Referral Patterns of Patients to an Oral and Maxillofacial Surgery Clinic Prior to the Initiation of Antiresorptive Medications and the Associated Workload: Five Year Experience of a VA Medical Center

The Los Angeles Veterans Affairs (VA) Medical Center, in response to the AAOMS’s Bisphosphonate-Related Osteonecrosis of the Jaw (ONJ) 2009 Update, established a special oral surgery clinic to treat patients prior to initiation of antiresorptive medication to reduce ONJ risk. Given that older veterans are likely to be prescribed antiresorptive medications and are known to have suboptimal oral health, we hypothesized a robust clientele in need of exodontia and conservative restorative procedures. In order to develop an accurate resource allocation model for future planning and staffing both locally and nationally, we determined the referral patterns and associated workload over a five year period.

The medical center’s electronic medical record was queried using search criteria: patient demographics, oral surgery consultations, antiresorptive medications, medical specialty, clinician job classification, and co-morbid medical diagnoses within the date range of 2009 – 2013.

During this timeframe, the medical center’s average census was 84,450 unique patients (94.5% male) having a mean age of 66. Each year, the center enrolled approximately 17,000 new patients and simultaneously lost to follow-up, a similar number. Between 2009 and 2013, the clinic received 149 consultations requesting evaluation of patients prior to beginning antiresorptive therapy. These patients were 94% male, 6% female, with a mean age of 69 ±12.

Consultations were most often received from board-certified attending physicians  or their fellows in internal medicine/primary care/women’s health (n = 51, 34%), rheumatology/allergy & immunology (n = 44, 30%), genitourinary oncology/hematology & oncology (n= 24, 16%), endocrinology (n = 11, 7%), and physical medicine & rehabilitation/orthopedics (n=10, 7%). The medical diagnoses most commonly necessitating the oral route of antiresorptive medication administration (n = 91) were osteoporosis/osteopenia (n = 74, 81%) and chronic steroid administration (for: rheumatoid arthritis, autoimmune disease) (n=9, 6%). The most common medical diagnoses requiring intravenous drug therapy (n = 45) were osteoporosis/osteopenia (n=23, 51%), multiple myeloma (n=8, 18%), malignant metastatic bone disease (n=7, 16%), and Paget’s disease (n=4, 9%). Medical diagnoses requiring subcutaneous drug therapy (n = 13) were prostate cancer with bone metastases (n=10, 77%) and osteoporosis/osteopenia (n=3, 23%).

All patients were appointed within 72 hours of consultation, however only 77% (114/149) attended their scheduled clinic visit. Of these, 68 patients required extractions (mean 3.8 teeth, range 1 – 23), with almost one-third requiring  ≥ 11 extractions. Osseous recontouring of the alveolus was conservatively performed for all surgical interventions involving two or more contiguous teeth. A majority (76%) of patients (n= 87) also required immediate general dentistry to restore, an average of 1.6 teeth (range 1 – 23) having carious lesions and faulty restorations.

This is the first study to report the magnitude of previously unmet dental care needs necessitating exodontia to minimize risk of antiresorptive related ONJ among veteran patients. The needs of similar socioeconomically positioned patients in other safety-net healthcare systems have not been previously reported. The referral pattern and work-load documented in this study provides vital data required by health care organization resource allocation methods to develop oral surgical staffing models to assure clinicians adequate treatment opportunities likely to moderate risk. This information will also assist in the development of outreach efforts to those physicians not yet facilitating necessary oral surgery services to their patients. The major limitation of our study, which will be addressed in a future prospective study, is the need to also obtain hospital-wide prescribing data to ascertain extent of missing data.

AAOMS position paper. Ruggiero SL, et al. AAOMS. J Oral Maxillofac Surg. 2009 May;67(5 Suppl):2–12.

Awareness and education of patients receiving bisphosphonates. Bauer JS, et al. J Craniomaxillofac Surg. 2012 Apr;40(3):277-82.