Tooth Extractions in Intravenous Bisphosphonate-Treated Patients: A Refined Protocol Matteo Scoletta, DDS, * Valentina Arata, DDS,y Paolo G. Arduino, DDS, MSc,z Ennio Lerda, DDS,x Andrea Chiecchio, PhD,jj Giorgia Gallesio, DDS,{ Crispian Scully, CBE,# and Marco Mozzati, MD ** Purpose: The aim of this prospective hospital-based study was to refine a surgical protocol for tooth ex- tractions in patients with a history of intravenous use of a potent bisphosphonate by modifying a previously reported protocol to produce a significantly shortened operating time. Patients and Methods: Prospective patients with a follow-up of at least 4 months were included. Tooth extractions were performed without a vestibular split-thickness flap; healing was stimulated by filling the extraction site with autologous plasma rich in growth factors (PRGF System, BTI Biotechnol- ogy Institute, Vitoria, Spain). Local and systemic infection control was obtained with dental hygiene and antibiotic therapy. Results: Sixty-three patients participated in the study. Two hundred two tooth extractions were per- formed. Differences between the present and previous protocols (the previous protocol used a vestibular flap) were analyzed and the surgical time proved significantly shorter for the present approach (P = .00). Conclusions: The proposed surgical protocol appears to be a better choice for patients treated with in- travenous bisphosphonates who need tooth extraction, because it seems to be faster and simpler than the previously reported successful protocol. Ó 2013 American Association of Oral and Maxillofacial Surgeons J Oral Maxillofac Surg 71:994-999, 2013 Bisphosphonates (BPs) are a commonly used class of drugs effective in the prevention and treatment of postmenopausal osteoporosis and Paget disease. They are also used intravenously in the prevention and treatment of bone metastasis associated with solid malignant tumors and multiple myeloma. BP-related osteonecrosis of the jaws (BRONJ) is the term frequently used to describe a complication in a subset of patients receiving this medication, mainly in those receiving intravenous BPs. 1-4 BRONJ has been described as an avascular area of necrotic bone in the maxillofacial area, with or without exposed bone, that has been evolving for longer than 8 weeks in patients without a history of irradiation in the maxillofacial region. 4-6 Potential risk factors asso- ciated with the development of BRONJ include, above all, a history of recent dentoalveolar trauma, the intravenous use of a potent BP (eg, zoledronic acid), and long duration of BP exposure. 7,8 The authors’ previously published successful surgi- cal extraction protocol for patients treated with intra- venous BPs 9 includes a vestibular flap (initially full Received from the University of Turin, Turin, Italy. *Consultant, Oral Surgery Section, Department of Biomedical Science and Human Oncology. yConsultant, Oral Surgery Section, Department of Biomedical Science and Human Oncology. zAcademic Researcher, Oral Medicine Section, Department of Biomedical Science and Human Oncology. xTrainer, Oral Surgery Section, Department of Biomedical Science and Human Oncology. jjTechnician, Faculty of Mathematics, Physics, and Natural Science. {Consultant, Oral Surgery Section, Department of Biomedical Science and Human Oncology. #World Health Organization Collaborating Center for Oral Health and General Health, Bristol, United Kingdom. **Private Practitioner, Turin, Italy. Address correspondence and reprint requests to Dr Arduino: Department of Biomedical Science and Human Oncology, University of Turin, Oral Medicine Section, Unito Lingotto Dental Institute, Via Nizza 230, 10126 Turin, Italy; e-mail: paologiacomo.arduino@ unito.it Ó 2013 American Association of Oral and Maxillofacial Surgeons 0278-2391/13/00050-5$36.00/0 http://dx.doi.org/10.1016/j.joms.2013.01.006 994