from longitudinal studies has accumulated and highlights the temporal relationship of these symptoms to the menopausal stage and the association with hormonal changes across the menopause transition (Hariri and Alzoubi, 2017). Oral findings in postmenopausal women may include decreased saliva, increased dental caries, dysesthesia (e.g., burning mouth syndrome), alterations in taste, atrophic gingivitis, periodontitis, and osteoporosis of the mandible or maxilla. The etiology of Osteoporosis Osteoporosis affects women disproportionately (Sozen, et al., 2017). For women, osteoporosis and low bone mass together rank among the most common chronic conditions in the United States. (Patton and Glick, 2016 HealthyPeople.gov, n.d.; Wang and McCauley, 2016) The prevalence trend of osteoporosis is related, in part, to population trends because the risk of osteoporosis increases with age. The number of adults 50 years of age or older with osteoporosis rose from 10.2 million in 2010 to an estimated 12.3 million in 2020 with a projected number of 13.6 million adults in 2030 in this age range afflicted with osteoporosis (US Preventive Services Task Force, 2018). Often the first indication of osteoporosis is bone fracture (American Academy of Orthopedic Surgeons, 2016; Patel, 2020). Bone density is an important determinant of fracture risk, especially in women aged 65 and older. Osteoporotic fractures remain a significant source of morbidity (and a contributor to mortality) in postmenopausal women. For an American woman aged 50 years, the risk of suffering an osteoporotic fracture in her remaining lifetime has been estimated at 40%. Hip fractures take a particularly devastating toll, resulting in higher mortality, disability, and cost than all other osteoporotic fracture types combined. Approximately 40% of osteoporotic patients who sustain a hip fracture cannot walk independently after one year and 60% require assistance with at least one activity of daily living. Unfortunately, 21%-30% of these patients die within one year of their hip fracture (US Preventive Services Task Force, 2018). The generalized bone loss that is typical of systemic osteoporosis may also accelerate the resorption of alveolar bone and make the teeth more susceptible to chronic periodontitis. A number of reports have described a putative relationship between periodontitis and osteoporosis, although its extent remains unclear (Penoni, et al., 2017). Preliminary data from the oral ancillary study of the pivotal Women’s Health Initiative suggested a significant correlation between mandibular basal bone mineral density (BMD) and hip BMD (Penoni, et al., 2017). More recent reports describe a significant association between the BMD of the mandible and the peripheral skeleton in postmenopausal women (Carmo and Medeiros, 2017). Accordingly, there has been an exploration of the potential role of some mandibular panoramic indices, such as mandibular cortical index and mandibular cortical width, for the identification of individuals who are candidates for BMD assessment (Tounta, 2017; Grocholewicz et al., 2018). However, further research is needed before adopting panoramic radiographs as a routine screening tool for osteopenia or osteoporosis. Treatment guidelines for osteoporosis from various bodies – such as the American Association of Clinical Endocrinologists, ACOG, and NOF – stress that individuals, regardless of osteoporosis risk factors, should be encouraged to take steps to prevent bone loss and fractures. Among their recommendations are eating a balanced diet, obtaining adequate calcium and vitamin D, participating in appropriate exercise, not smoking, avoiding excessive alcohol consumption, and instituting measures to prevent falls (Sozen, et al.,2017; Camacho et al., 2016; National Institute for aging, 2017). Effective pharmacologic management of osteoporosis requires strategic use of available agents and an understanding of the optimal use of recently approved drugs. Current pharmacologic
primary burning mouth syndrome is unknown, but this common condition predominantly affects postmenopausal women (Mayo Clinic, 2017a; Cleveland Clinic, 2019). In idiopathic burning mouth syndrome, palliative care and support are appropriate, although pharmacologic options also exist, including tricyclic antidepressants, benzodiazepines, anticonvulsants, alpha-lipoic acid, and topical capsaicin (Hennessy, 2020). options for women include the use of estrogen, with or without progestin or progesterone. Other drugs used in the treatment of osteoporosis are: ● Selective estrogen receptor modulators (SERMs) such as raloxifene (Evista). ● Bisphosphonates, such as alendronate (Fosamax), risedronate (Actonel), ibandronate (Boniva), and zoledronic acid (Reclast). ● Calcitonin (Miacalcin). ● The anabolic agent teriparatide (Forteo). A recent meta-analysis found that bazedoxifene was safe and effective in reducing the number of vertebral fractures and increasing spine BMD over periods of 3 and 7 years (Peng, Luo, & Lu, 2017). Since 2013, bazedoxifene has been approved by the FDA in combination with conjugated estrogens for the treatment of menopausal symptoms and osteoporosis and sold under the brand name Duavee (Drugs.com, 2021). However, this medication is for short-term use and can be taken only by women who have an intact uterus (Pfizer, 2017). A fairly new drug for osteoporosis is denosumab. This medication is effective in reducing bone turnover and fractures and that the benefits of the medication outweighed the risk of the development of (MRONJ) which ranges from 0.04% to 0.3% for those patients who receive the twice-yearly injection of this medication (Chan, et.a l., 2018). A continuation of the study found that the positive results held for at least 10 years (Bone et al., 2017). Denosumab, marketed under the brand name Prolia, has approval from the FDA for use in the treatment of osteoporosis (National Cancer Institute, 2018). Sometimes calcitonin is prescribed as a nasal spray (Zhang et al., 2018). This medication, though it has its own adverse effects, has not been reported to cause osteonecrosis of the jaw. Concerns have been expressed about cancer risk, but the evidence is weak (Wells, Chernoff, Gilligan, & Krause, 2016; Zhang et al., 2018). Agents under investigation include cathepsin K inhibitors (Lindström et al., 2018; Tanaka, Hashimoto, Hasegawa, Deacon, & Eastell, 2017) and monoclonal antibodies (Tu et al., 2018). Bisphosphonates are potent inhibitors of osteoclastic activity and thereby reduce bone remodeling (Khan, et al., 2017). Additionally, they have antiangiogenic properties and thus inhibit the bony microvascular blood supply. Clinical trials have demonstrated that bisphosphonates significantly increase BMD at the spine and hip in a dose-dependent manner and reduce the risk of fracture at some sites. Bisphosphonate therapy is also reported to have beneficial effects on the periodontium (Muniz, et. al., 2021). Although bisphosphonates are effective as a prophylaxis and intervention for osteoporosis, exposure to them has led to reports of medication-related osteonecrosis of the jaw (MRONJ) (Aldhalaan, et al., 2020). This condition is defined as the “presence of necrotic bone anywhere in the oral cavity in a patient who is taking bisphosphonates, who has not received radiation to the head and neck and in whom the necrotic area does not heal within 8 weeks after diagnosis after receiving proper care” (American College of Prosthodontists, 2018). Approximately 0.001%-0.01% of patients who take oral bisphosphonate medications will develop MRONJ compared to between 1% and 10% of patients for whom Intravenous (IV) bisphosphonates are utilized (American Dental Association, 2019). The use of IV bisphosphonates or denosumab therapy ● Bazedoxifene. ● Ospemifene.
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