One of the hot topics over the last few years has been managing our patients who are taking bisphosphonates in order to minimize the risk of osteonecrosis of the jaw. When I think about my practice it seems a higher and higher number of my female patients are on medication for osteoporosis or osteopenia. I decided to look this up and sure enough it is estimated that over 80 million Americans are on bisphosphonates. With that large a number and most of those folks being routine dental patients, what do we need to know? Just today I came across a blog post from my friend Dr. Marty Jablow on a recent ADA report for dentists on this topic. The ADA has complied the data and research between 2008 and 2011 on this topic and produced a report designed to help those of us in practice make some sense of this topic. I spent the morning reading the executive summary of the report and I finally feel like I understand what I need to about this issue.
- Be familiar with the brand names of popular medications used to treat osteoporosis and osteopenia, both bisphosphonates and monoclonal antibody therapy. These are alendronate (Fosamax®), alendronate/cholecalciferol (Fosamax® D), risedronate (Actonel®), ibandronate (Boniva®), and zoledronic acid (Reclast®). Denosumab (Prolia®).
- Document patients who are taking any of these medications.
- The risk of developing osteonecrosis of the jaw is relatively low. It is estimated to be 0.1% or 1 case in every 1000 patients.
- An increase risk is associated with specific procedures that increase bone trauma, particularly tooth extractions, age (older than 65 years), periodontitis, use of bisphosphonates for more than 2 years, smoking, denture wearing, diabetes and extensive surgical procedures.
- ONJ can occur spontaneously in patients taking any of these drugs.
- Make sure and discuss the risk with any patients who are taking bisphosphonates or monoclonal antitbody therapy.
In addition the executive summary looked at serum CTX testing to determine patients at risk of ONJ. Their conclusion was that there isn’t enough objective research to support a recommendation for testing in patients who are on these medications. The report also look sat the concept of a “drug holiday”, discontinuing the medication for a period of week to reduce the risk during dental procedures. The summary reports that there is not enough evidence to support this approach.
As a general practitioner the summary reassured me about this topic, whereas up until now I had been uncertain. It reaffirmed for me that the risk from untreated dental disease out weighs the risk of ONJ, and that I can confidently discuss this with my patients so they can chose what is best for them.