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THE MISCH INSTITUTE NEWSLETTER

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Beware of the Complications of a New Drug Class: The “Biologics”

A new class of therapeutic drugs are becoming more popular in the treatment of an array of medical conditions such as autoimmune disease and cancers. These new drugs are termed “Biologics”. Biologics use living organisms (genes) and are manufactured by using recombinant DNA technology in the form of vaccines, antitoxins, growth hormones, gene therapy, and recombined proteins and allergens. Biologic medications are advantageous because they specifically target cells that are involved in the pathogenesis of the disease. In contrast, immunosuppressive drugs are medications that are used to inhibit or prevent activity of the immune system. Immunosuppressive drugs are usually used to minimize rejection of transplanted organs and tissues and also for treatment of autoimmune diseases. These drugs have many side effects, with the majority of them acting non-selectively (acting on normal cells). Because of these side effects, the biologics are advantageous for many types of disorders.

Although biologic medications have become very popular in the treatment of many systemic disorders, caution must be exercised in patients that have been treated in the past or are currently being treated. Patients may be susceptible to increased infectious episodes, intraoperative bleeding, and compromised bone healing. A medical consult and evaluation is highly recommended prior to any proposed implant treatment. For most biologic drugs, concurrent use and the placement of implants is an absolute contraindication. Because of the lack of history and studies with these types of medications, severe caution must be exercised with past biologic use and future implant treatment. Recommended Protocol;

Past biologic therapy: Relative contraindication after MD consultation

Concurrent biologic therapy + Implant therapy: Absolute contraindication[vc_column width=”1/2″]

COMMON BIOLOGIC MEDICATIONS USED TODAY

Humira (Adalimumab) – Rheumatoid arthritis, Crohn’s disease, Ulcerative colitis, Psoriatic Arthritis, Ankylosing spondylitis
Remade (Infliximab) – Rheumatoid arthritis, Crohn’s disease, Ulcerative colitis, Psoriatic Arthritis, Ankylosing spondylitis
Enbrel (Etanercept) – Rheumatoid arthritis, Psoriatic arthritis
Herceptin (Trastuzumab) – HER2+ breast cancer
Lucentis (Ranibizumab) – Age-related macular degeneration
Avonex (Interferon beta-1a) – Multiple sclerosis (MS)
Glatiramer acetate (Copaxone) – Multiple Sclerosis (MS)
Brodalumab (Siliq) – Psoriatic Arthritis
Ixekizumab (Waltz) – Psoriatic Arthritis
Secukinumab (Cosentyx) – Psoriatic Arthritis, Ankylosing Spondylitis
Ustekinumab (Stelara) –

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ANNOUNCEMENTS

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COMING SOON

NOVEMBER 2018
(date to be announced)
New Jersey[vc_column width=”1/2″][us_image image=”3213″ align=”center”][vc_column width=”2/3″ offset=”vc_col-sm-offset-2″][us_separator][vc_column_text el_class=”align_center”]

HANDS-ON SURGERY & PROSTHETICS PROGRAM

Available ONLY to current Misch program attendees & former Misch graduates*

Learn & participate in surgical & prosthetic procedures on patients*

SURGICAL PROCEDURES: Difficult extractions, socket grafting, membrane augmentation, implant placement, sinus augmentations – transcrestal & lateral wall

PROSTHETIC PROCEDURES: Single, multiple crowns , full -arch zirconia prosthesis digital impressions, RFA, cement & screw-retained prostheses

*Restrictions: Valid license from any state, bring your own patients or patients provided by the Institute[vc_row el_class=”newsletter-row”][vc_column_text el_class=”align_center”]

NEWSLETTER CONTINUING EDUCATION QUESTIONS

** Answers Below **[vc_row color_scheme=”alternate” el_class=”newsletter-content”][vc_column width=”1/2″ el_class=”orange-right”][vc_row_inner][vc_column_inner width=”1/3″][us_image image=”3214″ size=”full”][/vc_column_inner][vc_column_inner width=”2/3″]

#1: CBCT PATHOLOGY

Upon CBCT evaluation of a patient, you notice the following incidental finding in the right maxillary sinus.

a. What is the differential diagnosis for this finding?

b. You refer the patient to an ENT physician for evaluation and treatment. How would you describe this condition radiographically in your referral letter?[/vc_column_inner][/vc_row_inner][vc_column width=”1/2″][vc_row_inner][vc_column_inner width=”1/3″][us_image image=”3215″][/vc_column_inner][vc_column_inner width=”2/3″]

#2: CBCT ANATOMY

In this coronal CBCT image for evaluation of posterior maxilla (for evaluation of sinus grafting), what three anatomic variants are present which may predispose the patient to mucociliary clearance complications post-operatively?[/vc_column_inner][/vc_row_inner][vc_row color_scheme=”alternate” el_class=”newsletter-content”][vc_column width=”1/2″ el_class=”orange-right”][vc_row_inner][vc_column_inner width=”1/3″][us_image image=”3216″ size=”full”][/vc_column_inner][vc_column_inner width=”2/3″]

#3: Prosthetics

One of the most common post-operative complications which occurs after prosthesis completion is abutment screw loosening. Various studies have reported a prevalence to be approximately 5 – 60% of cases. A common etiologic factor contributing to screw loosening is inadequate preload, which may be due to the “settling effect.” What is the settling effect and how can it be prevented?[/vc_column_inner][/vc_row_inner][vc_column width=”1/2″][vc_row_inner][vc_column_inner]

# 4: Legal – Medical

FRANK R. DELUCA DMD, J
Malpractice Attorney, Ft. Lauderdale, FL
deluca1958@yahoo.com

What does a implant practitioner do when he/she recommends a CBCT for a patient and the patient refuses and the legal ramifications?[/vc_column_inner][/vc_row_inner][vc_row el_class=”newsletter-row”]

PROGRAMS

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Medical Emergencies Implant Patients

July 12, 2018
Orlando, FL[us_btn link=”url:https%3A%2F%2Fnmgpilot.com%2Fproduct%2Fmedical-emergencies-orlando%2F|||” align=”center” style=”6″ size=”” label=”Register Now”][/vc_column_inner][/vc_row_inner][vc_column offset=”vc_col-md-4″][vc_row_inner][vc_column_inner width=”1/2″ offset=”vc_col-md-12″][us_image image=”3221″ align=”center”][/vc_column_inner][vc_column_inner width=”1/2″ offset=”vc_col-md-12″][vc_column_text el_class=”align_center”]

Surgical Program Session 4

July 13-14, 2018
Orlando, FL[us_btn link=”url:https%3A%2F%2Fnmgpilot.com%2F%23surgical-home|||” align=”center” style=”6″ size=”” label=”Register Now”][/vc_column_inner][/vc_row_inner][vc_column offset=”vc_col-md-4″][vc_row_inner][vc_column_inner width=”1/2″ offset=”vc_col-md-12″][us_image image=”3222″ align=”center”][/vc_column_inner][vc_column_inner width=”1/2″ offset=”vc_col-md-12″][vc_column_text el_class=”align_center”]

Prosthetic/Surgical Program

September 14, 2018
Las Vegas, NV[us_btn link=”url:https%3A%2F%2Fnmgpilot.com%2Fproduct%2Fprosthetic-program-las-vegas%2F|||” align=”center” style=”6″ size=”” label=”Register Now”][/vc_column_inner][/vc_row_inner][vc_row el_class=”answers”]

CE ANSWERS:

Question #1: CBCT Pathology

#1a

Odontogenic Rhinosinusitis
Acute Rhinosinusitis
Allergic Rhinosinusitis
Primary Mucocele
Fungal Rhinosinusitis
Neoplasm

#1b

Non-Patent Maxillary Ostium and Osteomeatal Complex
Completely Opacified Maxillary Sinus and Ethmoid

Question #2: CBCT Anatomy

Concha Bullosa – aerated middle turbinate, deflecting the unicinate process laterally, closing off the ostium (Prevalence = 34 %)
Deviated Septum – deviation of the septum to one side, resulting in compressing middle turbinate laterally, closing off the ostium (Prevalence = 80 %)
Paradoxical Middle Turbinate – backwards middle turbinate, projects laterally, blocking middle meatus and blocking the ostium (Prevalence = 26 %)

Question #3: Prosthetics

Once an abutment screw is torqued to the manufacturers specifications, there is an immediate loss of the preload (torque). This is termed “settling effect” and can be mitigated by using the following technique:

Torque abutment screw to the appropriate manufacturer specifications.
Wait 10 minutes and re-torque to those same specifications.

This technique will increase the torque back to the original preload, thereby decreasing the possibility of screw loosening.

Question #4: Medical – Legal

Usually, the refusal of a CBCT is the result of either radiation exposure or cost.

Radiation exposure. The dosage of radiation from a typical CBCT is minimal.We are exposed to normal background radiation exists in the environment every day. The amount of radiation from a typical CBCT is the equivalent of normal life expose for approximately a two week period.Therefore, the patient should be educated on minimal amount of exposure from a CBCT.
Cost. The easiest way to deal with the cost issue is to build the expense into the cost of the implant(s). If this is not feasible, for example for insurance reasons, then the patient needs to be educated on the significant advantages of a CBCT as compared to 2d radiography. Such education should include a demonstration of CBCT and its advantages over standard dental radiography. Our experience has shown that most patients are taken to technology and would like to see the best and most up to date methods used to treat them. The legal community attempted to deal with such patients by the use of a concept known as “informed refusal”. Informed refusal is where a patient, based on an complete understanding of the facts, implications and risks of not following a recommended course of treatment, declines a particular procedure. This legal concept is an offshoot of the “informed consent” process. In sum, a patient has a right to consent to treatment, as well as to refuse treatment with the caveat that they must be full informed of the consequences. Lawyers have devised an “informed refusal” form. Such language and execution by the patient is not however a panacea. It is not a get out of jail free card. Such forms should in this writers opinion be used with extreme caution. Always remember that ultimately you are the trained educated practitioner. You are charged with the ethical duty to treat patients appropriately. Patients cannot consent to negligent care .If it is against your best judgment to do the case without a CBCT, then do not proceed. In the long run you will save yourself a lot of headaches and time.

June 2018