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BIFOSFONATOS E OSTEONECROSE DOS MAXILARES: Revisão de Literatura e Aplicações na Implantodontia

Trabalho apresentado como requisito parcial ao programa de pós-graduação para a obtenção do título de especialista em Implantodontia, do curso de especialização em Implantodontia da Sociedade Educacional Herrero. Orientador: Prof. Marcus Woltmann
by

CAROLINA PRAZERES

on 18 March 2015

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Transcript of BIFOSFONATOS E OSTEONECROSE DOS MAXILARES: Revisão de Literatura e Aplicações na Implantodontia

INTRODUÇÃO
BFs
BIFOSFONATOS E OSTEONECROSE
DOS MAXILARES:
Revisão de Literatura e
Aplicações na Implantodontia

ONMAB
SOCIEDADE EDUCACIONAL HERRERO
FACULDADE DE TECNOLOGIA HERRERO
ESPECIALIZAÇÃO EM IMPLANTODONTIA
A reabilitação dentária por meio da instalação de implantes osseointegráveis vem sendo,
nos últimos anos, cada vez mais executada
(Chacon et al., 2006).

Os bifosfonatos (BFs) são análogos sintéticos dos pirofosfatos e tendem a se concentrar em locais de remodelamento ósseo ativo, modulando a sinalização osteoblasto-osteoclasto, diminuindo a reabsorção óssea pelos osteoclastos
(Hansen et al., 2006; Clarke et al., 2007).


Em 2003 o alendronato ocupava o 19º lugar
na lista dos medicamentos mais prescritos,
estima-se que em 2020, nos E.U.A., mais de
60 milhões de norte-americanos serão
afetados por situações de osteopenia
ou de osteoporose, e que anualmente
haverá 1.5 milhões de novas fraturas
(Bartl et al., 2007).
Até a publicação dos primeiros trabalhos associando o uso de bifosfonatos com o desenvolvimento de osteonecrose, as cirurgias para instalação de implantes osseointegráveis em pacientes fazendo uso destes medicamentos eram realizadas sem alterações de protocolos cirúrgicos
(Grant et al., 2008).
Este trabalho tem como objetivo a revisão da literatura sobre o tema, a discussão dos conhecimentos científicos apresentados até
os dias atuais, e a determinação
das aplicações destes na
implantodontia.

Adaptado de Sarin et al., 2008.

Adaptado de Sarin et al., 2008.
Análogos sintéticos dos
pirofosfatos inorgânicos;



Geração;

Potência;

Nitrogenados ou não;

Via de administração.

BFs
Propriedades farmacológicas,
químicas e
mecanismos de ação
Pereira et al., 2008.
Rodan & Fleisch,1996.
Meia vida
elevada;

Alta afinidade com
hidroxiapatita;

Efeito
antiangiogênico.

Apoptose(GTPases)
Alteração do turnover ósseo.
Conceito e classificação
Indicações clínicas e
perfil dos usuários
Osteoporose;
Osteopenias;
Cânceres;
Outras
patologias.
EFEITOS COLATERAIS
Sintomatologia gastrointestinal, cefaléia, dor óssea, náuseas, febre, hipocalcemia, hipofosfatemia, hipercolesterolemia, aumento da creatinina sérica, hipertensão, rachaduras cutâneas, tonturas, sintomatologia do tipo gripal, astenia, anemia, dispnéia e edema
(Bartl et al., 2007); (Lopes et al., 2009).

Histórico, conceito e
nomenclatura
Marx et al. (2003) -36 casos;
Wang et al. (2003) -3 anos;
Ruggiero et al. (2004) -63 casos;
Began et al. (2005) -10 casos.
Tratamento prévio ou atual com BFs, exposição óssea na região maxilofacial persistente por mais de oito semanas e ausência de radioterapia antecedente na região dos maxilares.
Ada, 2006.
ONMAB
Epidemiologia
Prevalência e
incidência indefinidas.

Durie et al. 2005.

Adrac, 2005.
Woo et al. 2006.
ADA, 2006.
Wang et al. 2007.
AAOMS, 2007.
Hess et al. 2008.
López et al. 2007.
Pazianas et al., 2007.
ONMAB
Aspectos radiográficos e clínicos
Carlson et al., 2009.
Freiberger, 2007.
Arce, et al. 2009.
Arce, et al. 2009.
Carlson et al., 2009.
Carlson et al., 2009.
Estágios clínicos
Estágio 0;

Estágio 1;

Estágio 2;

Estágio 3.
Freiberger, 2007.
Ruggiero et al. 2009.
ONMAB
Diagnóstico
1. Tratamento com BF prévio ou no presente;
2. Exposição óssea, sintomática ou não, na região maxilofacial persistente por mais de 8 semanas;
3. Sem histórico de radioterapia nos ossos maxilares
(Ruggiero et al., 2009).
Osteíte alveolar, sinusite, gengivite, doença periodontal, periodontite ulcerativa necrosante, trauma, infecções odontogênicas que conduzem à osteomielite, herpes zoster associado à osteonecrose, seqüestro da cortical óssea lingual, mucosite, osteomielite infecciosa, patologia periapical secundária à cárie, distúrbios temporomandibulares, osteorradionecrose, tumores e metástases ósseas
(Khosla, et al., 2007; Sarasquete et al., 2009).


TRATAMENTOS:
Conservador X Cirúrgico

Carlson et al., 2009.
Em risco: sem tratamento indicado; paciente em uso de BF oral ou EV mas sem osso necrótico aparente: orientação ao paciente.

Estágio 0: controle sistêmico, uso de analgésicos e antibióticos.

Estágio 1: bochechos antibacterianos, controle clínico trimestral, orientação ao paciente e revisão do uso contínuo de BFs.

Estágio 2: tratamento sintomático via oral, bochechos antibacterianos, controle da dor, debridamento superficial para alívio da irritação da mucosa.

Estágio 3: bochechos antibacterianos, terapia antibiótica e controle da dor, debridamento/ressecção cirúrgica para alívio da dor e infecção.

(Passeri et al. 2011).
ONMAB
Stark et al. (1995).
Meraw et al. (1999).
Jeffcoat
(2006).
Jeffcoat et al.
(2006).
Marx et al. (2007).
Aplicações na
implantodontia
Não existem evidências suficientes para a contra-indicação de cirurgias eletivas dentoalveolares em pacientes que fazem uso de bifosfonatos via oral por um período inferior a três anos, todos os pacientes devem ser questionados sobre seu uso e alertados sobre os possíveis riscos e benefícios inerentes aosprocedimentos
(ADA 2006; Chacon et al., 2006; Grant et al., 2008; Gonçales et al., 2009).
ADA, 2006.
Grant et al. (2008).
Fugazzoto (2007).
Bell & Bell (2008).
Giro et al. (2008).
Madrid &
Sanz (2009).
Shin et al. (2010).
Yip et al. (2012).
Jacobsen et al. (2013).
Taxel et al.
(2013).
Solomon et al. (2013).
Aplicações na
implantodontia
Aplicações na
implantodontia
CONSIDERAÇÕES
FINAIS
Estágios clínicos
A determinação sanguínea através do CTx, com valores superiores a 150pg/mL permitirá realizar qualquer tipo de cirurgia com mínimo risco e sem a necessidade de suspender o bifosfonato. Embora este parâmetro precise de maiores evidências científicas para confirmar sua validez
(Castillo et al., 2007).
Embora a chave de todos estes mecanismos não está totalmente elucidada, ainda sim, justificam as características clínicas destes medicamentos, capazes de melhorar a sobrevida dos pacientes com cânceres e demais patologias ósseas, por modificarem a história natural da doença óssea
(Began et al., 2005).
1) Tanto a etiopatogenia quanto a epidemiologia da ONMAB, permanecem não totalmente elucidadas.
2)A etiologia mais citada foi multifatorial, envolvendo tanto a ação dos BFs no turnover ósseo quanto, fatores locais, sistêmicos, medicamentosos e infecciosos.
3)O sintoma mais relatado foi dor e o sinal foi exposição de osso necrótico, sendo casos assintomáticos incomuns. Radiograficamente, não houve consenso na literatura.
4)Os protocolos de prevenção e tratamento apresentados apresentavam divergências e incertezas, porém a prevenção e a dosagem sérica do CTx, parecem ser as opções mais indicadas.
5)Na implantodontia, a casuística com sucessos e insucessos também foi variável, sendo os protocolos de prevenção e dosagem sérica do CTx os mais recomendados.
Mecanismo de ação: turnover ósseo.
Este efeito colateral não havia
sido verificado nos estudos clínicos prévios
(Hohneker, 2004).
Outros Protocolos:
Marx et al. 2005 e
Ruggiero et al. 2009.
ONMAB
Etiopatogenia
Fatores de risco e
risco estimado
0,8% a 12%
Yoneda et al., 2010.

OSTEONECROSE DOS MAXILARES ASSOCIADA AO USO DOS BIFOSFONATOS
“Osteonecrose
dos maxilares
induzida por
bifosfonatos”
Marx et al., 2009.
Fármaco;
Demográficos e sistêmicos;
Locais;
Genéticos;
Preventivos.
AAOMS, 2009.

Via: IV > Oral;

Potência: 3a. geração > 1 e 2a. gerações;

Posologia: Maior quant. (freq.?) > Menor;

Tempo de USO.
A hipótese mais aceita até o momento seria de uma complexa interação entre o metabolismo ósseo, trauma local, infecção, hipovascularização e o uso de BFs. Sabe-se, igualmente, que os BFs acumulam-se quase exclusivamente em locais esqueléticos que possuem alta atividade de remodelação óssea, como a maxila e mandíbula
(Ruggiero et al., 2006).
Osso neoformado

Anatomia
Trauma
Infecção
Processo cicatricial
Boca
ONMAB
BFs
Metabolismo ósseo
Antiangiogênese
Dinâmica celular
Hipóxia tecidual
"Não totalmente elucidada"

(Migliorati et al., 2005;
Ruggiero et al., 2006).
HISTÓRICO
Século XIX
1969
1980
Século XX
2007
2008
Dosagem sérica de
telepeptídeos-C
terminal
Interromper
BFs
Cedido por Dr. Marcus Woltmann (Blumenau, 2012).
DISCUSSÃO
Características dos BFs:
elevada biodisponibilidade e
fator antiangiogênico.
IMPLANTES:
Sucessos/
insucessos;
Orientações;
Não é contra-
indicado.
RISCO
X
EFICÁCIA
Autora: Carolina Prazeres
Orientador: Prof. Marcus Woltmann

TEMPO DE
USO
acima de 4 anos
3 - 4 anos
1 - 3 anos
Migliorati et al.(2006).
BAIXO
MÉDIO
ALTO
RISCO
Adaptado de Marx et al., 2007.
Os telepeptídeos-C terminal ou do colágeno tipo I (CTx) são fragmentos de colágeno que são liberados durante a remodelação e renovação óssea. Como os bisfosfonatos reduzem a formação dos CTx, acredita-se que a contagem dos níveis séricos de CTx poderia ser um indicador confiável no nível de risco
(AAOMS, 2007; Misch, 2008).
Suspensão
BFs
"Entidade clínica recente"
AAOMS, 2007.
Outros autores
x
Outras terminologias
PROTOCOLO PREVENTIVO
1)Avaliação odontológica;

2)Remoção de focos de infecção e fatores traumáticos;

3)Controle de higiene oral;

4)Esclarecimento ao paciente;

5)Consultas freqüentes;

6)Monitoramento radiográfico e adaptação de próteses;

7)Diálogo com oncologista ou médico responsável;

8)Monitoramento através do nível de CTx;


(Martins et al., 2009).
Protocolos de
prevenção
e tratamento

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