Dental Practitioners Knowledge and Attitudes on Bisphosphonate - - PowerPoint PPT Presentation

Dental Practitioners’ Knowledge and Attitudes on Bisphosphonate Related Osteonecrosis of the Jaw (BONJ)

James S. Bone, MS, DDS, FICD, MAGD

South Texas Oral Health Network

The University of Texas Health Science Center San Antonio

Why Study BONJ?

Fear Confusion Uncertainty Risk Panic Warning Litigation

Jump into unknown = Trouble F ear = Neglect

How much do we need to know?

1st Generation – oral bisphosphonates

Introduced in 1990’s Improve bone quality in Pagets Disease Osteoporosis Alternative to HRT in post menopause women Prevent fractures of spine, wrist and hip 2ndry to corticosteroid use, SLE, RA, Injectables introduced for pts with dosing difficulties, inability to sit upright for 60 mins or swallow tablets

2nd and 3rd Generation – IV bisphosphonates

Hypercalcemia of malignancy Prevent metastatic tumors in breast, lung and prostate cancer Prevent bone complications and pain in multiple myeloma and kidney disease Prevent post-operative fractures and weakness in kidney, liver and cardiac transplant patients

Wonder Drug?

19th most prescribed drug group worldwide Synthetic analogues of pyrophosphates Not metabolized ½ absorbed dose is distributed to bone Increase bone density and thickness Prevent tumors from removing bone and spreading Inhibit differentiation of bone marrow cells into osteoclasts Inhibit osteoclast activity Reduction in bone turnover and resorption Reduce local release of factors that stimulate tumor growth

Side effects

Osteoclast function severely impaired Osteocytes not replaced Capillary network in bone not maintained Bone becomes too dense, choking capillary network Avascular bone necrosis Osteonecrosis

Incidence of BONJ in Maxilla and Mandible

3000 world cases (191 million prescriptions) Mostly associated with intravenous (IV) bisphosphonates Zometa (Zoledronic Acid) Aredia (Palmidronate) Mostly following dental extractions or periodontal surgery Some spontaneously Chronic infection Trauma

Facts

IV Bisphosphonate = higher risk for BONJ 50% of dose is bio available for bone matrix Oral bisphosphonate = low risk for BONJ 1% of dose is absorbed by GI Tract Time Half life is 8-10 years

Risk Assesment?

Recent assessment test for necrosis potential Arun Garg/Marx - Miami C-Terminal Telopeptide (CTX) -– marker for serum bone turnover scores – controversial

Why a dental problem?

Bis Ph. accumulate in high turnover areas Higher concentrations of drug in mandible than elsewhere After trauma or infection bone cannot respond adequately Masticatory Forces Chronic Low Grade Trauma Unable to repair micro-fractures Necrotic Bone Bony sequestrum

What’s Been Studied

• Only reported cases
• Worst cases in IV……….
• How many are related to “Oral” doses
• What’s risk for “Oral” doses

– Time dependant? – Dose dependant? – Drug dependant?

• Treatment

STOHN BONJ Study

• “Oral” route most commonly seen in our

practices

• What are practitioners doing when

encountered?

– Basic Treatment – Referral??

• Baseline education level

– Is literature doing its job? – Altered treatment plans?

BONJ Study Development

Formulated the question Gathered current literature Formulated hypothesis Developed study plan and parameters

Developed survey Decided who to survey

Gained IRB approval Survey Data collection and statistics

Relative Potency

• Etidronate (Didronel)

1

• Tiludronate (Skelide)

10

• Pamidronate (Aredia)

100

• Alendronate (Fosamax)

1,000

• Risedronate (Actonel)

10,000

• Ibandronate (Boniva)

10,000

• Zolendronic acid (Zometa)

>100,000

Development of the STOHN Research Protocol

• Member suggested topics
• Members voted for their top 4 topics
• Issues related to patients taking

bisphosphonate

Literature Review

• Determine what is already known
• Determine what we should investigate
• Few studies to date

– A limited study on dentists’ and students’ knowledge performed in Murcia, Spain

1356-129

Development of Subcommittee

• STOHN staff, STOHN members,

and UTHSCSA Faculty

• Committee evaluated several drafts of the

research proposal and survey

Initiate Study

• 38 question online study developed
• UTHSCSA Institutional Review Board approval
• Survey sent out to STOHN members, local

dentists members of the San Antonio District Dental Society, and UTHSCSA Faculty

• Data collected through April 2011
• Department of Epidemiology and Biostatistics

analyzed data

Study Aims

• Aim 1: To assess practicing dentists’ perceptions,

attitudes and knowledge toward BONJ and treatment recommendations regarding the management of patients with a history of bisphosphonate therapy.

• Aim 2: To conduct a retrospective chart review to

determine the associations between (1) the accuracy of practitioners’ perceptions about the prevalence of bisphosphonate use and BONJ in their practice, (2) practioners’ attitudes and knowledge, and (3) the treatment recommendations provided.

• Aim 3: Develop educational materials to clarify

misunderstandings identified in Aim 1 & 2, and evaluate their potential to lessen misperceptions of BONJ risks and prevalence.

Data Collected and Analyzed

• Answer to questions directly
• Associations between the questions evaluated

– Expanded data – Collapsed data – Removal of specialist

Patients Taking Oral Bisphosphonates

• 1. Percent of patients taking or have taken ORAL

bisphosphonates 0-3% 14 (18.2) 4-6% 22 (28.6) 7-9% 13 (16.9) 10-15% 14 (18.2) 15-20% 7 (9.1) >20% 7 (9.1) Total 77

• Nearly ½ (46.8%)of the dental practitioners report having

less that 6% of their patients on oral bisphosphonates

Patients Taking IV Bisphosphonates

• 2. Percent of patients taking or have taken

INTRAVENOUS bisphosphonates <1% 52 (66.7) 1-2% 21 (26.9) 3-4% 3 (3.8) 5-6% 1 (1.3) >8% 1 (1.3) Total 78

• Few practitioners report having more than 2% of

patients taking IV bisphosphonates (6.4%)

BONJ Cases Encountered

• 3. Number BONJ cases encountered in my

practice 38 (49.4) 1-5 32 (41.6) 6-10 4 (5.2) 10-15% 3 (3.9) Total 77

• However, about ½ of the practitioners have seen a

BONJ case in their practice

Talk To Patients about BONJ

• 5. If one of my patients is taking

bisphosphonates, I discuss the risk of BONJ n (%) Always 54 (69.2) Sometimes 19 (24.4) Rarely 4 (5.1) Never 1 (1.3) Total 78

• Most dentists talk to their patients about the

risk of BONJ

Have Seen A BONJ Case

Has the dental practitioner seen a BONJ case? Yes No Total P-value Dental Specialty, n (%) 0.24 General Dentistry 27 (58.7) 31 (70.5) 58 (64.4) All Specialties 19 (41.3) 13 (29.5) 32 (35.6) Total 46 44 90

• Almost ½ of the general dentists
• Almost 2/3 of the specialists
• BONJ may be more prevalent than we initially anticipated

Specific Informed-Consent

• 21. I have a specific informed-consent form

for bisphosphonate-using patients True 27 (34.6) False 50 (64.1) Don't Know 1 (1.3) Total 78

Approximately 1/3 of dentists have a specific consent form for BONJ

Confident Managing BONJ Case

• 16. I feel confident that I could manage a

case of BONJ Strongly Agree 7 (9.1) Agree 12 (15.6) Neutral 16 (20.8) Disagree 26 (33.8) Strongly Disagree 16 (20.8) Total 77

• 24.7% Strongly Agree/Agree
• 54.6% Disagree/Strongly Disagree

Consent Form vs. Confidence

True False/ Don’t Know Total P- value 0.004 I feel confident Strongly Agree 7 (25.9) 0 (0) 7 (9.1) that I could manage Agree 5 (18.5) 7 (14) 12 (15.6) a case of BONJ, n (%) Neutral 5 (18.5) 11 (22) 16 (20.8) Disagree 6 (22.2) 20 (40) 26 (33.8) Strongly Disagree 4 (14.8) 12 (24) 16 (20.8) Total 27 50 77 I have a specific informed-consent form for bisphosphonate-using patients

Specific Informed-Consent Form for Patients Using Bisphosphonates

• No consent (63.8%) > Consent (42.4%)

– Do not feel comfortable managing a case of BONJ

• Consent (39.4%) > No Consent (13.8%)

– Felt confident managing a case of BONJ – When OMS removed 39.4% dropped to 28.6%

• Perhaps having or not having specific consent is

associated with confidence level in managing a case of BONJ

– If going to treat = having a consent – If not treating = no need for consent

Patients Delay Bisphosphonate Therapy

• 23. Some of my patients elect to delay

bisphosphonate therapy until dental treatment is completed True 25 (32.1) False 30 (38.5) Don't Know 23 (29.5) Total 78

Approximately 1/3 of the patients delay bisphosphonate therapy until dental treatment is completed

BONJ Cases Encountered

• 3. Number BONJ cases encountered in my

practice 38 (49.4) 1-5 32 (41.6) 6-10 4 (5.2) 10-15% 3 (3.9) Total 77

Delay of Bisphosphonates vs Cases Encountered

True False/ Don’t Know Total P-value 0.07 Number of BONJ 9 (36) 29 (56.9) 38 (50) cases encountered 1-5 15 (60) 16 (31.4) 31 (40.8) in my practice, n (%) 6-10 0 (0) 4 (7.8) 4 (5.3) >10 1 (4) 2 (3.9) 3 (3.9) Total 25 51 76 Some of my patients elect to delay bisphosphonate therapy until after dental treatment

• DDS has not seen a case of

BONJ = 58.6% patients do NOT delay bisphosphonate tx

• DDS that has seen 1-5 cases

BONJ = 62.5% patients DO elect to delay bisphosphonate tx

Patients Delay/Avoid Bisphosphonate Therapy Until Dental Tx is Completed

Identify BONJ

• 15. I feel confident that I could identify a

case of BONJ Strongly Agree 22 (28.2) Agree 37 (47.4) Neutral 12 (15.4) Disagree 6 (7.7) Strongly Disagree 1 (1.3) Total 78

Most dentists feel they could identify a case

• f BONJ. (75.6%)

Delay Bisphosphonates vs Identify BONJ

True False/Don’t Know Total P-value <0.001 I feel confident that Strongly Agree/Argee 31 (96.9) 34 (57.6) 65 (71.4) I could identify a case Neutral 1 (3.1) 15 (25.4) 16 (17.6)

• f BONJ, n (%)

Disagree/ Strongly Disagree 0 (0) 10 (16.9) 10 (11) Total 32 59 91 Some of my patients elect to delay bisphosphonate therapy until after dental treatment

Patients Delay/Avoid Bisphosphonate Therapy Until Dental Is Completed

• 96.9% of Pt that delay

bisphosphonate = dentists who feel confident to recognize BONJ

• Dentists who feel they

could not indentify BONJ = no patients delayed bisphosphonate.

Patients Delay/Avoid Bisphosphonate Therapy Until Dental Tx is Completed

• Suggests that practitioners’ knowledge/

awareness of BONJ influences pts’ decision to delay bisphosphonate tx

– Is it appropriate that patients alter their care based on the practitioner’s confidence or lack of confidence?

Dental Clearance Prior to IV Bisphosponates

• Most dentists are aware of eliminating sources of

infection prior to starting IV bisphosponates

• 95.5% vs 4.5%
• 97.6% of dentists will modify treatment when

patient taking IV bisphosphonates and advise to avoid elective invasive treatment

• 83.6% of dentists will refer to specialist for

necessary invasive treatment

• Dentists are aware of the risks associated with IV

bisphosphonates

Delay Dental Treatment

• 22. Some of my patients elect to delay

dental treatment due to bisphosphonates use True 39 (51.3) False 24 (31.6) Don't Know 13 (17.1) Total 76

½ patients delay dental treatment

Discuss the Risk of BONJ

• 5. If one of my patients is taking

bisphosphonates I discuss the risk of BONJ Always 54 (69.2) Sometimes 19 (24.4) Rarely 4 (5.1) Never 1 (1.3) Total 78

Most dentists discuss the risk of BONJ (93.6%)

Delay Dental Treatment vs Discuss Risk

True False/ Don’t Know Total P-value 0.008 If one of my patients is Always/Sometimes 48 (100) 35 (85.4) 83 (93.3) taking bisphosphonates Rarely/Never 0 (0) 6 (14.6) 6 (6.7) I discuss the risk of Total 48 41 89

• BONJ. n (%)

Some of my patients elect to delay dental treatment due to bisphosphonate use

• Of dentists who discuss the risk of BONJ, 100%
• f the patients elect to delay treatment

Delay Dental Treatment vs Discuss Risk

Treatment

• Although dentists are well informed and can

identify BONJ (75.3%), only 23% felt they could manage a BONJ case

• Both 83.7% dentists aware that infection

should be eliminated and 80% dentists not aware wanted to know more about the condition and how to treat it

• OPPORTUNITY TO DEVELOP EDUCATIONAL

MATERIAL

Specialist vs General Dentist

• Order blood work prior to invasive treatment

– Specialist 23.5% vs Generalist 23.2%

– Not much data to support blood workup

• Advise IV pts to avoid elective invasive tx

– Specialist 93.9% vs Generalist 96.6%

• Sound oral hygiene and regular dental care

lowers risk of BONJ

– Specialist 85.3% vs Generalist 86.2%

• Similar results for both groups here

• Confidence in managing BONJ case

– Specialist 36.4% vs Generalist 15.8%

• Not confident in managing BONJ case

– Specialist 36.4% vs Generalist 66.7%

• Although there is no significant difference

when it comes to awareness/knowledge, there is a difference when it comes to treating these patients

Specialist vs General Dentist

Opportunities

• Where are dentists getting their information?
• Although informed, want more information
• Develop Educational Material
• Develop Continuing Education Courses
• Develop Training/Guideline

– When or how to provide routine treatment

Questions

Thank You!

South Texas Oral Health Network (STOHN)

The University of Texas Health Science Center at San Antonio

Practice Based Research Network