Osteonecrosis and Xgeva

[ctflatlander]

Been a while since last post. I have been on the Xgeva 3 month shot since June 2019. Just been diagnosed with TMJ and my last shot was Mar 2022. How long will it take for Xgeva to leave the system since TMJ still feels like it is progressing? My oral surgeon does not want to operate unless a piece of bone becomes separated from the jaw bone. A tooth may have to remove as well. I have discomfort but not in pain. My bone density has improved since doing weight bearing exercises at the gym : left forearm -1.3, left hip -.9, lumbar spine -.5, femoral neck -1.2 See my profile for current medications. Any thoughts?

[pjoshea13]

My wife was told by her oncologist to delay major dental work for 3 months & delay resumption of Xgeva for another 3 months.

On the other hand, her dentist says that the stuff never really washes out. (Although 140 days is considered good enough.)

Anyway, with each 28 days you will lose another 50%.

With a 3 month delay, you will still have 1/8th of the starting level.

-Patrick

[ctflatlander in reply to pjoshea13]

Thank you Patrick

[dentaltwin]

Is TMJ surgery in play? Obviously I can't know the situation but surgery on the TMJ is very much a last resort. Drug holidays are less well-researched with denosumab compared with bisphosphonates. The half-life of denosumab in blood is relatively short, and apparently much shorter in bone than bisphosphonates. But I see little agreement about the benefits of drug holidays for denosumab. It is possible I haven't seen the latest research. I've seen two months before and two months after, but I suspect this number was pulled from where the sun don't shine.

I have not heard of osteonecrosis of the TMJ (mandibular condyle, glenoid fossa)--it is far more likely with extraction, where the bone is exposed to saliva.

Steve (DDS retired)

[ctflatlander in reply to dentaltwin]

Hi Dr. Thank you for responding. The oral surgeon assessment: ulcer and exposed bony over left lingual posterior mandibular tori with possible correlation with stage 1 medicine related osteonecrosis of the jaw

Recommendation:

continue soft diet

warm water rinse

RX peridex to use periodoically but use more frequently if pain and swelling develops. Antibiotics can be prescribed empirically if swelling and/or symptoms become much worse.

No surgical intervention warranted at this point. If develop signs of necrotic bony sequestrum with purtencen then can consider this.

if medically feasible would recommend no Xgeva

In my opinion I don't see this situation getting better and I hope I don't lose the rear tooth near the exposed bone. Does this help?

Thanks Bob

[dentaltwin]

Well, osteonecrosis on a torus has no bearing on the TMJ. As far as surgery to debride the area of osteonecrosis, to my knowledge it's controversial. The conventional wisdom is that surgery doesn't help; but I've been at a lecture where a surgeon was much more aggressive; I believe he used PET to help visualize the area of affected bone.

The torus is a tough area because the overlying tissue is very thin and because the torus is prominent the tissue is easily traumatized. I honestly don't have standing to agree or disagree with your surgeon. Certainly in terms of whether a drug holiday would be useful it seems to me it has a greater chance of helping than if you had been on Zometa or another bisphosphonate. I would be inclined to caution if the surgeon wants to avoid surgery. The necessity for extraction has to be considered separately unless the area of osteonecrosis is right adjacent to the tooth (teeth) in question.

[j-o-h-n in reply to dentaltwin]

You're a MENSCH,,,,,,,,,,,,,thank you for you.......

Love and Kisses from your Twin......

Good Luck, Good Health and Good Humor.

j-o-h-n Tuesday 07/05/2022 7:35 PM DST