Oral Health Care Practitioners Perceptions of Bisphosphonate Related Osteochemonecrosis of the Jaws

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Matilda Clarke
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1 Oral Health Care Practitioners Perceptions of Bisphosphonate Related Osteochemonecrosis of the Jaws Student: Kelly Cottrell Preceptor: T Dolan DDS, MPH Mentor: J Nieto MPH, MD, PhD

2 Outline: Background Methods Results Discussion Conclusion

3 Bisphosphonate Related Osteochemonecrosis of the Jaws (BRONJ): In 2003, cases of necrotic bone in the mouth were reported in patients being treated with bisphosphonate, medications for diseases such as metastatic breast cancer, multiple myeloma, and osteoporosis. Drugs identified: zoledronic acid (Zometa, Novartis, East Hanover, NJ), pamidronate (Aredia, Novartis, East Hanover, NJ), alendronate (Fosamax, Merck and Co., Whitehouse Station, NJ), risedronate (Actonel, Proctor & Gamble Pharmaceuticals, Cincinnati, Ohio) A little more about the conditions that required bisphosphonate use in the first place.

Drugs identified: zoledronic acid (Zometa, Novartis, East Hanover, NJ), pamidronate (Aredia, Novartis, East Hanover, NJ), alendronate (Fosamax, Merck

4 Cancer: In advanced cancer, 50% of patients with bone metastases develop a skeletal related event Bone pain, fractures, spinal cord compression, hypercalcemia BPs are an established treatment for metastatic bone disease because they inhibit bone resorption, which occurs tumor cells invade bone Most often the drug is given intravenously (IV) Ex: Zometa / zolendronate and Aredia / pamidronate Frequency of BRONJ: 6%

bone disease because they inhibit bone resorption, which occurs tumor cells invade bone Most often the

5 Osteoporosis: Normal bone Osteoporosis Osteoporosis characterized by compromised bone strength Increased risk of fracture 44 million in U.S with osteoporosis 2 million fractures/year Hip fractures devastating 1 in 5 die first year after fracture Drugs Utilized: Fosamax, Alendronate How taken: Orally Frequency of BRONJ: %

$S with osteoporosis 2 million fractures/year Hip fractures devastating 1 in 5 die$

6 BRONJ: Clinical Presentation: Exposed, necrotic bone in the jaws May be painful or infected Most commonly the condition follows removal of a tooth, but can also develop spontaneously. Notoriously difficult to treat

the condition follows removal of a tooth, but can

7 Study Rationale: Survey oral healthcare practitioners in Florida: Identify clinicians perceptions, experience and beliefs about BRONJ and its impact on their daily clinical practice. Hypothesis: Ambiguity surrounding the development and treatment of BRONJ would lead to changes in clinical practice

8 Methods: WHO: Faculty of a dental school in Florida Community dental practitioners in Florida General practice and various subspecialties WHAT: Subject information letter & Questionnaire Self addressed interdepartmental envelope OR Self addressed prepaid return envelope HOW: Anonymous Questionnaire: Likert, best option/best fit

letter & Questionnaire Self addressed interdepartmental envelope OR Self addressed

9 Clinical Experience with BRONJ 43% no experience 43% between 1 and 5 patients 8% between 6 to 10 patients 6% experience with >10 patients

10 Q: How do you stay informed about BRONJ? 89% read journals 70% attend continuing education courses (CE) 70% favor personal communication with dental colleagues 25% search internet 16% communicate with their peers in the medical field % utilize textbooks

favor personal communication with dental colleagues 25% search internet

11 Personal comfort level when treating 53% indicated a degree of discomfort in treating patients taking the IV form. patient on BP 37% characterized a degree of discomfort in treating patients taking any/either form of bisphosphonate. IV IV or Oral Oral 10% felt uncomfortable in treating patients on oral BP.

patient on BP 37% characterized a degree of discomfort in treating patients

12 Patients and BP Use: Modifications to the patient medical history questionnaire in your office? 69% Yes Verbally question about use of oral BP, even if drug not listed? 72% Yes Verbally question about use of IV BP, even if drug not listed? 56% Yes

69% Yes Verbally question about use of oral BP, even if drug

13 Q: Reporting BRONJ to Data Registry N/A Report Research Group Other Pharmaceutical Co Local Dental Society Not Report 86%

14 Discussion: Clinical Experience ~ 60% of clinicians sampled have identified at least one patient with evidence of BRONJ Number of patients identified varied by specialty. Oral surgeons (OS) were most likely to report identifying BRONJ in practice

Number of patients identified varied by specialty.

15 Discussion: Staying Informed Useful to know when trying to disseminate important updates or other information Referred journals preferred by many clinicians Continuing education courses and informal peer consultations also important sources of information Journals CE Course Den Peers Internet Med Peers Textbook

Continuing education courses and informal peer consultations also important

16 Discussion: Clinician Discomfort Majority of participants felt that treating patients taking BP s generated personal discomfort, even if there was no clinical evidence of BRONJ Possible explanations Guilt or other emotions associated with the idea that a benign dental treatment could induce a painful adverse condition Perceived threat of medico legal action Ambiguity of the risk factors associated with BRONJ Lack of predictable treatment

emotions associated with the idea that a benign dental treatment could induce a painful adverse condition

17 Discussion: Clinician Discomfort As the understanding of the full spectrum of BRONJ and its management evolves, the perceived apprehension will likely decrease amongst oral health care providers. New information since study collection completed: BRONJ associated with oral bisphosphonates may be amenable to treatment with new therapies such as teriparatide, pentoxifylline and tocopherol and/or supervised discontinuation of the medication

New information since study collection completed: BRONJ associated with oral bisphosphonates may be amenable

18 Discussion: Modifications to Practice Almost 70% of clinicians modified the office medical history questionnaire given to patients Important for office documentation to remain current: Documents use of BP medication Prompts patient s memories of BP use Simple way to initiate a conversation about the condition

documentation to remain current: Documents use of BP medication Prompts

19 Discussion: Modifications to Practice Verbal inquiries about the use of BPs: Over 70% clinicians specifically ask about oral BPs use Over 55% of clinicians specifically ask about IV BP use Important practice for clinicians to engage in. IV BPs are not taken every day and the patient may not be consider it as a part of their medication list May lump IV BP in with chemotherapy Completed/discontinued BP therapy is still relevant given the long half life, particularly in IVBP

in. IV BPs are not taken every day and the patient may not be consider it as a part of their medication list May lump

20 Discussion: Reporting Cases 86% of clinicians do not report cases to a case registry of any kind. 14% report their cases to a spectrum of agencies Frequency of BRONJ may be underestimated! Population based registry would provide the tools necessary to study this condition and outcomes

14% report their cases to a spectrum of agencies Frequency of BRONJ may

21 Limitations: Responder bias Anonymous survey, however: Possibly still motivated by ideal response Heterogeneity of study population: Type of specialty, the location of practice (academic vs. private practitioner) and experience of clinician with BRONJ Didn t partition responses based on actual vs. imagined BRONJ contact: Cannot distinguish between general sentiment and actual conduct or experience

22 Conclusions: Insights into the methods by which clinicians stay informed of changes that could impact their daily practice. Many clinicians have made modifications to their daily clinical practice in response to BRONJ The frequency of BRONJ may be underestimated

23 Thank you

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