Worries Over Bisphosphonates
About five years ago I began to hear about problems women were having with osteonecrosis of the jaw from taking a class of drugs known as bisphosphonates. In some cases the women developed the condition spontaneously. In other cases it resulted subsequent to an extraction or other invasive dental treatment. While this was distressing enough, at the time a predictable course of treatment for this type of osteonecrosis was not agreed upon by medical and/or dental specialists. Now known as BIONJ (bisphosphonate-induced osteonecrosis of the jaws), the condition reveals itself as exposure of bone in a jaw that persists for more than eight weeks.
Bisphosphonates are a category of drug given to persons who are suffering from osteoporosis; a serious condition which is characterized by thinning of bone tissue and loss of bone density over time. Osteoporosis is considered to be the most common type of bone disease. It is estimated that 1 out of 5 women over the age of 50 have osteoporosis, and about half of these women will at some time experience a fracture of the hip, wrist or vertebra. Osteoporosis is believed to result when the body is unable to form sufficient new bone, when too much old bone is reabsorbed - or both.
According to the U.S. National Library of Medicine, the leading causes of osteoporosis are a drop in estrogen in women at the time of menopause (over age 50) or a drop in testosterone in men over age 70. Other causes are chronic rheumatoid arthritis, chronic kidney disease, taking corticosteroid medications every day for more than 3 months, a history of hormone treatment for prostate or breast cancer, low body weight, and too little calcium in the diet. Often persons who have osteoporosis have no symptoms until they develop some type of bone fracture. Since osteoporosis is such a serious condition, drugs to control it have become widely prescribed. Brand names include: Acotonel, Aredia, Boniva, Fosamax, Zometa, Bonefos, Reclast, and Didronel. They may be administered orally or by IV. It has been reported that IV bisphosphonate usage results in a higher chance of BIONJ.
In addition to osteonecrosis, there have been reports of increased risk of femur fractures in women taking a bisphosphonate for more than five years. In fact, law-suits over this complication are ongoing. It is particularly upsetting to discover that a drug designed to strengthen bones actually is implicated as a cause in the fracture of one of the densest bones in the body. The exact opposite of what it is supposed to be doing! According to the literature, Fosamax, one of the most widely prescribed osteoporosis drugs, has been implicated as the oral bisphosphonate most commonly associated with femur fracture.
Some oral surgeons recommend that a person discontinue bisphosphonates for a period of several months prior to undergoing an extraction. Certain blood tests may also reveal if a person is at increased risk for osteonecrosis. The CTX (serum C-terminal telopeptide test) can assess whether an individual might experience problems. It is reported that a result over 150 pg/ml indicates minimal risk following surgery or implant procedures. While 25% of the cases of BIONJ are said to occur spontaneously, 38% have been associated with tooth extraction, 29% with active periodontitis, and 3% with dental implants.
The literature now gives suggestions for treating an established case of BIONJ. Treatment includes the use of chlorhexidine 0.12% mouthrinse to be “swished and spit” at least once daily, a drug holiday (if possible) for at least 6 months, and antibiotics such as penicillin, doxycycline and metronidazole for a period of time. Resolution of 90% of the cases are said to occur following this treatment. Prevention of BIONJ includes a drug holiday of 3-6 months (if the patient can tolerate going off the drug safely) prior to extractions or invasive procedures.
The problem for dental practitioners is two-fold. How do we provide information to our patients about possible problems, and when would it be “safe” to perform an invasive procedure? Some dentists are avoiding all extractions or invasive procedures on anyone taking bisphosphonates. Others are requiring the results of a CTX test and physician opinion prior to these procedures. Some are providing an informed consent form and discussion to anyone taking a bisphosphonate regardless of pending treatment.
With hundreds of women taking Fosamax and other drugs listed in this category, many of our patients may be at risk of developing osteonecrosis either spontaneously or subsequent to a dental procedure. At the very least we need to know, via our medical history questionnaire, which of our patients might be impacted. It is likely that more information will be available in coming years as to the best treatment for this devastating drug complication. Until then, prevention seems the best method to approach the issue.
Carol Tekavec RDH is the director of Hygiene for McKenzie Management. Carol can improve your hygiene department in just one day of training “in your office.” Interested in knowing more about how to improve your hygiene department? Email firstname.lastname@example.org.
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