Everyone deserves to feel confident about their smile. Unfortunately, for some patients, this is easier said than done. Anything from minor blemishes and gum discoloration to cracks and missing teeth can make you hesitant to show off those pearly whites.

At the Periodontal Associates of Memphis, we offer cosmetic and implant dentistry services designed to restore your teeth, gums and mouth to prime condition. Let’s take a closer look at the differences between cosmetics and implants and how to choose between them.

What Is Cosmetic Dentistry?

Cosmetic dentistry refers to any dental work that enhances the appearance of your teeth and gums. While some procedures focus solely on aesthetics, many also improve functionality. Here are the cosmetic periodontal treatments we offer:

• Gum Biopsy: Removes blemishes from the gums
• Gum Lightening: Eliminates discoloration from the gums
• Crown Lengthening: Reshapes the gums to expose more teeth
• Gum Grafts: Enhances the gum-line to conceal more teeth
• Pinhole Surgical Technique: Stretches the already existing gum-line
• Orthodontic Uncoveries: Repositions abnormally growing teeth
• Soft Tissue Ridge Augmentation: Strengthens tissue around a missing tooth
• Wilckodontics: Combines surgery with braces to realign teeth quickly
• Temporary Anchorage Devices: Realigns teeth through temporary anchorage devices

Dr. Godat and Dr. King will typically start with an initial consultation, during which they’ll thoroughly examine your mouth. Then, they’ll devise a treatment plan designed to produce a healthier smile. While cosmetic procedures can be performed on their own, they’re often combined with other treatments, such as dental implants.

What Is Implant Dentistry?

Implant dentistry is a type of cosmetic dentistry designed specifically for missing teeth. It involves surgically installing dental implants to fill out gaps in your smile. The implant itself consists of a small, titanium fixture that’s placed directly into the jawbone — over the course of a few months, the fixture will fuse with the jawbone. Once it’s secured, Dr. Godat will cover it with a dental crown that looks and feels just like regular teeth. Dental implants are often preferred over other tooth replacement options (such as dentures) due to the following benefits:

• Natural appearance: Dental implants look, feel and function just like regular teeth.
• Durable: Unlike dentures, dental implants do not slip out while you talk or chew.
• Long-lasting: The titanium roots are designed to last a lifetime.
• Low maintenance: To care for dental implants, all you need to do is brush and floss like usual.
• Improves oral health: Implants help stimulate the jawbone, which is good for oral health.

On the downside, not everyone is eligible for dental implants. To support the implants, you need to have both healthy gum tissue and bone structure. During an initial consultation, the Periodontal Associates of Memphis team can determine whether you’re a good candidate for implant dentistry. In some cases, we may recommend undergoing another procedure (such as bone grafting) to fortify your jawbone first. In other cases, we may recommend a different treatment entirely.

How Do I Choose Between Cosmetics and Implants?

With so many different treatment options available, you might be wondering: which is right for me? Do I need dental implants or another cosmetic procedure? The answer depends on the following factors:

• The results you’re looking for
• Your personal preferences
• Your oral health

First, you should consider the results you’re hoping to achieve. Dental implants are helpful for patients who are missing one or more teeth. If you have another problem (like misalignment or crooked teeth), you may benefit from a different procedure, such as orthodontic uncovery or Wilckodontics.

The next factor is personal preferences. Implant dentistry involves surgical procedures, which can be nerve-wracking. At the Periodontal Associates of Memphis, we offer sedation dentistry to help alleviate dental anxiety. However, if you’d prefer something less invasive, you might be better off with an alternative treatment (like dentures).

The final factor to consider is oral health. If you have a weak bone structure or unhealthy gums, you may need to undergo another procedure (such as bone grafting or a thorough dental cleaning) before receiving dental implants.

Can I Get Cosmetic Treatments and Implants Together?

When looking through the different cosmetic and implant dentistry treatments available, you might decide you’d like both. For example, a patient with gum discoloration and a missing tooth may want to experience both gum lightening and dental implants. The good news is, you can receive both these treatments — in fact, in many cases, cosmetic treatments and dental implants go hand-in-hand. Treatments that are often performed before dental implants include:

• Gum grafts
• Pinhole surgical technique
• Soft tissue ridge augmentation

For dental implants to be effective, they must be supported by gum tissue. If you have receding gums, there may not be enough tissue for an implant. Cosmetic procedures like gum grafts or the pinhole surgical technique can enhance the gum-line, consequently creating a greater surface area to support implants.

In addition to healthy gum tissue, dental implants require a strong jawbone. When a tooth is missing, the corresponding gum and bone may also be lost, resulting in a “sunken” appearance. A soft tissue ridge augmentation strengthens the tissue surrounding the gap, creating a solid foundation for a replacement tooth.

Where Can I Find Cosmetic and Implant Treatments?

Choosing between dental procedures can be overwhelming. When you have so many treatments available, it’s not always easy to pick the right one. Fortunately, you don’t have to do it alone. At Periodontal Associates of Memphis, we strive to ensure every patient receives the best possible treatment for their needs.

At your first appointment, our team will ask questions to learn more about your preferences and determine what you’re looking for. Then, we’ll carefully examine your teeth, mouth and gums to get a bigger picture of your oral health. After this consultation, we’ll work with you to devise a treatment plan. This may involve dental implants, another cosmetic treatment or multiple procedures. Ultimately, our goal is to help patients achieve the smile of their dreams. Start improving your oral health by requesting an appointment today!

The post Cosmetics and Implants: What Are Your Options? appeared first on Periodontal Associates of Memphis.

Periodontal Associates of Memphis takes the treatment of periodontal disease to the highest standard possible. We understand that gum disease can have many negative implications on your life. Untreated periodontal issues can lead to even more serious medical concerns such as heart problems and diabetes. This understanding and passion for helping others led to the decision our periodontists made to become board certified by the American Board of Periodontology, or ABP. We are the only dental office in Memphis that has two board certified periodontists on our team, Dr. Mitchel S. Godat and Dr. Grant T. King.

Understanding the Periodontal Specialty

Many of us have a strong grasp on what our various doctors and medical professionals take responsibility for when it comes to each patient’s health. The lines begin to become more defined as we get into specialists that focus on particular parts of the human body. In the world of oral health, a periodontist specializes in gum health. Preventing, diagnosing and treating gum disease, also known as periodontal disease, is the scope of a periodontist’s duties.

Periodontists such as our own Dr. King and Dr. Godat are experts in their field, receiving extensive training and education beyond the standard requirements. Given how sensitive gums are and how large of an impact they have on the rest of our health, periodontal research and methodologies are always evolving. Being a reputable and trusted periodontist means a never-ending commitment to staying updated on periodontal breakthroughs and best practices. Hands-on work is also needed in cases where cosmetic fixes are needed to treat the damage done by periodontal disease.

Aside from repairing damaged gums, periodontists perform many different procedures for prevention and treatment of gum disease. These include:

• Scaling and root planing
• Removing infection from roots
• Treating gum disease with laser technology such as LANAP
• Gum grafting surgery

Family dentists will often bring on a periodontist for the implementation of tray delivery systems. These systems are used by patients to administer medication to the gums while at home. Periodontists are also called to the office for consultation on cases of severe gum disease or if the patient has other medical conditions that may be interacting with their gum health.

How a Periodontist Becomes Board Certified

The path to board certification for a periodontist is a long one. To start off, periodontists must first complete an undergraduate program at an accredited dental school. It takes four years of studying, research and examination before being able to graduate. After graduation, students are awarded the title of Doctor of Medical Dentistry or Doctor of Dental Surgery, DMD and DDS respectively.

Once a student has graduated with one of these distinctions, they transition their training to more specialized programs called residencies. Periodontal residencies must be accredited by the American Dental Association, or ADA. The residency can take three to seven years to complete training before participants are able to become licensed as periodontists. When a periodontist completes training and obtains their license, they can begin practicing periodontology in a private or public practice. Some doctors will stop here, but those truly committed to providing the best periodontal care possible will take it another step further.

The American Board of Periodontology was founded in 1939 to maintain a high level of care and research advancement amongst periodontists. In doing so, the ABP began establishing what it means to be a periodontist that is truly committed to the science and their patients. The certification process is done through an annual exam. The exam analyzes the achievements and credentials obtained by the periodontist that goes above and beyond the required schooling. While the certification lasts for six years after completion, many periodontists choose to renew their board certification each year.

The ABP states that those who have passed their exam and obtained board certification have “”demonstrated comprehensive mastery of all phases of periodontal disease and treatment.” To further show their confidence in their certification, each board certified periodontist is considered an American Board of Periodontology diplomate. This denomination allows for periodontists to work in a more active capacity. This may be at a dental school, government agency or with a research team to test new procedures and treatments of periodontal disease.

Why You Need a Board Certified Periodontist

Board certification for periodontists is more than an added level of expertise. It shows that your periodontist understands everything about their specialty and is able to provide the proper treatment. Periodontists that forgo board certification may not be as concerned about staying up to date on safe practices, leading to possible complications during treatment. Even general dentists that treat certain signs of gum disease will bring in a board certified periodontist to help with more severe or complex cases.

What sets ABP board certification apart from the rest is that the organization and their accreditation are both recognized by the ADA. There are less than 10 boards formally recognized by the American Dental Association as the requirements and standards are extremely stringent. Certification is regularly renewed so an ongoing commitment is made by every periodontist who wishes to maintain their status with the board.

You can seek periodontal treatment from nearly every dentist but you’ll receive varying levels of success. Putting your oral health as a top priority when finding a dental office will help you avoid unsafe treatment. You’ll also be able to find a doctor who has the training and experience required to properly administer periodontal services. Choosing to only work with board certified periodontists is choosing a doctor that respects, understands and addresses all of your periodontal concerns.

If you’re interested in receiving the most up-to-date periodontal treatment including surgery and the treatment of gum disease, please reach out to us here at Periodontal Associates of Memphis. Dr. Godat and Dr. King provide compassionate and transparent care for every patient they see.

The post What It Means To Be a Board Certified Periodontist in Memphis appeared first on Periodontal Associates of Memphis.

We’re very excited to have him join us in continuing our tradition of providing our patients with high-quality periodontal care.

Dr. King graduated with honors from Clemson University in 2010 with a Bachelors Degree in Microbiology.  He then went on to attend the University of Tennessee College of Dentistry, where he received his DDS (Doctor of Dental Surgery) and MDS (Master of Dental Science), as well as specialty training in periodontics and implant dentistry. During his final year at UTHSC, he had the privilege of being appointed and serving as chief resident.

He is a current member of several dental organizations, including:

• American Academy of Periodontology
• American Dental Association
• Academy of Osseointegration
• Tennessee Dental Association
• Southern Academy of Periodontology

Dr. King and his wife Catherine reside in Midtown and he is a native of East Tennessee. He comes from a family of dentists. His father is a Pedodontist, and his brother is a General Dentist.

Outside the office, he and his wife enjoy spending time together outdoors (hiking, camping, running, fly fishing), cooking, and watching sports (especially Clemson Football).

To learn more about our practice or to schedule an appointment with Dr. King, please call us at 901-761-3770.

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When someone throws a punch or if we get into an automotive accident, our arms and hands fly up to our face to make an effort to protect ourselves from any serious damage. Much of the time, we do not even consider the response of covering our face–we just do this instantly.

Maxillofacial trauma is injuries that are a threat for being quickly neglected, and this carelessness can cause harmful problems and inconvenience later on if they are not addressed in a prompt manner. This form of facial trauma can lead to soft tissue damage, nasal, mandibular, and orbital fractures, and other issues. Any harm that is sustained to the maxillofacial area needs specialized treatment and observation because many of our essential sensory systems and fundamental structures are established in the neck, face, and head.

Mandibular fractures, also known as jaw fractures, are the second most frequent skeletal facial injury only after nasal fractures. Furthermore, it is estimated that mandibular fractures represent as high as 70% of maxillofacial injuries. This is because of the way our jaws naturally protrude and since the chin has a lot less support from the cranium than other areas of the face. The mandibular is a mobile U-shaped bone that connects on either side of the mandible. The range of motion of this bone enables us to move our jaw and it also houses our teeth. Some of the most frequent sources of jaw fractures consist of:

▪ Automotive Accidents
▪ Falls
▪ Physical Assault
▪ Physical Activities

Warnings of a Fracture

Commonly, the jaw will crack in two regions: at the site of the direct collision and also in the place directly opposite of the original area. Any kind of injury sustained to the mandible bone ought to be seen by a doctor within 24 hours of the accident. The key symptoms of mandibular fractures involve redness, ache, swelling, and loss of functionality specifically breathing, talking, and chewing. Also, bruising and tingling of the neck and face might come with these bone fractures. If a patient believes that they have injured the jaw, it is crucial to seek medical attention immediately. A broken jaw may potentially obstruct the respiratory tract, cutting off the capability to breathe.

Trauma to the Teeth

Considering that the jaw bone holds all of our teeth, tooth injury is an issue when taking care of these kinds of wounds. Malocclusion is the failure to correctly line up the teeth due to trauma. It can manifest in just about any combination of places including the mandibular and maxillary arch, and the anterior and posterior sections. Additional things to pay close attention to include tooth and root fractures, and cracked or missing teeth. Treatment techniques consist of corrective dentistry, orthodontics, soft tissue repair, temporomandibular joint operations, and additional procedures depending on the type and severity of the injury.

Oral Specialists

When a medical professional has identified the issue, they will typically refer the patient to an oral or maxillofacial surgeon for further care. Basically, oral and maxillofacial surgeons provide services for the medical diagnosis and treatment of injuries involving the facial location. These specialists have been trained in both medical and dental areas to make sure that they are capable of
addressing a variety of common oral surgical conditions such as:

▪ Salivary Gland Issues
▪ Oral Cancer
▪ Face Harm
▪ Temporomandibular Joint Disorders

Remedies and Recovery

Orthognathic surgery, also called corrective jaw surgery, is executed by the OMS–the oral and maxillofacial surgeon–when they have established that this method is suitable for the degree of trauma that the patient is experiencing. When the mandible has been repositioned or reshaped, the operating surgeon will choose various methods to secure the mandible in the new position while it recovers. Medical gadgets like rubber bands, screws, wires, and surgical plates will be set up in the jaw during the operation. Maxillofacial damages and the resulting oral harm call for more than one medical professional to help the patient in therapy and recovery. As an example, endodontists can carry out root canal procedures and restorative dentists can address broken and cracked teeth.

For those who need surgery to correct their damages, the recuperation procedure can take up to six weeks. A soft food diet is vital during the course of this period since tougher types of foods can lead the medical plates to crack. Furthermore, a great oral health routine at the time of the first few weeks immediately after the operation will let the surgery site to fight any type of disease. As stated by the King’s College Hospital, the patient needs to cleanse their mouth out with warm salt water or mouthwash approximately 3 times a day for a week promptly following surgical operation. A small soft-bristled toothbrush, similar to a kid’s, is suitable to maintain the teeth near the stitches. The King’s College Hospital also recommends that patients do not smoke at the time of the recovery process as it might enhance the likelihood of infection.

A maxillofacial injury may be triggered by a variety of experiences. It is essential for the patient to seek medical attention immediately if they suspect that they might just have suffered an affliction to the face region, or if they experience any of the problems that have been listed above.

Our team at Periodontal Associates of Memphis is on social media! If you want more fun dental trivia and educational articles, follow us on Facebook!

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A PERIODONTISTS TRAINING IS VERY EXTENSIVE AND THEIR EDUCATION GOES WELL BEYOND DENTAL SCHOOL.

After a formal 4 year dental education, the periodontist spends an additional 2 to 3 years training in a residency program that is accredited by the American Dental Association. After successful completion of the accredited training program in periodontics and dental implants, periodontists may earn national board certification from the American Board of Periodontology (ABP) by passing comprehensive written and oral examinations covering all phases of periodontal disease and treatment.

A periodontist must be licensed as a dentist as well as a periodontist. They also have hospital-based training on sedation and have a license for that to maintain patient comfort. Periodontists can work in dental schools, hospitals, the business sector, and state, national and international agencies. They can also focus on research opportunities, such as testing emerging therapies and studying the interrelationships between periodontal and systemic diseases.

PERIODONTAL DISEASE IS A TERM FOR A GROUP OF DIFFERENT DISEASES.

These diseases have the same outcome: loss of attachment of the gum to the tooth, loss of connecting tissue and bone to your teeth. A periodontist is skilled in many types of periodontal procedures. In the early stages of gum disease, normally referred to as gingivitis, general dentists are trained and educated to treat the problem but if the problem worsens the dentist will recommend you see a periodontist for more advanced periodontal procedures to obtain health and save teeth. This will especially occur if the disease progresses and involves both a gum and bone infection, called periodontitis. This may involve cleaning the surfaces of the root to remove tartar, plaque and bacterial toxins from the gum pockets. This may also involve non-surgical periodontal treatment or a gingivectomy or gingivoplasty with a laser.

In many cases after this extensive cleaning, if the patient flosses and brushes daily, they will have successful results. In more extreme cases of periodontal infections, a periodontist is skilled in regeneration (bone regrowing). Today this doesn’t have to involve folding the gum tissue back to remove bacteria and infection but instead may involve using a laser along with bone grafts to regrow the bone in a kinder and more gentle manner. This procedure is called the Laser Assisted New Attachment Procedure (LANAP).

Membranes (filters), bone grafts or tissue-stimulating proteins are used to encourage your body’s natural ability to regenerate bone and tissue.

ANOTHER AREA OF EXPERTISE FOR A PERIODONTIST IS PERIODONTAL PLASTIC SURGERY.

If you have an exposed root, a periodontist can regrow the gum over the root to save your teeth so you can smile and eat with confidence again. This procedure is referred to as connective tissue grafting. This will reduce your sensitivity and even out your gum line. Some patients may have excess gum showing, so a crown lengthening procedure can be performed to enhance the beauty of the smile. This is where the bone tissue and the gum excess is reshaped to show more of the natural tooth.

SOME PERIODONTISTS WILL PERFORM RIDGE AUGMENTATION.

This procedure is used to correct gum and jawbone indentations (holes in the gum and bone from infection and tooth loss). It is also used to recapture the natural contour of your jaw and gum, so it appears that tooth replacements are growing naturally out of the tissue of the gum.

IN ADDITION, PERIODONTISTS ARE SPECIALLY TRAINED IN THE PLACEMENT, MAINTENANCE, AND REPAIR OF DENTAL IMPLANTS.

If you have lost a tooth through periodontal disease, decay, a fracture, or some other situation the periodontist will perform a dental implant. Dental implants are replacement tooth roots. Implants provide a strong foundation for fixed (permanent) or removable replacement teeth that are made to match your natural teeth. During the procedure, an artificial root post is placed in your jaw, after an initial healing period an artificial tooth will be attached to the post. In some situations, teeth may be able to be placed the same day as dental implant placement.

If you are concerned that you may have advanced periodontal disease or you already have a systemic disease such as diabetes or cardiovascular disease or a missing tooth/teeth, you may consider seeing a periodontist right away before the problems worsen. Normally, if you are having any of these issues, your dentist will recommend you see a periodontist. Upon that first visit, you will be evaluated and a medical history will be taken. The periodontist will examine your mouth, throat, teeth, gums and jaw joints. After this X-rays will be taken and the periodontist will discuss and develop a treatment plan.

The post What is a Periodontist Trained to Do? appeared first on Periodontal Associates of Memphis.

The team at Periodontal Associates of Memphis wants to take this time to give you a little more information about gum disease, and answer some frequently asked questions. 

FAQs:

Q: Who is the best option to treat my gum disease? A dentist or periodontist?

A: Typically, it is highly recommended to have both your dentist and periodontist involved in your treatment. Working together, your dentist and periodontist will be able to properly diagnose your condition, and put together a good treatment plan. If followed, your treatment plan should restore your gums to a healthy condition.

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Q: Is it possible for my child to have developed gum disease?

A: It is very uncommon for a young child, or teenager, to develop gum disease. However, this does not mean that your child or teenager shouldn’t learn the importance of proper hygiene care. Good hygiene habits are formed at a young age, and become habitual over time. If you start your child out young on a path of good habits, it will likely translate to when they are adults. 

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Q: What type of health issues are associated with gum disease?

A: Gum disease can be associated with a variety of health issues. These issues include:

– diabetes

– arthritis

– heart disease

– pancreatic cancer

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Q: How contagious is gum disease?

A: In theory, gum disease, unlike the common cold or the flu, cannot be passed from one person to another. With this being said, however, gum disease may be able to be transferred from one person to another through their saliva. Therefore, you should avoid sharing a drink with someone, using the same utensils as someone, or using the same oral health equipment (a toothbrush) as someone, if you know they have gum disease. 

Q: What symptoms can I look for? Is gum disease very common? What are the best ways to prevent myself from developing gum disease?

A: See the video below for answer to all of these questions, and more:

(via The American Academy of Periodontology.)

We are always welcoming new patients!

Do you live in the Memphis area? If so, and you are in need of a periodontist, we welcome you to contact us today to schedule an appointment. 

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With the great success in 2017, we look to make even more progress in 2018. The 2018 event will take place January 26th and 27th at Bellevue Baptist Church in Cordova, TN. The 2018 event will require the help of 1,000 volunteers, both dental and non-dental. If you would like to volunteer, click here. If you would like volunteer, but are unavailable, you can still help. The Mid-South Mission of Mercy event relies on donations to defray expenses. You can click here to donate to the cause. We have a budget of $250,000 for the event. Interested in sponsoring the event? Click here.

Want to keep up with the Mid-South Mission of Mercy? You can either visit their website or follow along on Facebook or Instagram.

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Here are some tips to help with this medical issue, often referred to as bruxism.

• Reduce Stress-Stress is the main cause of teeth grinding. Eliminate the major sources of stress, if possible.
• Get on a regular sleep pattern.
• Have fun and enjoy life. Unwind with friends and family.
• Have a balanced diet.
• Watch what you eat and drink before you sleep. Often alcohol and caffeine can be triggers of bruxism.
• Try not to clench your jaw or grit your teeth while you are awake. Try and relax your jaw when you notice you are clenching.
• Relax before bed. Try different methods, like listening to soothing music, while you are getting ready for or laying in bed. Try not to sleep with the television on.
• Contact your Periodontist! We can help you diagnose and treat your bruxism!

Grinding your teeth can be a painful way to spend your sleeping hours. Don’t worry, Memphis patients, getting relief is possible!

For more information on bruxism and how to get relief, contact us, and like us on Facebook!

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Bevacizumab (Avastin®): Another Drug Associated With Osteonecrosis of the Jaw

First it was the intravenous bisphosphonates, zoledronic acid (Zometa®) and palmidronate (Aredia®), then the oral bisphosphonates (the Fosamax® family of drugs), then the anti-RANKL drug, denosumab (Prolia®, Xgeva®). Now it’s a human monoclonal antibody known as bevacizumab (Avastin) that is associated with osteonecrosis of the jaw (ONJ) syndrome.

Bevacizumab (Avastin) belongs to a class of drugs known as antiangiogenic agents, used with increasing frequency in treating cancer. Bevacizumab is indicated for the treatment of metastatic colorectal cancer, and metastatic nonsquamous, nonsmall cell lung cancer. Angiogenesis in tumor cells involves the formation and growth of new blood vessels which help tumor growth. Bevacizumab acts to block angiogenesis through inhibition of cell proliferation and vessel sprouting, as well as by decreasing circulating vascular endothelial growth factor (VEGF) levels. This action is similar to the antiangiogenic action ascribed to the bisphosphonates. There are literature reports on patients receiving bevacizumab who developed ONJ. These reports are described in this month’s newsletter.

A case of ONJ associated with bevacizumab exposure was reported in a letter to the editor in 2008 (Greuter S, Schmid F, Ruhstaller T, et al, “Bevacizumab Associated Osteonecrosis of the Jaw,” Ann Oncol, 2008, 19(12):2091-2).

A 63-year old woman was treated for breast cancer. Bone scans were normal and she had never taken bisphosphonates. While being treated with liposomal doxorubicin and bevacizumab, the patient experienced left-sided maxillary pain after one-month therapy. A tooth infection was diagnosed and numbers 25 and 26 were extracted. One month later, a mouth-antrum fistula was surgically revised and occluded. Soon afterward, the patient suffered from a trigeminal neuralgia. Imaging showed maxillary sinusitis and signs of ONJ. The jaw lesion was extirpated and the sinus drained. Histology verified the clinical diagnosis of ONJ and an infiltration from the cancer was excluded. At 3 months of follow-up, the patient remained free of lesions and symptoms.

The authors commented that bevacizumab acts to block angiogensis through inhibition of cell proliferation and vessel sprouting, as well as by decreasing circulating vascular endothelial growth factor (VEGF) levels. This action is similar to the antiangiogenic action described for the bisphosphonates.

The authors stated that this was the third published case of ONJ associated with bevacizumab therapy. The doxorubicin the patient was taking is an anthracycline antineoplastic agent that has been on the market for many years and has never been known for causing ONJ. The authors suspected that bevacizumab, which hampers wound healing and possibly bone remodeling, was the causative agent in this case.

The other two published cases were included in a report by Estilo, et al (Estilo CL, Fornier M, Farooki A, et al, “Osteonecrosis of the Jaw Related to Bevacizumab,” J Clin Oncol, 2008, 26(24):4037-8).

A 51-year-old female with a history of infiltrating ductal carcinoma of the right breast was diagnosed in late 2001 and treated with mastectomy in 2002. She subsequently underwent treatment with chemotherapy, doxorubicin, cyclophosphamide, and letrozole for various cycles over a 3-year period. Since 2006, she underwent additional chemotherapy, capecitabine therapy, and radiation. In late December 2006, she was started on bevacizumab at a dose of 15 mg/kg every 3 weeks for a total of 8 doses, the last dose given in May 2007. Six weeks after the last dose, the patient presented with a 2-month history of complaints of lower jaw discomfort and protruding bone in the lower jaw. Examination revealed an area of bone exposure in the left posterior lingual mandible approximately 1 X 1 mm in diameter. The area appeared necrotic. The surrounding tissue had no evidence of infection. The exposed bone was smoothed with a bone file and the patient prescribed chlorhexidine 0.12% oral rinse. The bevacizumab and capecitabine were then discontinued. The area of exposed bone had resolved within a few weeks. The overlying mucosa appeared normal. At that time, a new area of exposed bone appeared in the right posterior lingual mandible of 1 X 1mm in area. Histology showed devitalized necrotic bone with a scalloped “moth eaten” appearance. Bacterial colonies occupied the demineralized areas.

The other case was a 33-year-old woman with a history of glioblastoma multiforme diagnosed in November 2006. She underwent surgery followed by radiation therapy and temozolomide from December 2006 through January 2007. The patient started bevacizumab therapy in Feb 2007 at a dose of 10 mg/kg every 2 weeks. Thirteen weeks later, she was referred to the dental clinic for evaluation of a 2-week history of spontaneous mucosal breakdown overlying her right mandible. The patient complained of gingival pain. On examination, there appeared a 1 X 2 cm dehiscence at the junction of the unattached/attached gingiva in the mucobuccal fold overlying the lower right first and second premolar and first molar teeth. There was exposed necrotic bone visible through the dehiscence extending inferiorly and posteriorly. There was no evidence of infection. Other than that, the oral mucosa appeared healthy with intact dentition. The patient continued on biweekly bevacizumab. In August 2007, she returned with a small mucosal defect posterior to the original lesion. There was soft tissue dehiscence with no evidence of exposed bone.

The authors commented that the clinical features of bone exposure in the two cases were compatible with ONJ in patients exposed to bisphosphonate therapy. The two patients had no history of bisphosphonate use. The authors suggested that bevacizumab contributed to the oral mucosal breakdown with exposed necrotic mandibular bone in the two patients. The antiangiogenic property of bevacizumab could compromise microvessel integrity in the jaw and lead to subclinical compromise of the osteonecrosis. Trauma from tooth brushing or chewing could also increase the demand on this compromised bone to repair itself and result in localized bone necrosis, periosteal death, and eventual exposed necrotic bone.

Estilo et al went on to explain that angiogenesis is a critical step in tumor growth, invasion, and metastasis. VEGF is a family of cytokines that exert important functions in tumor angiogenesis. VEGF is overexpressed in various human tumors and overexpression of VEGF is associated with tumor progression. VEGF is also essential for osteogenic differentiation and bone formation. Thus bevacizumab, used as a VEGF inhibitor to suppress tumor progression, could also suppress the osteogenic differentiation and bone formation. This could result in failure to repair bone trauma.

In the two patients described, additional factors possibly contributing to the development of ONJ were the advanced cancer and chemotherapy. The authors cautioned that clinicians involved in the care of patients treated with bevacizumab should be aware of the potential complication of ONJ.

Antiangiogenic Agents and the Risk of ONJ

Christodoulou et al reported that a combination of bisphosphonates and antiangiogenic factors induces ONJ more frequently than bisphosphonates alone (Christodoulou C, Pervena A, Klouvas G, et al, “Combination of Bisphosphonates and Antiangiogenic Factors Induces Osteonecrosis of the Jaw More Frequently Than Bisphosphonates Alone,” Oncology, 2009, 76(3):209-11). Their introduction in the report stated that antiangiogenic agents may add to the risk of ONJ, especially when used in combination with bisphosphonates. The purpose of the study was to do a back review of data of patients receiving bisphosphonates with or without antiangiogenic factors for osseous metastases from various tumors between June 2007 and June 2008.

Among 116 patients being treated for various malignancies, 25 received concurrent treatment with antiangiogenic agents at some point. Twenty-two were taking bevacizumab, two were taking a drug called sunitinib, and one was taking a drug called sorafenib. The median duration to exposure to bisphosphonates was 28.5 months for the 25 patients taking the antiangiogenic drugs and 24 months for those not taking any antiangiogenic drugs. There were no significant differences between the two groups regarding treatment duration with the bisphosphonate.

Of the 25 patients receiving concurrent treatment with bisphosphonates and the antiangiogenic drug, 4 developed ONJ (incidence of 16%). Of the 91 patients receiving bisphosphonates without antiangiogenic factors, 1 developed ONJ (incidence 1.1%). This difference was statistically significant.

In this study, the diagnosis of ONJ was according to the clinical diagnoses made by dentists specializing in treating cancer patients and consisted of pain in the jaw with exposed, necrotic bone, some with purulent discharge. The authors commented that bisphosphonates have also been reported to possess antiangiogenic activity, particularly zoledronic acid (Zometa®) — a widely popular bisphosphonate used as an adjunct agent in cancer treatment.

Greuter et al (above) summed it up best by stating “if more cases of bevacizumab-associated ONJ are reported, special dental management (jaw x-ray, optimal dental health, and good oral hygiene) should become standard before patients start bevacizumab.”

Dental Management to Reduce the Risk of ONJ

The importance of special dental management to reduce the risk of ONJ in patients taking bevacizumab was shown in a recent report (Francini F, Pascucci FF, Francini E, et al, “Osteonecrosis of the Jaw in Patients with Cancer Who Received Zoledronic Acid and Bevacizumab,” J Am Dent Assoc, 2011, 142(5):506-13). They looked at cancer patients on zoledronic acid and chemotherapy combined with bevacizumab who underwent a dental exam before starting treatment. They found that none of the patients developed ONJ.

The study included 59 patients with either breast cancer or nonsmall cell lung cancer who received 4 mg zoledronic acid I.V. every 4 weeks and 15 mg per kg bevacizumab every 3 weeks. The median time of receiving zoledronic acid was 18 months and the median time of receiving bevacizumab was 16 months. All subjects received a dental exam and panoramic x-rays before starting treatment and every three months thereafter until the patient died or was lost to follow-up. If needed, patients received periodontal disease treatment and underwent tooth extraction before they received any drug.

None of the patients required dentoalveolar surgery while undergoing cancer treatment. After a median follow up of 19.7 months, none of the participants developed ONJ. The conclusion was that a bisphosphonate combined with an antiangiogenic drug did not predispose to ONJ in participants with cancer that metastasized to the bone, who underwent a baseline dental examination and preventive dental measures.

Indications for Bevacizumab (Avastin®) Approved by FDA:

Treatment of metastatic colorectal cancer; treatment of unresectable, locally advanced, recurrent or metastatic nonsquamous, nonsmall cell lung cancer; treatment of metastatic HER-2 negative breast cancer (who have not received chemotherapy for metastatic disease); treatment of progressive glioblastoma; treatment of metastatic renal cell cancer (not an approved use in Canada).

Note: For the treatment of metastatic breast cancer, effectiveness is based on improvement in progression-free survival; not indicated for the treatment of breast cancer with metastatic disease that has progressed following anthracycline and taxane treatment. For the treatment of glioblastoma, effectiveness is based on improvement in objective response rate.

Unlabeled/Investigational Use:

Treatment of recurrent ovarian cancer; recurrent cervical cancer; soft tissue sarcomas (angiosarcoma or hemangiopericytoma/solitary fibrous tumor); age-related macular degeneration (AMD).

Recommendations from Periodontal Associates of Memphis:

Our recommendation is to have all dental treatment prior to cancer treatment. This should help avoid the above problems. Please contact us with any questions.

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The ADA pushes for Bone Health Research by recently announcing support for S. 966, the Bone Health Promotion and Research Act. Introduced by Sen. Kirsten Gillibrand (D-N.Y.), the bill would strengthen federal support for bone disease research through grants to independent facilities and at the National Institutes of Health.

The bill also would enhance the public health infrastructure for monitoring, preventing, and controlling bone-related maladies through the Centers for Disease Control and Prevention. It would also support a national awareness campaign that could be used to educate the public about enamel erosion, periodontal disease, osteonecrosis of the jaw, and other bone-related conditions of the oral cavity. The ADA’s letter of support is available here.

Bone is important to anchor teeth and preserve your facial appearance. Regrowing bone also helps to support teeth and dental implants to replace teeth.

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