In the last two decades, the use of bisphosphonates has increased significantly. So has our understanding of
their benefits and risks. In the dental world, there is growing recognition of an association with osteonecrosis of the jaw, most often in the wake of a traumatic dental procedure.
Bisphosphonates have been available since the 19th century but it’s only since the 1990s, with the advent of Fosamax for the treatment of osteoporosis (thinning of the bones) that they have become more widely prescribed. They are an antiresorptive medication and their role is to increase bone thickness and lower the risk of fractures.
Osteoporosis affects roughly 3m people in the UK and of that number, 230,000 people suffer related fractures. The majority of patients taking bisphosphonates are postmenopausal women. However, they are additionally prescribed for cancer patients, to lower calcium levels, treating hypercalcaemia and bone deposits. More rarely, they
Bisphosphonates and endodontics are taken by children with a bone fragility syndrome.
While bisphosphonates undoubtedly reduce the risk of older people being admitted to hospital with hip fractures, there is growing evidence for dental implications.
In patients taking a bisphosphonate medication, osteonecrosis of
the jaw (ONJ) can occur after an extraction or after surgical procedures. It’s not known why the osteonecrosis
presents in the jaw and not in other parts of the skeleton. As yet, there have been no RCTs so our knowledge is based on a retrospective analysis of case reports and expert opinion.
It is clear that IV administration of bisphosphonates carries a higher risk than oral administration. However, the guidelines of the American Association of.
Due to the absence of any RCTs, the AAE convened a committee to investigate the effect of bisphonsophonates. On the basis of the committee’s work, the AAE released some recommendations for endodontists and other dental professionals.
The association suggests that preventive procedures to reduce the risk of ONJ should be adopted.
Preventive care might include:
? caries control,
? conservative periodontal and restorative treatments,
? non-surgical endodontic treatment of teeth that otherwise would be extracted.
The AAE recommends that teeth with extensive carious lesions might be treated by non-surgical endodontic therapy, possibly followed by crown resection and restoration.
Meanwhile, for patients at higher risk of developing bisphosphonate-related ONJ, surgical procedures such as tooth extractions, endodontic surgical procedures or placement of dental implants should be avoided if possible. Patients at higher risk for bisphosphonate-related ONJ include those patients taking IV bisphosphonates.
Use the entire health care team, including the patient’s oncologist and oral surgeon, when developing treatment plans for these patients.
Patients taking oral bisphosphonates are considered to be lower risk. Appropriate clinical procedures for this group might include caries control, appropriate periodontal and restorative treatments and patient education about the symptoms of bisphosphonate-related ONJ and their low risk for developing ONJ from surgical or soft tissue procedures.
In conclusion, by stepping in early to save a tooth, we can help patients whose health is compromised by cancer or those suffering from osteoporosis take their medication with reduced risk of ONJ.
References available on request
Key points
? Recognise the risk factors of bisphosphonate-related ONJ.
? IV administration of bisphosphonates carries a higher risk than oral
administration – but the AAE says all patients taking the medication should
be considered at some risk.
? Preventive care is recommended – this might include caries control,
conservative periodontal and restorative treatments and, similar to
the management of the patient with osteoradionecrosis, non-surgical
endodontic treatment of teeth that might otherwise be extracted.
? Use the entire health care team, including the patient’s oncologist and
oral surgeon, when developing treatment plans for these patients.
References available on request.