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The treatment should be tailored to the cause involved and the severity of the disease process. With oral osteoporosis the emphasis should be on good nutrient absorption and metabolic wastes elimination through a healthy gastro-intestinal function, effective hepatic metabolism of toxicants such as exogenous estrogens, endogenous acetaldehyde and heavy metals, a balanced diet, healthy lifestyle, assessment of factors related to potential coagulopathies, and treatment of periodontal diseases and other oral and dental infections.
In cases of advanced oral ischaemic osteoporosis and/or ONJ that are not bisphosphonates related, clinical evidence has shown that surgically removing the damaged marrow, usually by curettage and decortication, will eliminate the problem (and the pain) in 74% of patients with jaw involvement. Repeat surgeries, usually smaller procedures than the first, may be required. Almost a third of jawbone patients will need surgery in one or more other parts of the jaws because the disease so frequently present multiple lesions, i.e., multiple sites in the same or similar bones, with normal marrow in between. In the hip, at least half of all patients will get the disease in the opposite hip over time; this pattern occurs in the jaws as well. Recently, it has been found that some osteonecrosis patients respond to anticoagulation therapies alone. The earlier the diagnosis the better the prognosis. Research is ongoing on other non-surgical therapeutic modalities that could alone or in combination with surgery further improve the prognosis and reduce the morbidity of ONJ. A greater emphasis on minimizing or correcting known causes is necessary while further research is conducted on chronic ischaemic bone diseases such as oral osteoporosis and ONJ.
In patients with bisphosphonates-associated ONJ, the response to surgical treatment is usually poor. Conservative debridement of necrotic bone, pain control, infection management, use of antimicrobial oral rinses, and withdrawal of bisphosphonates are preferable to aggressive surgical measures for treating this form of ONJ. Although an effective treatment for bisphosphonate-associated bone lesions has not yet been established, and this is unlikely to occur until this form of ONJ is better understood, there have been clinical reports of some improvement after 6 months or more of complete cessation of bisphosphonate therapy.
Culture and sensitivity of the wound site determines the choice of antibiotic. Repeated culture and sensitivity testing is often carried out in OM since the treatment is prolonged and antibiotic resistance may occur, when a change in the drug may be required.
Generally buccal exostoses require no treatment. However, they may be easily traumatized causing ulceration, or may contribute to periodontal disease if they become too large, or can interfere with wearing a denture (false teeth). If they are creating problems, they are generally removed with a simple surgical procedure under local anesthetic.
Treatment is usually symptomatic, (i.e., analgesic medications) and also the removal of debris from the socket by irrigation with saline or local anesthetic. Medicated dressings are also commonly placed in the socket; although these will act as a foreign body and prolong healing, they are usually needed due to the severe pain. Hence, the dressings are usually stopped once the pain is lessened. Examples of medicated dressings include antibacterials, topical anesthetics and obtundants, or combinations of all three, e.g., zinc oxide and eugenol impregnated cotton pellets, alvogyl (eugenol, iodoform and butamen), dentalone, bismuth subnitrate and iodoform paste (BIPP) on ribbon gauze and metronidazole and lidocaine ointment. A systematic review of the efficacy of treatments for dry socket concluded that there was not enough evidence to discern the effectiveness of any treatments. People who develop a dry socket typically seek medical/dental advice several times after the dental extraction, where the old dressing is removed, the socket irrigated and a new dressing placed. Curettage of the socket increases the pain and has been discouraged by some.
Endodontic intervention can help conserve the existing health of affected permanent teeth. It is difficult to perform an endodontic therapy on teeth that develop abscesses as a resultant of obliteration of the pulp chambers and root canals. An alternative to conventional therapy would be retrograde filling and periapical curettage. However, these therapies are not recommended for teeth with roots that are too short.
The best method of maintaining the health of teeth is to practice exemplary oral hygiene. More tooth loss is likely to occur if intervention takes place. However, factors such as present complaint, patient age, severity of the problem, can affect the treatment plan or options.
The first three cases of bisphosphonate-associated osteonecrosis of the jaw were spontaneously reported to the FDA by an oral surgeon in 2002, with the toxicity being described as a potentially late toxicity of chemotherapy. In 2003 and 2004, three oral surgeons independently reported to the FDA information on 104 cancer patients with bisphosphonate-associated osteonecrosis of the jaw seen in their referral practices in California, Florida, and New York. These case series were published as peer-reviewed articles — two in the "Journal of Oral and Maxillofacial Surgery" and one in the "Journal of Clinical Oncology". Subsequently, numerous instances of persons with this ADR were reported to the manufacturers and to the FDA. By December 2006, 3607 cases of people with this ADR had been reported to the FDA and 2227 cases had been reported to the manufacturer of intravenous bisphosphonates.
The International Myeloma Foundation's web-based survey included 1203 respondents, 904 patients with myeloma and 299 with breast cancer and an estimate that after 36 months, osteonecrosis of the jaw had been diagnosed in 10% of 211 patients on zoledronate and 4% of 413 on pamidronate. A population based study in Germany identified more than 300 cases of osteonecrosis of the jaw, 97% occurring in cancer patients (on high-dose intravenous bisphosphonates) and 3 cases in 780,000 patients with osteoporosis for an incidence of 0.00038%. Time to event ranged from 23–39 months and 42–46 months with high dose intravenous and oral bisphosphonates. A prospective, population based study by Mavrokokki "et al.". estimated an incidence of osteonecrosis of the jaw of 1.15% for intravenous bisphosphonates and 0.04% for oral bisphosphonates. Most cases (73%) were precipitated by dental extractions. In contrast, safety studies sponsored by the manufacturer reported bisphosphonate-associated osteonecrosis of the jaw rates that were much lower.
Although the majority of cases of ONJ have occurred in cancer patients receiving high dose intravenous bisphosphonates, almost 800 cases have been reported in oral bisphosphonate users for osteoporosis or Pagets disease. In terms of severity most cases of ONJ in oral bisphosphonate users are stage 1–2 and tend to progress to resolution with conservative measures such as oral chlorhexidine rinses.
Owing to prolonged embedding of bisphosphonate drugs in the bone tissues, the risk for BRONJ is high even after stopping the administration of the medication for several years.
This form of therapy has been shown to prevent loss of bone mineral density (BMD) as a result of a reduction in bone turnover. However, bone health entails quite a bit more than just BMD. There are many other factors to consider.
In healthy bone tissue there is a homeostasis between bone resorption and bone apposition. Diseased or damaged bone is resorbed through the osteoclasts mediated process while osteoblasts form new bone to replace it, thus maintaining healthy bone density. This process is commonly called remodelling.
However, osteoporosis is essentially the result of a lack of new bone formation in combination with bone resorption in reactive hyperemia, related to various causes and contributing factors, and bisphosphonates do not address these factors at all.
In 2011, a proposal incorporating both the reduced bone turnover and the infectious elements of previous theories has been put forward. It cites the impaired functionality of affected macrophages as the dominant factor in the development of ONJ.
In a systematic review of cases of bisphosphonate-associated ONJ up to 2006, it was concluded that the mandible is more commonly affected than the maxilla (2:1 ratio), and 60% of cases are preceded by a dental surgical procedure. According to Woo, Hellstein and Kalmar, oversuppression of bone turnover is probably the primary mechanism for the development of this form of ONJ, although there may be contributing co-morbid factors (as discussed elsewhere in this article). It is recommended that all sites of potential jaw infection should be eliminated before bisphosphonate therapy is initiated in these patients to reduce the necessity of subsequent dentoalveolar surgery. The degree of risk for osteonecrosis in patients taking oral bisphosphonates, such as alendronate (Fosamax), for osteoporosis is uncertain and warrants careful monitoring. Patients taking dexamethasone and other glucocorticoids are at increased risk.
Matrix metalloproteinase 2 may be a candidate gene for bisphosphonate-associated osteonecrosis of the jaw, since it is the only gene known to be associated with bone abnormalities and atrial fibrillation, both of which are side effects of bisphosphonates.
A 2013 Cochrane review assessed clinical studies on surgical (open reduction) and non-surgical (closed reduction) management of mandible fractures that do not involve the condyle. The review found insufficient evidence to recommend the effectiveness of any single intervention.
The infected tissue of the periapical cyst must be entirely removed, including the epithelium of the cyst wall; otherwise a relapse is likely to occur. Root canal treatment should be performed on the tooth if it is determined that previous therapy was unsuccessful. Removal of the necrotic pulp and the inflamed tissue as well as proper sealing of the canals and an appropriately fitting crown will allow the tooth to heal under uninfected conditions.
Surgical options for previously treated teeth that would not benefit from root canal therapy include cystectomy and cystostomy. This route of treatment is recommended upon discovery of the cyst after inadequate root canal treatment. A cystectomy is the removal of a cyst followed by mucosa and wound closure to reduce chances of cyst regeneration. This type of treatment is more ideal for small cysts.
A cystostomy is recommended for larger cysts that compromise important adjacent anatomy. The cyst is tamponaded to allow for the cyst contents to escape the bone. Over time, the cyst decreases in size and bone regenerates in the cavity space.
Marsupialization could also be performed, which involves suturing the edges of the gingiva surrounding the cyst to remain open. The cyst then drains its contents and heal without being prematurely closed. The end result is the same as the cystostomy, bone regeneration. For both a cystostomy and marsupialization, root resectioning may also be required in cases where root resorption has occurred.
A systematic review reported that there is some evidence that rinsing with chlorhexidine (0.12% or 0.2%) or placing chlorhexidine gel (0.2%) in the sockets of extracted teeth reduces the frequency of dry socket. Another systematic review concluded that there is evidence that prophylactic antibiotics reduce the risk of dry socket (and infection and pain) following third molar extractions of wisdom teeth, however their use is associated with an increase in mild and transient adverse effects. The authors questioned whether treating 12 patients with antibiotics to prevent one infection would do more harm overall than good, in view of the potential side effects and also of antibiotic resistance. Nevertheless, there is evidence that in individuals who are at clear risk may benefit from antibiotics. There is also evidence that antifibrinolytic agents applied to the socket after the extraction may reduce the risk of dry socket.
Some dentists and oral surgeons routinely debride the bony walls of the socket to encourage hemorrhage (bleeding) in the belief that this reduces the incidence of dry socket, but there is no evidence to support this practice. It has been suggested that dental extractions in females taking oral contraceptives be scheduled on days without estrogen supplementation (typically days 23–28 of the menstrual cycle). It has also been suggested that teeth to be extracted be scaled prior to the procedure.
Prevention of alveolar osteitis can be exacted by following post-operative instructions, including:
1. Taking any recommended medications
2. Avoiding intake of hot fluids for one to two days. Hot fluids raise the local blood flow and thus interfere with organization of the clot. Therefore, cold fluids and foods are encouraged, which facilitate clot formation and prevent its disintegration.
3. Avoiding smoking. It reduces the blood supply, leading to tissue ischemia, reduced tissue perfusion and eventually higher incidence of painful socket.
4. Avoiding drinking through a straw or spitting forcefully as this creates a negative pressure within the oral cavity leading to an increased chance of blood clot instability.
Pathologic fracture of the mandible is a possible complication of OM where the bone has been weakened significantly.
The best treatment for condylar fractures is controversial. There are two main options, namely closed reduction or open reduction and fixation. Closed reduction may involve intermaxillary fixation, where the jaws are splinted together in the correct position for a period of weeks. Open reduction involves surgical exposure of the fracture site, which can be carried out via incisions within the mouth or incisions outside the mouth over the area of the condyle. Open reduction is sometimes combined with use of an endoscope to aid visualization of fracture site. Although closed reduction carries a risk of the bone healing out of position, with consequent alteration of the bite or the creation of facial asymmetry, it does not risk temporary damage to the facial nerve or result in any facial scar that accompanies open reduction. A systematic review was unable to find sufficient evidence of the superiority of one method over another in the management of condylar fractures. Paediatric condylar fractures are especially problematic, owing to the remaining growth potential and possibility of ankylosis of the joint. Early mobilization is often recommended as in the Walker protocol.
If cause-specific measures are insufficient, soft-tissue graft surgery may be used to create more gingiva. The tissue used may be autologous tissue from another site in the patient's mouth, or it can be freeze-dried tissue products or synthetic membranes. New research is focused on using stem cells to culture the patients' own gums to replace receded gums.
The treatment aims are to eliminate the bacteria from the exposed surface of the root(s) and to establish the anatomy of the tooth, so that better plaque control can be achieved. Treatment plans for patients differ depending on the local and anatomical factors.
For Grade I furcation, scaling and polishing, root surface debridement or furcationplasty could be done if suitable.
For Grade II furcation, furcationplasty, open debridement, tunnel preparation, root resection, extraction, guided tissue regeneration (GTR) or enamel matrix derivative could be considered.
As for Grade III furcation, open debridement, tunnel preparation, root resection, GTR or tooth extraction could be performed if appropriate.
Tooth extraction is usually considered if there is extensive loss of attachment or if other treatments will not obtain good result (i.e. achieving a nice gingival contour to allow good plaque control).
When treatment is required, this is usually by surgical removal of the cyst. There are four ways in which cysts are managed:
- Enucleation - removal of the entire cyst
- Marsupialization - the creation of a window into the wall of a cyst, allowing the contents to be drained. The window is left open, and the lack of pressure within the cyst causes the lesion to shrink, as the surrounding bone starts to fill in again.
- Enucleation following marsupialization - Sometimes marsupialization is carried out as a single procedure, but usually it is followed by a second procedure to remove the cyst. This is particularly the case when cysts are very large and their removal would leave a significant surgical defect.
- Enucleation with curettage - this is removal of the cyst and some of the surrounding bone, which may contain some of the lining of the cyst.
Treatment usually involves surgical removal of the lesion down to the bone. If there are any adjacent teeth, they are cleaned thoroughly with scaling and root planing (SRP) to remove any possible source of irritation. Recurrence is around 10%.
Treatment is by surgical excision (complete removal) of the fibrous tissue overgrowth and addressing the causative factor to prevent recurrence of the lesion. Other sources suggest that surgical excision may not be required in all cases. Common techniques for removal of the excess tissue include traditional removal with a surgical scalpel, electrical scalpel, or laser excision with a laser scalpel, e.g. a carbon dioxide laser, , Neodymium-YAG laser, or diode laser. The poorly fitting denture can be adapted to fit better (a "reline") or a new denture constructed. Alternatively, the section of flange that is sharp/over-extended can be smoothed and reduced with a drill.
Depending on the shape of the gum recession and the levels of bone around the teeth, areas of gum recession can be regenerated with new gum tissue using a variety of gum grafting "periodontal plastic surgery" procedures performed by a specialist in periodontics (a periodontist). These procedures are typically completed under local anesthesia with or without conscious sedation, as the patient prefers. This may involve repositioning of adjacent gum tissue to cover the recession (called a pedicle graft) or use of a free graft of gingival or connective tissue from the roof of the mouth (called a "free gingival graft" or a Subepithelial connective tissue graft). Alternatively, a material called acellular dermal matrix (processed donated human skin allograft) may be used instead of tissue from the patient's own palate.
All impacted teeth, unless otherwise contraindicated, are considered for surgical removal. Thus, dental extractions will often take place. The type of extraction (simple or surgical) often depends on the location of the teeth.
In some cases, for aesthetic purposes, a surgeon may wish to expose the canine. This may be achieved through open or closed exposure. Studies show no advantage of one method over another.
Treatment is surgical, and usually is able to be performed once life-threatening injuries are stabilized, to allow the patient to survive the general anesthesia needed for invasive orthopedic restructuring. First a "frontal bar" is used, which refers to the thickened frontal bone above the frontonasal sutures and the superior orbital rim. The facial bones are suspended from the bar by open reduction and internal fixation with titanium plates and screws, and each fracture is fixed, first at its superior attachment to the bar, then at the inferior attachment to the displaced bone. For stability, the zygomaticofrontal suture is usually replaced first, and the palate and alveolar ridge are usually fixed last. Finally, after the horizontal and vertical maxillary buttresses are stabilized, the orbital fractures are fixed last.
The most common treatment for mandibular prognathism is a combination of orthodontics and orthognathic surgery. The orthodontics can involve braces, removal of teeth, or a mouthguard.
The surgery required has led, in some cases, to identity crises in patients, whereby the new facial structure has a negative impact mentally on how the patients perceive themselves.
Long term randomized clinical trials need to be conducted to determine if regular routine scaling and polishing is clinically effective for reducing the risk of chronic periodontitis in healthy adults.
Lasers are increasingly being used in treatments for chronic periodontitis. However, there is some controversy over their use:
"No consistent evidence supports the efficacy of laser treatment as an adjunct to non-surgical periodontal treatment in adults with chronic periodontitis."
To date, no treatment has been proven to effectively reverse or prevent the progression of PAM. Lung transplantation is an option for end stage disease, but is typically only recommended as a last resort when quality of life is significantly impaired.
Etidronate is a bisphosphonate and can reduce the formation of calcium hydroxyapatite crystals. It has led to clinical and radiological improvements in few cases.
If the fracture is small, it is usually sufficient to treat with rest and support bandage, but in more severe cases, surgery may be required. Ice may be used to relieve swelling.
Displaced avulsion fractures are best managed by either open reduction and internal fixation or closed reduction and pinning. Open reduction (using surgical incision) and internal fixation is used when pins, screws, or similar hardware is needed to fix the bone fragment.
Osteitis is inflammation of bone. More specifically, it can refer to one of the following conditions:
- Osteomyelitis, or "infectious osteitis", mainly "bacterial osteitis")
- Alveolar osteitis or "dry socket"
- Condensing osteitis (or Osteitis condensans)
- Osteitis deformans (or Paget's disease of bone)
- Osteitis fibrosa cystica (or Osteitis fibrosa, or Von Recklinghausen's disease of bone)
- Osteitis pubis
- Radiation osteitis
- Osteitis condensans ilii
- Panosteitis, a long bone condition in large breed dogs
- In horses, pedal osteitis is frequently confused with laminitis.