitioners should liaise to determine the optimum treatment for both the patient’s mouth and their bones. WHAT ARE THE RISKS fOR PATIEnTS USInG InTRAvEnOUS bISPHOSPHOnATES? Recently, intravenous dosages of bisphosphonates have been introduced for osteoporosis. There are considerable advantages to the patient as it involves a single infusion rather than weekly tablets. It is important that such patients have their mouth checked by a dentist prior to the infusion. Bone turnover decreases rapidly in patients on IV bisphosphonates and remains low for one to two years. Thus, drug holidays are more difficult and the second or subsequent infusion should be deferred until after dental extraction. HOW SHOULD ESTAbLISHED OnJ bE TREATED? Patients with established bisphosphonate associated ONJ are best treated by specialist dentists working in association with either the patient’s medical practitioner or a metabolic bone diseases physician. If possible medically, the bisphosphonate should be ceased for a prolonged period. Treatment of established ONJ is preferably not aggressive and the use of 0.12% clorhexidine mouthwashes and antibiotics for soft tissue pain and swelling is indicated. Surgery should only be performed for the removal of loose sequestrae or in the event of severely painful end stage ONJ, then jaw resection could be considered. IS OnJ MORE LIKELY TO OCCUR In CAnCER PATIEnTS? It should be noted that ONJ is much more likely to occur in cancer patients on intravenous bisphosphonates. The risk there of ONJ following extractions is much higher, of the order of 1 in 10 to 1 in 15. Such patients are best managed by specialist oral and maxillofacial surgeons and the patient’s medical oncologist. Dental Therapeutics Committee Copies of this joint Information Sheet are available for perusal and can be downloaded from the ADA Inc. website: ada.org.au
ADA News Bulletin September 2010
ADA News Bulletin November 2010