Prevent and Treat ONJ with Forteo

July 31, 2015 @ 7:54 am
posted by Dr Ginther

Dentists and Oral Surgeons are sometimes wary of their patients being on ANY Osteoporosis Medications when they undergo tooth extractions or other dental proceedures.  One osteoporosis medication is different from all the others.  Forteo is the only Anabolic medication currently available in the USA.  Forteo does not cause dental and jaw problems.  Forteo can be used to treat ONJ and other bone problems of the jaw.

OsteoNecrosis of the Jaw (ONJ) is a rare complication of tooth extraction.  If you have cancer, are on chemotherapy, have uncontrolled diabetes, or are on the higher doses of Antiresorptive Osteoporosis Medications used in Cancer Patients with Metastases, ONJ is less rare.

ONJ is the result of too slow bone repair by the OsteoBlasts (the cells that make new bone matrix).  Antiresorptive medications slow down both OsteoClasts (the cells that resorb bone) and OsteoBlasts.

Forteo cannot cause ONJ.  Forteo (Teriparatide) stimulates OsteoBlasts.  That increases new bone matrix formation.  Therefore, Forteo can prevent and treat ONJ.

Forteo has been shown to improve bone healing in dental surgery, including implant osseointegration and healing alveolar defects.  Ref:  Batshutski JD, Eber RM, Kinney JS, et al.  Teriparatide and osseous regeneration in the oral cavity.  N Engl J Med. 2010, 363:2396-2405.  Ref:  Kuchler U, Luvizuto ER, Tangl S, et al.  Short-term Teriparatide delivery and osseointegration: a clinical feasibility study.  J Dent R. 2011:90(8):1001-1006.

As a former orthopedic surgeon, I have discussed these issues with several of our local oral surgeons and dentists.

If you are facing oral surgery or tooth extraction, discuss your osteoporosis medications with your dental surgeon.  Most osteoporosis medications should be held for your surgery.  Forteo is the exception.  Forteo actually helps your jaw heal after dental surgery.

Jay Ginther, MD

RAGBRAI is a Blue Zone

July 25, 2015 @ 4:44 pm
posted by Dr Ginther

RAGBRAI ends today.  It is one of the largest organized week-long recreational activites anywhere.  Officially the (Des Moines) Register Annual Great Bicycle Ride Across Iowa, the 2015 event included 17,000 registered participants for the entire 7 days.  Thousands more tag along for a day or two near their homes.

With neighbors, we hosted an extended family group of ten, including children down to age 5.  The family had gathered from Charleston, SC, Pittsburgh, PA, Ames and Iowa City, IA to spend a week together.  We supplied showers, beds, laundry facilities, supper and breakfast.  Many other Waterloo-Cedar Falls residents supplemented the official campground at UNI.

The sheer numbers of bicyclists created local traffic havoc for hours as they snaked their way from Souix City to Davanport covering 467 miles (the shortest route ever).  The towns affected got to meet interesting folks from nearly every state and several foreign countries.

We thoroughly enjoyed getting to know our guests.  The families we hosted have enjoyed a full week together seeing and meeting Iowa and its people.

Read “The Blue Zones” and “Thrive” by Dan Buettner.  Plan to have a Blue Zones experience of your own.

Jay Ginther, MD

Determining the correct 25-hydroxy Vitamin D level is still a work in progress.  In the 8 years I have been attending meetings, we have made considerable progress.  NOF 2007 was the first time any society proposed an intake above 400 IU daily and a 25-hydroxy Vit D level of more than 20 ng/ml.

At the 2015 U. Wisconsin “Bare Bones Symposium” the latest recommendations were discussed.  I have summarized them here.

Take Vitamin D3.  D3 is Cholecalciferol (what we make in sunshine).  Vitamin D2 is Ergocalciferol (what plants make and use).  D3 works much better in people than D2 becuse it is the right stuff.   It lasts 5 times longer and the assay is more accurate.

Test for 25-hydroxy Vitamin D level and aim for between 40 and 80 ng/ml.  At 40 ng/ml over 98% of people can absorb and utilize Calcium fully.  You want to have some margin of safety since lab test results vary by at least 20%.  If you are seriously deficient, we give 50,000 IU of D3 every M, W, F based on your level and size, to correct the level quickly.

If you do not want to test your level, and you are the “average person” of 154# or 70 kg, you should take 3800 IU daily.  This should achieve the 40 ng/ml level – eventually.  If you are very deficient, this could take a year or more.  If you are larger than the old average, or you have digestive issues, you will need more.

Finally, some cancer researchers believe that 70 ng/ml is better for preventing and treating cancers.  If they are right, you should go for the higher level.  If they are wrong, you have done no harm by going for the higher level.

Take Control of your Bone Health.  Take enough D3.

Jay Ginther, MD

Several patients have concerns about oral surgery while taking Prolia.  This is not a problem – if you follow guidelines.

Prolia is different from other Antiresorptives.  Prolia does not accumulate in bone.  5 to 6 months after your last dose, Prolia has lost its effect of slowing bone turnover.  Therefore, it is safe to proceed with surgery on bone (including dental surgery) 6 months after your last dose.

Patients worry about OsteoNecrosis of the Jaw (ONJ), but this is very rare.  In fact ONJ virtually never occurs without a tooth extraction or serious periodontal disease.  Even then, it is rare unless you also have cancer,  have poorly controlled diabetes, or are seriously Deficient in Vitamin D3, or Calcium, or Protein intake.

Elective Orthopedic Surgery timing is the same.  If you need a Total Hip Replacement (THR) or Total Knee Replacement (TKR), schedule the surgery for 6 months after your last dose of Prolia.

Any time you plan to have surgery on bone, you should Optimize Your Bone Health First.  Get a Complete Bone Health Evaluation.  Optimize your Vitamin D level (at 40 to 80 ng/ml).  Optimize your Calcium intake in foods and supplements combined (at 400 to 500 mg at all 3 meals daily).  Optimize your daily Protein intake (1 g Protein for every kg body weight).

Sometimes you will also need the Anabolic, Forteo, to increase bone matrix and improve healing.  More about that another time.

Get the best possible result from orthopedic or dental surgery.  Wait 6 months after Prolia, and do your part to optimize your bone health.

Jay Ginther, MD