Dental Bisphosphonate Awareness Guide

I’m writing today about a subject I feel is under-addressed in medical professions, with a significant amount of potential. This subject pertains to bisphosphonate therapy, and I want this information to reach you from the perspective of a dentist who treats some of the complications you may not see firsthand.

Generally speaking, bisphosphonates hold a tremendous amount of potential preserving a person’s bone quality before or after the onset of osteoporosis, allowing them to avoid a fracture during a fall which could otherwise be debilitating or fatal. For these circumstances or others involving complex pathology, bisphosphonates have become a standard treatment modality.

Although these drugs preserve bone, they create a significant risk for patients with dental problems. This is because teeth are the only osseous component of the body which have a direct communication from the exterior to the interior. As such, if a patient loses a tooth or experiences a dental infection destroying bone in the jaws, the site would be challenged to fill with bone, or heal entirely. If a tooth is extracted and bone cannot fill the socket in a proper amount of time, the patient may develop an unhealing wound between the oral cavity and the inner part of the jaw bone. This can lead to bone death, or osteonecrosis, which then spreads, consuming more bone. This complication is known as Medication Related Osteonecrosis of the Jaw, or “MRONJ”. MRONJ can also come from antiosteopirotic drugs such as the RANK ligand inhibitor Denosumab, or some antiangiogenic drugs.

MRONJ ranges from minor to serious complications such as damage and/or death to hard and soft tissue in the skull, tooth and/or bone loss, physical impairment, and in some cases, potential life threatening complications, such as the rampant expansion of dying bone, which can be fatal. For bisphosphonate-related complications, additional treatment and specialty referral is necessary, which may include debridement, hyperbaric oxygen therapy, or the surgical removal and/or resection of jaw bone. There is the potential for additional financial expenditures being necessary, which may be drastic in scale, in some cases exceeding six figures.

Even if the surgical sites are covered directly with soft tissue from a surgical flap, bone death may still expand beneath the approximated site, and worse, it can be undetectable for long periods of time. In some cases, necrosis can spread and be unstoppable.

Additionally, because drugs such as bisphosphonates suppress bone turnover, bone becomes brittle and unable to repair physiologic micro fractures. This is particularly relevant in the jaw bones, because micro fractures occur with routine activity such as chewing, or from damage due to sudden impact. When a tooth is lost or several teeth, the jaw bone also shrinks dramatically in the area, and this can further heighten the risk.

There is a 0.1% chance of developing MRONJ if oral bisohosphonates are used for under the first two years, and a 2-4% chance if an IV bisphosphonate is used for more than only two months. The risk goes up as the drug is taken longer. The risk is further heightened in cases with diabetes mellitus, cancers or tumors, immunosuppressives, or radiation therapy to the jaw.

In dental surgery, such complications lead to some of the few conditions we may not have the ability to stop, and these complications are capable of defying recovery expectations and risking death if not managed properly. The way in which these cases are planned is by having a dentist assess a patient prior to the initiation of bisphosphonate therapy, and to provide what is called “dental clearance” for care.

To be a good candidate for bisphosphonate therapy, a patient is to have:
– A Comprehensive Oral Examination (COE), which is a complete dental exam
– The removal of all non-restorable or questionable teeth
– Sound periodontal health through treatment of gum disease or bone loss around affected teeth
– All dental cavities treated so teeth do not carry a questionable prognosis or reach non-restorable conditions

The good news is most of these complications are easily avoidable with proper dental involvement, and many situations involving MRONJ result from a patient taking the medication without dental clearance or dental treatment to carry a good prognosis.

I hope this information serves you well and complements the steps you take to ensure good health. Please consider this letter as a resource when it comes to preparing for bisphosphonate therapy, and if you wish to include me as a provider in this process, I am happy to do so.