Fall, 2008
Alert for Patients Taking Bisphonates (Osteoporosis Medications)
Dear Patients:
We have received many calls from concerned patients regarding recently released news articles concerning Fosamax and several other drugs that treat low bone density osteoporosis. There are likely to be many more such articles in the near future.
Fosamax belongs to a class of "bone building" drugs called bisphosphonates, which fall into two general categories. The oral drugs include Fosamax, Boniva and Actonel. The IV drugs include Zomeda and Aredia.
First the IV drugs; they are primarily used to treat bone metastasis in patients with different types of cancer like multiple myeloma, breast cancer metastases, etc. Very few patients on these drugs have demonstrated the complication of osteonecrosis of the jaw. Osteonecrosis means that a section of the jawbone becomes infected and is "pushed out" of the gum. This is a problem that so far has no effective treatment. It is also rare, although it may occur in 10-15% of patients who receive these IV medications. The osteonecrosis can be triggered be any oral surgery including tooth extraction, implant placement or periodontal surgery. It can also be triggered by a poorly fitting denture with associated denture sores. Sometimes, it can happen spontaneously without any obvious cause. Patients on IV bisphosphonate drugs should avoid dental surgery including implant placement. It should be noted that these patients also have a serious underlying disease. It is vitally important that patients undergoing treatment of cancer with these drugs have a thorough dental evaluation before they start their cancer treatment.
The oral drugs are a different story as they are not nearly as potent as the IV drugs. There have only been a few cases of osteonecrosis on patients taking these drugs described in dental and medical journals.
Regardless, we have to admit that there is an increased risk for complications from oral surgical procedures for patients on oral bisphosphonates. Critically looking at our patient base over the last five years, we cannot identify a problem with osteonecrosis. We think that long-term administration (greater than three to five years) of the drug may increase the risk of complications. You should know that we have seen hundreds of patients on oral bisphosphonates who have had dental surgical procedures during that time, so our experience with complications has been negligible.
For now, we have to operate under the assumption that IV bisphosphonates are a true contraindication to treatment. On the other hand, oral bisphosphonates should be viewed as a relative contraindication, much like cigarette smoking, diabetes, hypertension or steroid use. Patients should certainly be informed that use of these particular drugs could be associated with a complication, but certainly do not predispose one. Again, from our experience, that means that it probably adds less than 0.1% risk to a procedure. We will factor bisphosphonate use into our evaluation of a patient prior to making treatment recommendations. If a person smokes, is a poorly controlled diabetic and is also taking a bisphosphonate drug, we may recommend against treatment, at least until other factors are improved. If a patient does not need to take the bisphosphonates, they may be able to lower their complication risk by discontinuing it for several months. Again, we don’t really know how long someone has to go off the drug in order to reduce their risk. Some sources have suggested over ten years. Any alteration in your medications should be discussed with your prescribing physician.
Please feel free to discuss your concerns with us or call your prescribing physician.
Barry F Sukoneck, DDS, FAGD
Richard S Wilson, DMD FAGD
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