A 56 year old woman is prescribed prednisolone 15 mg daily for polymyalgia rheumatica. She has a body mass index of 17.5kg/m2, smokes 20 cigarettes a day and drinks 18 units of alcohol a week. Her last menstrual period was approximately 2 years ago. Oral hygiene is poor and she has been taking warfarin following a mitral valve prosthesis.
The prescribing notes on Osteoporosis in section 6.6, BNF 56, indicate that this patient is at risk of osteoporosis because she is postmenopausal, smokes, drinks excess alcohol, has a low body mass index, and has been started on a long course of prednisolone.
The prescribing notes on Corticosteroids in section 10.1.2.1, BNF 56, advise that treatment should be continued until remission of disease activity and then doses are reduced gradually to about 7.5-10mg daily for maintenance. Relapse is common if therapy is stopped prematurely. Many patients require treatment for at least 2 years and in some patients it may be necessary to continue long-term low-dose corticosteroid treatment.
The prescribing notes on Osteoporosis in section 6.6, BNF 56, state that the greatest rate of bone loss occurs during the first 6-12 months of corticosteroid use and so early steps to prevent the development of osteoporosis are important. Patients taking (or who are likely to take) a systemic corticosteroid for 3 months or longer should be assessed and where necessary given prophylactic treatment against osteoporosis.
The prescribing notes on Osteoporosis in section 6.6, BNF 56, recommend that those at risk of osteoporosis should maintain an adequate intake of calcium and vitamin D and any deficiency should be corrected by increasing dietary intake or taking supplements.
A first-line option for prophylaxis includes a bisphosphonate such as alendronic acid or risedronate. Hormone replacement therapy is an option when other therapies cannot be used.
The prescribing notes on Bisphosphonates in section 6.6.2, BNF 56, state that osteonecrosis of the jaw has been reported rarely in those taking oral bisphosphonates. Ideally remedial dental work should be carried out before starting a bisphosphonate in this patient with concomitant risk factors such as corticosteroid therapy and poor oral hygiene. Adequate oral hygiene should be maintained during and after treatment with a bisphosphonate.
The Summary of Antibacterial Prophylaxis in Table 2, section 5.1, BNF 56, no longer recommends antibacterial prophylaxis for the prevention of infective endocarditis in this patient. Such prophylaxis may expose her to the adverse effects of antibacterials when the evidence of benefit has not been proven. Furthermore, routine daily activities such as tooth brushing may present a greater risk of bacteraemia than a single dental procedure.
She should be advised to maintain good oral hygiene and told to report any unexplained illness that develops after the extraction. Any infection should be investigated promptly and treated appropriately to reduce the risk of endocarditis.
The prescribing notes on Thromboembolic Disease under Medical Problems in Dental Practice, BNF 56, advise that if the INR is stable, the INR should be assessed 72 hours before the dental procedure. This allows sufficient time for dose modification if necessary. If this INR is below 4, she can continue warfarin without dose adjustment and the tooth can be extracted while taking measures to minimise bleeding.