Drugs Used to Treat Osteoporosis and Bone Cancer Perio & Implant Centers The Team for of the Monterey Bay (831) 648-8800 Jochen P. Pechak, DDS, MSD in Silicon Valley (408) 738-3423 Which May Cause Osteonecrosis of the Jaws mobile: www.DrPechakapp.com he many bisphosphonates and monoclonal antibodies which are used to treat osteoporosis and bone cancer often web: GumsRus.com causeDrugsDrugs osteonecrosis Used Used of the to jaws.to Treat AsTreat dental clinicians,Osteoporosis Osteoporosis it is important that and andwe are Bone awareBone of this Cancers Cancers side effect before Ttreating our patients who are taking these drugs. The tables below summarize these drugs, the route these drugs are administered, andWhich Whichtheir likelihood May May of causing Cause Cause osteonecrosis Osteonecrosis Osteonecrosis of the jaws as reported byof of Dr. the theRobert Jaws JawsMarx at the University of Miami Division of Oral and Maxillofacial Surgery. PDL tm Osteoporosis Drugs Drugs Osteoporosis Used to Treat Drugs Osteoporosis PerioDontaLetter Jochen P. Pechak, DDS, MSD, Periodontics and Implant Dentistry Spring DrugDrug ClassificationClassification ActionAction DoseDose RouteRoute %% of of ReportedReported CasesCases of of OsteonecrosisOsteonecrosis AlendronateAlendronate BisphosphonateBisphosphonate OsteoclastOsteoclast 7070 mg/wk mg/wk OralOral 8282%% From Our Office A Concise Guide to Treating (Fosamax(Fosamax ToxicityToxicity to Yours... Generic)Generic) Painful Oral ResidronateResidronate BisphosphonateBisphosphonate OsteoclastOsteoclast 3535 mg/wk mg/wk OralOral 1%1% As dentists specializing in treat- (Actonel Toxicity (Actonel Toxicity ment of diseases of the oral cavity atients present frequently with Treating Cold Sores Atelvia)Atelvia) and associated structures, we are painful oral lesions. They are often also called upon to treat pain- IbandronateIbandronate BisphosphonateBisphosphonate OsteoclastOsteoclast 150150 mg/mos mg/mos OralOral 1%1% usually not serious, but patients And Canker Sores (Boniva) Toxicity IV ful oral lesions in the mouth. This P appreciate our attention to them, our (Boniva) Toxicity IV issue of The PerioDontaLetter con- ZoledronateZoledronate BisphosphonateBisphosphonate OsteoclastOsteoclast 55 mg/ mg/yryr IVIV 66%% reassurance they are not serious, and If the sore is on the , it is (Reclast) Toxicity tains guidelines on how to treat caused by a herpes virus infection (Reclast) Toxicity these common oral lesions. specific prescriptions for treatment. DenosumabDenosumab MonoclonalMonoclonal OsteoclastOsteoclast 6060 mg/6 mg/6 SubcutaneousSubcutaneous 1010%% There is usually no cure, but there are and is contagious. These are (Prolia) Antibody Impairment mos The back page of this issue con- (Prolia) Antibody Impairment mos tains a table summarizing the con- treatments that shorten their duration commonly called “cold sores” or Teriparatide (Forteo) and raloxifene (Evista) are also used to treat osteoporosis but work differently so TeriparatideTeriparatide (Forteo) (Forteo) and raloxifene and ralox (Evista)ifene (Evista) are also used are alsoto treat used osteoporosis to treat osteoporosisbut work differently, but work so they differently don’t cause so fusing array of bisphosphonates and reduce the pain. Some of these “fever blisters.” Patients should osteonecrosisthey don’t andcause no specialosteonecrosis precautions and are no necessary. special precautions are necessary. avoid touching them and then they don’t cause osteonecrosis and no special precautions are necessary. and monoclonal antibodies which are recurrent and others are self- are used to treat osteoporosis and induced such as trauma touching their eyes since the herpes DrugsDrugsDrugs Used Used Used to Treatto to Treat Treat Bone BoneCancer Bone Cancer Cancer bone cancer. This table includes the and burns from hot foods. virus can spread to the eye and then route these drugs are administered, Always be mindful of looking for is much more difficult to treat. Drug Classification Action Dose Route % of Drug Classification Action Dose Route % of and their likelihood of causing , and any Treatment: Over the counter Reported Reported drug-induced osteonecrosis of the suspicious . Abreva crème applied five times a CasesCases of of jaws — a side effect which we clini- OsteonecrosisOsteonecrosis cians need to be aware of in treat- ZoledronateZoledronate BisphosphonateBisphosphonate OsteoclastOsteoclast 44 mg/mo mg/mo IVIV 67%67% ing our patients who are taking (Zometa) Toxicity these drugs. Figure 1. (Zometa) Toxicity Recurrent apthous Pamidronate Bisphosphonate Osteoclast 90 mg/mo IV 18% We hope you find this information Pamidronate Bisphosphonate Osteoclast 90 mg/mo IV 18% ulcers occur on (Aredia) Toxicity helpful. (Aredia) Toxicity moveable oral Bevacizumab Monoclonal VEGF 100-400 IV <1% As always, we welcome your Bevacizumab Monoclonal VEGF 100-400 IV <1% comments and questions. mucosa inside the (Avastin)(Avastin) AntibodyAntibody InhibitorInhibitor mg/mg/ 14 14 days days mouth and are not SunitinibSunitinib TyrosineTyrosine Kinase Kinase OsteoclastOsteoclast 55 mg/yr mg/yr IVIV <1%<1% contagious. (Sutent)(Sutent) InhibitorInhibitor ToxicityToxicity DenosumabDenosumab MonoclonalMonoclonal OsteoclastOsteoclast 120120 mg/mo mg/mo IVIV 15%15% (Xgeva)(Xgeva) AntibodyAntibody InhibitorInhibitor

PDL tm

21 Upper Ragsdale Drive • Monterey, CA 93940 • (831) 648-8800 • [email protected] 21 Upper Ragsdale Drive • Monterey, CA 93940 • (831) 648-8800 • [email protected] Jochen P. Pechak, DDS, MS Jochen P. Pechak, DDS, MS 516 Remington Drive, Suite 5A • Sunnyvale, CA 94087 (408) 738-3423 • [email protected] 516 Remington Drive, Suite 5A • Sunnyvale, CA 94087 (408) 738-3423 • [email protected] Diplomate, American Board of Diplomate, American Board of Periodontology mobile: DrPechakapp.com • web: www.GumsRus.com • Dr. Pechak’s direct email: [email protected] mobile: DrPechakapp.com • web: www.GumsRus.com • Dr. Pechak’s direct email: [email protected] day will shorten their duration. Over ” containing Benadryl, severe cases, a steroid called the counter Carmex applied Maalox, and viscous xylocaine will Clobetasol 0.05% (15gm tube) can be at the first tingle will help the pain. reduce pain dramatically. For larger prescribed and applied with a Q-tip Valtrex can be prescribed — two outbreaks, the steroid dexamethasone twice daily. Alternatively, dexa- grams in the morning and two grams can be added to the mixture. These methasone elixir 0.5mg/ml (12 oz. in the evening — taken at the first sign mixtures are compounded by a local bottle) can be used as a rinse, one of an outbreak. Zovirax or Denavir pharmacist. Alternatively, prescription tablespoon for two minutes four times ointments can also be prescribed, but dexamethasone elixir alone, 0.5mg/ per day. In severe cases, this rinse can are very expensive ($800-$900 per ml, can be used as a rinse – one be used in combination with Clobetasol tube) and often not covered by medical tablespoon for two minutes four times gel. For Desquamative , a day – or OTC Rincinol can be used insurance. A local compounding doxycycline 100 mg once a day for 30 Figure 4. Herpes virus infection Figure 5. Erosive Figure 6. Oral Cancer occurs as a rinse to coat the lesions. pharmacist can make up a much less days has been found very useful. occurs on the lip and is occurs on the cheeks or most commonly on the base of expensive generic version of Zovirax These conditions are a sometimes- contagious. Primary herpes and is characterized by white the tongue or in the throat. (5.5% acyclovir ointment). Treating Generalized painful annoyance, but are not serious infection occurs inside the mouth. striations. Early diagnosis is critical. Painful Ulcerations and recurrence is common. If not The most common sore inside the painful, no treatment is needed. mouth is an apthous ulcer, commonly More generalized, or occasionally Treating Yeast solve in the mouth five times a day a sexually transmitted virus which is Primary Herpes Infection will called a “canker sore.” These are not localized, blood-filled erosive lesions for 14 days. An alternative is Nystatin causing throat cancer in younger sometimes occur, most often in Infections viral, occur on movable tissue like the with the tissue sloughing (Nikolsky’s oral (100,000 units/ people. Testing positive for HPV16 tongue or cheeks, and are not children, but occasionally in adults. ml-dispense 240 ml), take one means you are at greater risk of throat sign) sometimes form on the and Sores on the corners of the mouth contagious. The cause is unknown and cheeks. These are usually caused by This infection is characterized by very teaspoon and swish for two minutes, cancer and need to be monitored more are called Angular and cause they tend to recur. (Benign painful ulcers throughout the then swallow, four times a day. For closely. These cancers occur most pain when opening and closing the Treatment for individual sores Mucous Membrane ). mouth, including the gums and throat. more severe yeast infections, Diflucan commonly on the base of the tongue mouth. These sores are usually caused includes application of over-the- Generalized or localized painful It is often accompanied by fever, 100 mg can be prescribed -- 15 or in the throat, so these areas need to by a yeast infection (Candida albicans) counter (OTC) Zilactin B, Canker-X, erosive lesions on the cheeks or tongue swollen lymph nodes, difficulty eating tablets, take two tablets, then one be examined thoroughly during an secondary to wear or loss of teeth. The Orajel with benzocaine, or prescription characterized by white striations are and fatigue. The outbreak usually lasts daily for 13 days. oral cancer examination. A simple loss of teeth in turn causes overclosure Orabase with the steroid Kenalog. caused by Erosive Lichen Planus. from seven to 14 days and then goes salivary DNA test can determine if a of the mouth, creating a crease at the These coat and numb the lesion. The These are both considered auto- away on its own. It is a very painful, Diagnosing patient is HPV positive. The Centers prescription steroid ointment Lidex is immune diseases, and treatment is but not a serious condition. It is corners of the mouth where saliva for Disease Control recommends that another possibility. In office, Debacterol palliative not curative. contagious during the outbreak. accumulates. Oral Cancer all boys and girls between the ages of can be applied which will cauterize the Treatment: An anti-oxidant gel Treatment: prescription Valtrex, Treatment of : 12 and 26 be vaccinated against lesion and reduce the pain. called PerioSciences AO ProVantage 500 mg, take two caplets twice daily Patients should avoid licking the area Lesions that may be oral cancer HPV16, ideally prior to sexual For multiple canker sores, Antioxidant Gel can be applied five for five days. Treatment with the with their tongue. They should keep include a sore in the mouth that exposure to the virus. treatment with the so-called “Magic times a day for mild cases. For more so-called “Magic Mouthwash” the corners of their mouth dry by doesn’t heal, a lump that does not go Oral cancer kills more people containing Benadryl, Maalox and dabbing frequently with a facial tissue. away, a white patch anywhere in the annually than cervical or prostate viscous xylocaine will reduce pain Prescription Mycolog-II ointment is mouth, difficulty swallowing, or a cancer. Oral cancer has only a five dramatically. Chloraseptic spray can then applied four times a day until swollen lymph node in the neck. The percent survival rate at five years. If numb the tissue before eating. healing occurs. Alternatively, OTC gold standard is to biopsy any found early, survival increases dra- Monostat 7 vaginal can be suspicious lesion. Sometimes, a matically, so any suspicious lesion Vulgaris causes more applied four times a day. special fluorescent light can be used should be examined, and possibly serious, diffuse, very painful to help screen for cancer and biopsied, as soon as noticed. ulcerations throughout the mouth, and Inside the mouth, yeast infection is determine if a biopsy is indicated. on the skin, and requires a special usually characterized by white patches Risk factors for oral cancer are Conclusion immunofluorescent biopsy to dia- that often can be scraped off. , excessive alcohol con- gnose. Fifty percent of patients with Occasionally, it shows up as red sumption, and especially chewing We have reviewed the diagnosis and this condition present first with oral patches, or as a black, hairy tongue. tobacco or snuff. Chewing tobacco management of the most common Figure 2. Desquamative Figure 3. Histological section lesions before the onset of skin lesions This infection is usually caused by increases the risk of oral cancer by a painful oral lesions that you will Gingivitis produces generalized reveals separation of the resembling a burn. prolonged antibiotic use, steroid staggering 50 times. Stopping any of encounter in daily practice. We hope blood-filled erosive lesions with epithelium due to lack of Treatment: This is a serious condi- inhalants, or lowered immune system. these habits will substantially reduce this information will assist you in their tissue sloughing (Nikolsky’s adhesion along the basement tion and requires management by a Treatment of yeast infections the risk of oral cancer. diagnosis and treatment. sign). membrane. dermatologist, often with systemic inside the mouth: Mycelex troche An emerging risk factor is Human steroids. (clotrimazole) 10 mg allowed to dis- Papillomavirus (HPV16) infection,

PerioDontaLetter, Spring day will shorten their duration. Over Mouthwash” containing Benadryl, severe cases, a steroid gel called the counter Carmex lip balm applied Maalox, and viscous xylocaine will Clobetasol 0.05% (15gm tube) can be at the first tingle will help the pain. reduce pain dramatically. For larger prescribed and applied with a Q-tip Valtrex can be prescribed — two outbreaks, the steroid dexamethasone twice daily. Alternatively, dexa- grams in the morning and two grams can be added to the mixture. These methasone elixir 0.5mg/ml (12 oz. in the evening — taken at the first sign mixtures are compounded by a local bottle) can be used as a rinse, one of an outbreak. Zovirax or Denavir pharmacist. Alternatively, prescription tablespoon for two minutes four times ointments can also be prescribed, but dexamethasone elixir alone, 0.5mg/ per day. In severe cases, this rinse can are very expensive ($800-$900 per ml, can be used as a rinse – one be used in combination with Clobetasol tube) and often not covered by medical tablespoon for two minutes four times gel. For Desquamative Gingivitis, a day – or OTC Rincinol can be used insurance. A local compounding doxycycline 100 mg once a day for 30 Figure 4. Herpes virus infection Figure 5. Erosive Lichen Planus Figure 6. Oral Cancer occurs as a rinse to coat the lesions. pharmacist can make up a much less days has been found very useful. occurs on the lip and is occurs on the cheeks or tongue most commonly on the base of expensive generic version of Zovirax These conditions are a sometimes- contagious. Primary herpes and is characterized by white the tongue or in the throat. (5.5% acyclovir ointment). Treating Generalized painful annoyance, but are not serious infection occurs inside the mouth. striations. Early diagnosis is critical. Painful Ulcerations and recurrence is common. If not The most common sore inside the painful, no treatment is needed. mouth is an apthous ulcer, commonly More generalized, or occasionally Treating Yeast solve in the mouth five times a day a sexually transmitted virus which is Primary Herpes Infection will called a “canker sore.” These are not localized, blood-filled erosive lesions Infections for 14 days. An alternative is Nystatin causing throat cancer in younger viral, occur on movable tissue like the with the tissue sloughing (Nikolsky’s sometimes occur, most often in oral suspension (100,000 units/ people. Testing positive for HPV16 tongue or cheeks, and are not children, but occasionally in adults. ml-dispense 240 ml), take one means you are at greater risk of throat sign) sometimes form on the gums and Sores on the corners of the mouth contagious. The cause is unknown and cheeks. These are usually caused by This infection is characterized by very teaspoon and swish for two minutes, cancer and need to be monitored more are called Angular Cheilitis and cause they tend to recur. Desquamative Gingivitis (Benign painful ulcers throughout the then swallow, four times a day. For closely. These cancers occur most pain when opening and closing the Treatment for individual sores Mucous Membrane Pemphigoid). mouth, including the gums and throat. more severe yeast infections, Diflucan commonly on the base of the tongue mouth. These sores are usually caused includes application of over-the- Generalized or localized painful It is often accompanied by fever, 100 mg can be prescribed -- 15 or in the throat, so these areas need to by a yeast infection (Candida albicans) counter (OTC) Zilactin B, Canker-X, erosive lesions on the cheeks or tongue swollen lymph nodes, difficulty eating tablets, take two tablets, then one be examined thoroughly during an secondary to wear or loss of teeth. The Orajel with benzocaine, or prescription characterized by white striations are and fatigue. The outbreak usually lasts tablet daily for 13 days. oral cancer examination. A simple loss of teeth in turn causes overclosure Orabase with the steroid Kenalog. caused by Erosive Lichen Planus. from seven to 14 days and then goes salivary DNA test can determine if a of the mouth, creating a crease at the These coat and numb the lesion. The These are both considered auto- away on its own. It is a very painful, Diagnosing patient is HPV positive. The Centers prescription steroid ointment Lidex is immune diseases, and treatment is but not a serious condition. It is corners of the mouth where saliva for Disease Control recommends that another possibility. In office, Debacterol palliative not curative. contagious during the outbreak. accumulates. Oral Cancer all boys and girls between the ages of can be applied which will cauterize the Treatment: An anti-oxidant gel Treatment: prescription Valtrex, Treatment of Angular Cheilitis: 12 and 26 be vaccinated against lesion and reduce the pain. called PerioSciences AO ProVantage 500 mg, take two caplets twice daily Patients should avoid licking the area Lesions that may be oral cancer HPV16, ideally prior to sexual For multiple canker sores, Antioxidant Gel can be applied five for five days. Treatment with the with their tongue. They should keep include a sore in the mouth that exposure to the virus. treatment with the so-called “Magic times a day for mild cases. For more so-called “Magic Mouthwash” the corners of their mouth dry by doesn’t heal, a lump that does not go Oral cancer kills more people containing Benadryl, Maalox and dabbing frequently with a facial tissue. away, a white patch anywhere in the annually than cervical or prostate viscous xylocaine will reduce pain Prescription Mycolog-II ointment is mouth, difficulty swallowing, or a cancer. Oral cancer has only a five dramatically. Chloraseptic spray can then applied four times a day until swollen lymph node in the neck. The percent survival rate at five years. If numb the tissue before eating. healing occurs. Alternatively, OTC gold standard is to biopsy any found early, survival increases dra- Monostat 7 vaginal cream can be suspicious lesion. Sometimes, a matically, so any suspicious lesion causes more applied four times a day. special fluorescent light can be used should be examined, and possibly serious, diffuse, very painful to help screen for cancer and biopsied, as soon as noticed. ulcerations throughout the mouth, and Inside the mouth, yeast infection is determine if a biopsy is indicated. on the skin, and requires a special usually characterized by white patches Risk factors for oral cancer are Conclusion immunofluorescent biopsy to dia- that often can be scraped off. smoking, excessive alcohol con- gnose. Fifty percent of patients with Occasionally, it shows up as red sumption, and especially chewing We have reviewed the diagnosis and this condition present first with oral patches, or as a black, hairy tongue. tobacco or snuff. Chewing tobacco management of the most common Figure 2. Desquamative Figure 3. Histological section lesions before the onset of skin lesions This infection is usually caused by increases the risk of oral cancer by a painful oral lesions that you will Gingivitis produces generalized reveals separation of the resembling a burn. prolonged antibiotic use, steroid staggering 50 times. Stopping any of encounter in daily practice. We hope blood-filled erosive lesions with epithelium due to lack of Treatment: This is a serious condi- inhalants, or lowered immune system. these habits will substantially reduce this information will assist you in their tissue sloughing (Nikolsky’s adhesion along the basement tion and requires management by a Treatment of yeast infections the risk of oral cancer. diagnosis and treatment. sign). membrane. dermatologist, often with systemic inside the mouth: Mycelex troche An emerging risk factor is Human steroids. (clotrimazole) 10 mg allowed to dis- Papillomavirus (HPV16) infection,

PerioDontaLetter, Spring Drugs Used to Treat Osteoporosis and Bone Cancer Perio & Implant Centers The Team for of the Monterey Bay (831) 648-8800 Jochen P. Pechak, DDS, MSD in Silicon Valley (408) 738-3423 Which May Cause Osteonecrosis of the Jaws mobile: www.DrPechakapp.com he many bisphosphonates and monoclonal antibodies which are used to treat osteoporosis and bone cancer often web: GumsRus.com causeDrugsDrugs osteonecrosis Used Used of the to jaws.to Treat AsTreat dental clinicians,Osteoporosis Osteoporosis it is important that and andwe are Bone awareBone of this Cancers Cancers side effect before Ttreating our patients who are taking these drugs. The tables below summarize these drugs, the route these drugs are administered, andWhich Whichtheir likelihood May May of causing Cause Cause osteonecrosis Osteonecrosis Osteonecrosis of the jaws as reported byof of Dr. the theRobert Jaws JawsMarx at the University of Miami Division of Oral and Maxillofacial Surgery. PDL tm Osteoporosis Drugs Drugs Osteoporosis Used to Treat Drugs Osteoporosis PerioDontaLetter Jochen P. Pechak, DDS, MSD, Periodontics and Implant Dentistry Spring DrugDrug ClassificationClassification ActionAction DoseDose RouteRoute %% of of ReportedReported CasesCases of of OsteonecrosisOsteonecrosis AlendronateAlendronate BisphosphonateBisphosphonate OsteoclastOsteoclast 7070 mg/wk mg/wk OralOral 8282%% From Our Office A Concise Guide to Treating (Fosamax(Fosamax ToxicityToxicity to Yours... Generic)Generic) Painful Oral Lesions ResidronateResidronate BisphosphonateBisphosphonate OsteoclastOsteoclast 3535 mg/wk mg/wk OralOral 1%1% As dentists specializing in treat- (Actonel Toxicity (Actonel Toxicity ment of diseases of the oral cavity atients present frequently with Treating Cold Sores Atelvia)Atelvia) and associated structures, we are painful oral lesions. They are often also called upon to treat pain- IbandronateIbandronate BisphosphonateBisphosphonate OsteoclastOsteoclast 150150 mg/mos mg/mos OralOral 1%1% usually not serious, but patients And Canker Sores (Boniva) Toxicity IV ful oral lesions in the mouth. This P appreciate our attention to them, our (Boniva) Toxicity IV issue of The PerioDontaLetter con- ZoledronateZoledronate BisphosphonateBisphosphonate OsteoclastOsteoclast 55 mg/ mg/yryr IVIV 66%% reassurance they are not serious, and If the sore is on the lip, it is (Reclast) Toxicity tains guidelines on how to treat caused by a herpes virus infection (Reclast) Toxicity these common oral lesions. specific prescriptions for treatment. DenosumabDenosumab MonoclonalMonoclonal OsteoclastOsteoclast 6060 mg/6 mg/6 SubcutaneousSubcutaneous 1010%% There is usually no cure, but there are and is contagious. These are (Prolia) Antibody Impairment mos The back page of this issue con- (Prolia) Antibody Impairment mos tains a table summarizing the con- treatments that shorten their duration commonly called “cold sores” or Teriparatide (Forteo) and raloxifene (Evista) are also used to treat osteoporosis but work differently so TeriparatideTeriparatide (Forteo) (Forteo) and raloxifene and ralox (Evista)ifene (Evista) are also used are alsoto treat used osteoporosis to treat osteoporosisbut work differently, but work so they differently don’t cause so fusing array of bisphosphonates and reduce the pain. Some of these “fever blisters.” Patients should osteonecrosisthey don’t andcause no specialosteonecrosis precautions and are no necessary. special precautions are necessary. avoid touching them and then they don’t cause osteonecrosis and no special precautions are necessary. and monoclonal antibodies which are recurrent and others are self- are used to treat osteoporosis and induced such as toothbrush trauma touching their eyes since the herpes DrugsDrugsDrugs Used Used Used to Treatto to Treat Treat Bone BoneCancer Bone Cancer Cancer bone cancer. This table includes the and burns from hot foods. virus can spread to the eye and then route these drugs are administered, Always be mindful of looking for is much more difficult to treat. Drug Classification Action Dose Route % of Drug Classification Action Dose Route % of and their likelihood of causing oral cancer, and biopsy any Treatment: Over the counter Reported Reported drug-induced osteonecrosis of the suspicious lesion. Abreva crème applied five times a CasesCases of of jaws — a side effect which we clini- OsteonecrosisOsteonecrosis cians need to be aware of in treat- ZoledronateZoledronate BisphosphonateBisphosphonate OsteoclastOsteoclast 44 mg/mo mg/mo IVIV 67%67% ing our patients who are taking (Zometa) Toxicity these drugs. Figure 1. (Zometa) Toxicity Recurrent apthous Pamidronate Bisphosphonate Osteoclast 90 mg/mo IV 18% We hope you find this information Pamidronate Bisphosphonate Osteoclast 90 mg/mo IV 18% ulcers occur on (Aredia) Toxicity helpful. (Aredia) Toxicity moveable oral Bevacizumab Monoclonal VEGF 100-400 IV <1% As always, we welcome your Bevacizumab Monoclonal VEGF 100-400 IV <1% comments and questions. mucosa inside the (Avastin)(Avastin) AntibodyAntibody InhibitorInhibitor mg/mg/ 14 14 days days mouth and are not SunitinibSunitinib TyrosineTyrosine Kinase Kinase OsteoclastOsteoclast 55 mg/yr mg/yr IVIV <1%<1% contagious. (Sutent)(Sutent) InhibitorInhibitor ToxicityToxicity DenosumabDenosumab MonoclonalMonoclonal OsteoclastOsteoclast 120120 mg/mo mg/mo IVIV 15%15% (Xgeva)(Xgeva) AntibodyAntibody InhibitorInhibitor

PDL tm

21 Upper Ragsdale Drive • Monterey, CA 93940 • (831) 648-8800 • [email protected] 21 Upper Ragsdale Drive • Monterey, CA 93940 • (831) 648-8800 • [email protected] Jochen P. Pechak, DDS, MS Jochen P. Pechak, DDS, MS 516 Remington Drive, Suite 5A • Sunnyvale, CA 94087 (408) 738-3423 • [email protected] 516 Remington Drive, Suite 5A • Sunnyvale, CA 94087 (408) 738-3423 • [email protected] Diplomate, American Board of Periodontology Diplomate, American Board of Periodontology mobile: DrPechakapp.com • web: www.GumsRus.com • Dr. Pechak’s direct email: [email protected] mobile: DrPechakapp.com • web: www.GumsRus.com • Dr. Pechak’s direct email: [email protected]