1

The Bisphosphonate Challenge● Bisphosphonates are experimental

and may increase bone density and lessen pain

● They reduce life of osteoclasts and let osteoblasts produce bone

● Now used in osteogenesis imperfecta and other fibro-osseous conditions

● Used for osteoporosis in children with profound disability and no mobility

• No evidence of BRONJ in kids• Possible implications for tooth

eruption, movement, avulsion, implants

2

The Bisphosphonate Challenge

● No evidence or guidelines exist for children• Consult with MD● IV BIS is worse than oral BIS for BRONJ• Consider discontinuation of BIS for three months

prior to oral surgery• Allow tissues to fully heal before beginning BIS

therapy if possible

3

Cancer or Sickle Cell Disease?● Hydroxyurea is an antineoplastic

now used to reduce frequency and severity of sickle cell crises

● Antibiotics are not routinely requested for dental treatment of children with SCD

• Consult MD about need for supplemental antibiotics if taking penicillin

• Request blood studies if on hydroxyurea (Hydrea) and surgery needed

4

What Does Evidence Say About Care?

5

Pulp Therapy and Infection RiskIs there evidence to preclude pulptherapy for children with heart disease?● Traditionally, pulp therapy was not

recommended in congenital heart disease or cancer patients

● Success rates have improved● Life span has improved requiring

some sort of long-term consideration for tooth replacement

● Space maintainers and removable appliances may present greater risk of infection

• OK to do vital pulpotomies in some patients

6

Prematurity/Low BirthweightDo They Present Dental

Challenges?Today, thousands of

babies are saved in

NICUs and grow up to

become happy

healthy children, but

many bring with them a

host of developmental

problems that impact

oral health

7

Premies and Behavioral Problems • Klassen AF et al. Health status and health-related quality of

life in a population-based sample of neonatal intensive care unity graduates. Pediatrics 2004;113:594-600.

• Doyle LW et al. Outcome at 14 years of extremely low birthweight infants: a regional study. Arch Dis Child Fetal Neonatal Ed 2001;85:F159-64.

• Hack M et al. Outcomes in young adulthood for very-low birthweight infants. N Engl J Med 2002;346:149-57.

● These children grow up to have lower IQs, learning problems, and more general health problems, but they don’t get into trouble typical for many teens!

8

Not All MDs Agree on AB CoverageFor Dialysis Patients

• Tong RC et al. Antibiotic prophylaxis in dialysis patients undergoing invasive dental treatment. Nephrology 2004;9:167-70.

● Give ABs if artificially created shunt

● No ABs if peritoneal dialysis● No ABs for hemodialysis● Always check with MD

9

What About Periodontal Disease in These Obese DM2 Kids?

● We’re not sure yet; too soon to tell• Aren G et al. Periodontal health, salivary status, and

metabolic control in children with type 1 diabetes mellitus. J Periodontol 2003;74:1789-95.

● Compared 16 children with newly diagnosed DM, 16 long-term DM (4 yrs) and 16 healthy controls

● Perio Index: HC<ND<LT ● Pocket depth same for HC and ND but deeper for LT● LT had > bleeding on probing than other two

groups