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News Bulletin : ADA News Bulletin August 2011
24 AUGUST 2011 Letters to the Letters are published at the Editor’s discretion and customary editorial rights are reserved. We request that letters be brief, of interest to the general membership and signed. Letters published are an expression of a personal point of view of the writer and are not necessarily representative of the policies or opinions of the Australian Dental Association Inc. feedback editor MAnAGEMEnT Of PATIEnTS TAkInG bISPHOSPHOnATES Sir, I read with interest the recent correspondence in Feedback [News Bulletin, April 2011] concerning the management of patients taking bisphosphonates who require dental extractions. I offer the following comments. I am in no way speaking for the NSW Health in putting forward these comments, but I am simply commenting from my personal experience on what was written in Feedback. Antibiotic prophylaxis as recommended by Michael McCullough is intended to minimize bacteraemia at the time of extraction. The use of antibiotics with patients taking bisphosphonates has a different purpose. The aim in this situation is to eliminate, or reduce, infection in the bone at the extraction site at the time of the extraction. It can be assumed that teeth requiring extraction, and the adjoining bone, in a patient taking bisphosphonates are infected. The 10 day antibiotic course advocated by NSW Health will probably reduce the bacterial load sufficiently to minimize the effect of infection on healing at the extraction site. However, this should be regarded as a miminum duration of antibiotic therapy to eliminate chronic bone infection in a patient who is also usually medically compromised. The single shot of 2 grams of amoxicillin taken orally 1 hour prior to extraction will have virtually no effect on reduction of the bacterial load in the bone at the extraction site. The protocol outlined here in no way infers that infection causes ONJ, however the presence of infection at the surgical site can be assumed to interfere with healing. Amoxicillin has a long history of being generally quite effective in treating infections of dental origin. However, some authorities, including Infectious Diseases Centres advocate the use of clindamycin for the management of infections in the bone. So there is a rationale for the use of clindamycin in the bisphosphonate situation. However, clindamycin has potential significant side-effects that should be considered before prescribing it. These comments may not particularly clarify the, as yet, uncertain dental management of patients taking bisphosphonates but aim to correct what, from my limited experience, I see as overly prescriptive and inappropriate comment. Paul Bowker Ashburton 3147 RESPOnSE fROM THE AdA dEnTAL THERAPEUTICS COMMITTEE Sir, The recent letter by Mr Paul Bowker highlights an interesting point that is often a key misunderstanding regarding the aetiology of BRONJ. In his letter he states “the aim of this situation is to eliminate, or reduce, infections in the bone in the extraction site at the time of extraction. It can be assumed that teeth requiring extraction and the adjoining bone in a patient taking bisphosphonates are infected”. In patients requiring extractions that are on a bisphosphonate, the jaw bone is usually not infected. If this was the case then the patient would have a pre- existing osteomyelitis which is a completely different clinical problem. It has been described widely in world literature, and referred to in our recent letter that BRONJ is not primarily an infection, but rather a problem of abnormal healing which occurs after invasive treatment. Because of the effect of the bisphosphonates on the bone, the jaws cannot respond and heal normally. We would further state the key message is that antibiotics are drugs which should not be used widely but carefully targeted towards specific bacteria known to be pathogenic for the particular problem. Clindamycin has a poor spectrum of effectiveness for the bacteria found superficially infesting sequestra from BRONJ; poor bone penetration and significant morbidity. Michael McCullough ADA Dental Therapeutics Committee dR CHRIS bOURkE Sir, I was delighted to read of the election of Dr Chris Bourke to the ACT Legislative Assembly. He has been a loyal and active member of the ADA including service as a Divisional Chairman, a private practitioner of high repute but, most of all, one who has always endeavoured to put something back into the community. Members may not be aware that it was Chris Bourke who inspired the ADA to institute a scholarship scheme for Indigenous dental students. For some time prior to this scheme commencing, he had taken it upon himself to provide financial assistance to Indigenous undergraduates, personally. It was his suggestion that the ADA might like to join him in this project that developed into the scholarship scheme. I am sure that the ACT Legislative Assembly will benefit by gaining such a member. Rob Butler Shoreham 3916
ADA News Bulletin July 2011
ADA News Bulletin September 2011