Anti-resorptive therapy in the osteometabolic patient affected by periodontitis. A joint position paper of the Italian Society of Orthopaedics and Traumatology (SIOT) and the Italian Society of Periodontology and Implantology (SIdP)

• Published in: Journal of orthopaedics and traumatology Vol. 24; no. 1; p. 36
• Main Authors: Landi, L., Leali, P. Tranquilli, Barbato, L., Carrassi, A. M., Discepoli, N., Muti, P. C. M., Oteri, G., Rigoni, M., Romanini, E., Ruggiero, C., Tarantino, U., Varoni, E., Sforza, N. M., Brandi, M. L.
• Format: Journal Article
• Language: English
• Published: Cham Springer International Publishing 15-07-2023; Springer Nature B.V; SpringerOpen
• Subjects: Anti-resorptive therapy; Bisphosphonate-Associated Osteonecrosis of the Jaw - epidemiology; Bisphosphonate-Associated Osteonecrosis of the Jaw - etiology; Bisphosphonate-Associated Osteonecrosis of the Jaw - therapy; Bisphosphonates; Bone Density Conservation Agents - therapeutic use; Bone turnover; Cardiovascular diseases; Comorbidity; Conservative Orthopedics; Dental implants; Dental prosthetics; Dentistry; Dentists; Diabetes mellitus; Diphosphonates - adverse effects; Disease control; Disorders; Drugs; Fractures; Fragility; Gum disease; Health risks; Health services; Humans; Inflammation; Inflammatory diseases; Integrated approach; Joints (anatomy); Medicine; Medicine & Public Health; Metabolism; MRONJ; Orthopedics; Osteonecrosis; Osteoporosis; Osteoporosis - complications; Patient education; Patients; Periimplantitis; Periodontics; Periodontitis; Periodontitis - chemically induced; Periodontitis - complications; Periodontitis - therapy; Review; Review Article; Rheumatoid arthritis; Rheumatology; Risk factors; Risk management; Sports Medicine; Steroid hormones; Surgical Orthopedics; Teeth; Therapy; Transplants & implants; Traumatic Surgery; Traumatology; Osteoporosis; Periodontitis; MRONJ; Anti-resorptive therapy; Periimplantitis
• ISSN: 1590-9999; 1590-9921; 1590-9999
• DOI: 10.1186/s10195-023-00713-7

This joint report from the Italian Society of Orthopaedics and Traumatology (SIOT) and the Italian Society of Periodontology and Implantology (SIdP) aims for a consensus around the scientific rationale and clinical strategy for the management of osteoporotic patients affected by periodontitis who are undergoing anti-resorptive (AR) therapy to manage the risk of the occurrence of a medication-related osteonecrosis of the jaws (MRONJ). Osteoporosis and periodontitis are chronic diseases with a high prevalence in aging patients, and they share some of the same pathogenetic mechanisms based upon inflammation. Available evidence shows the relationship among osteoporosis, AR agents, periodontitis and implant therapy in relation to the incidence of MRONJ. Uncontrolled periodontitis may lead to tooth loss and to the need to replace teeth with dental implants. Tooth extraction and surgical dental procedures are recognized as the main risk factors for developing MRONJ in individuals taking AR therapy for osteometabolic conditions. Although the incidence of MRONJ in osteometabolic patients taking AR therapy may be as low as 0.9%, the increasing prevalence of osteoporosis and the high prevalence of periodontitis suggest that this potential complication should not be overlooked. Good clinical practice (GCP) guidelines are proposed that aim at a more integrated approach (prescriber, dentist, periodontist and dental hygienist) in the management of periodontitis patients undergoing AR therapy for osteometabolic disorders to reduce the risk of MRONJ. Dental professional and prescribers should educate patients regarding the potential risk associated with the long-term use of AR therapy and oral health behavior.
Highlights
AR drugs such as bisphosphonates (BPs), denosumab (DNB) and romosozumab (RMB) are very effective in the treatment of osteoporosis and in the prevention of fragility bone fractures.
Periodontitis is a widespread infective inflammatory disease that is the major cause of tooth loss, and it is strongly connected with other systemic diseases, including osteoporosis.
MRONJ is a serious and rare complication associated with the use of AR drugs in osteoporotic patients. The reported incidence is rather low and ranges between 0.01 and 0.9%, but may be higher in the presence of comorbidities.
Periodontitis and MRONJ share some risk factors, such as diabetes, smoking, steroids, cardiovascular diseases and rheumatoid arthritis.
The risk of developing MRONJ in a case of successfully treated periodontitis is much lower than the risk of fragility fracture in a high-risk person such as one with a previous fracture.
Oral and periodontal conditions should be assessed before starting an AR therapy, and local intra-oral inflammation should be brought under control. Periodontal therapy is effective at reducing the risk of teeth extraction and therefore the need for major bone reconstructive intervention and implant placement.
Control of periodontal inflammation should be achieved and maintained over time in osteoporosis-affected patients treated with AR.
Peri-implant diseases rather than dental implant placement may be considered a trigger for MRONJ; for this reason, periodontitis and peri-implant inflammatory disease control and the inclusion of patients in a supportive periodontal program are critical.
AR therapy should not be discontinued or deferred by the dentist unless done in accordance with the prescriber.
The suspension of BP therapy is not recommended on a routine basis, as BP binds to the skeletal sites and continue to be released for months or years after treatment, with a long tail effect on bone metabolism.
DNB administration should not be withdrawn because the rebound effect may increase the risk of bone fractures. A therapeutic window in which to perform dento-alveolar surgical procedures is suggested.
It is advisable to calibrate the timing of dental extraction and surgical procedures between the dentist and prescribers according to the oral condition, the general health condition, and the time and type of AR drugs used.
A more integrated approach between prescriber, dentist, periodontist and dental hygienist should be encouraged, particularly in the management of periodontitis-affected patients who are taking AR drugs for osteometabolic disorders.
Prescribers and dentists must educate patients regarding the potential risk associated with long-term use of AR therapy.