What are the considerations for a 41-year-old patient on Risedronate (bisphosphonate) and steroid (corticosteroid) undergoing tooth extraction?

From the Guidelines

For a 41-year-old patient on risedronate and corticosteroids undergoing tooth extraction, careful management is essential to minimize complications, and the dentist should consult with the patient's physician before proceeding with the extraction, considering a drug holiday of 2 months before and after the extraction if medically feasible, as recommended by recent guidelines 1. The patient's history of risedronate and corticosteroid use increases the risk of osteonecrosis of the jaw (ONJ) and delayed healing.

• Key considerations include:
  • The duration of risedronate use: patients on oral bisphosphonates for less than 4 years without additional risk factors may proceed with routine dental procedures without discontinuation of the medication.
  • The use of corticosteroids: which increases the risk of ONJ and delayed healing.
  • The need for a drug holiday: consider a 2-month drug holiday before and after the extraction if medically feasible.
  • Prophylactic antibiotics: may be recommended to reduce infection risk, such as amoxicillin 500mg three times daily starting 1 day before extraction and continuing for 5-7 days.
  • Minimal trauma extraction: perform the extraction with minimal trauma, using primary wound closure and avoiding extensive flap elevation.
  • Excellent oral hygiene: maintain excellent oral hygiene, using chlorhexidine mouthwash (0.12%) twice daily for 2 weeks post-extraction.
  • Close follow-up: necessary to monitor healing and watch for signs of medication-related ONJ, including exposed bone, pain, or infection, as highlighted in recent studies 1. It is crucial to weigh the benefits and risks of each approach, considering the patient's individual risk factors and medical history, to minimize complications and ensure optimal outcomes, as emphasized in the latest guidelines 1.

From the FDA Drug Label

5.4 Jaw Osteonecrosis Osteonecrosis of the jaw (ONJ), which can occur spontaneously, is generally associated with tooth extraction and/or local infection with delayed healing, and has been reported in patients taking bisphosphonates, including risedronate Known risk factors for osteonecrosis of the jaw include invasive dental procedures (for example, tooth extraction, dental implants, boney surgery), diagnosis of cancer, concomitant therapies (for example, chemotherapy, corticosteroids, angiogenesis inhibitors), poor oral hygiene, and co-morbid disorders (for example, periodontal and/or other pre-existing dental disease, anemia, coagulopathy, infection, ill-fitting dentures). The risk of ONJ may increase with duration of exposure to bisphosphonates. For patients requiring invasive dental procedures, discontinuation of bisphosphonate treatment may reduce the risk for ONJ. Clinical judgment of the treating physician and/or oral surgeon should guide the management plan of each patient based on individual benefit/risk assessment Patients who develop ONJ while on bisphosphonate therapy should receive care by an oral surgeon. In these patients, extensive dental surgery to treat ONJ may exacerbate the condition. Discontinuation of bisphosphonate therapy should be considered based on individual benefit/risk assessment [see Adverse Reactions (6.2)].

Considerations for a 41-year-old patient on Risedronate and steroid undergoing tooth extraction:

• The patient is at risk for osteonecrosis of the jaw (ONJ) due to the use of bisphosphonates (Risedronate) and concomitant corticosteroid therapy.
• The risk of ONJ may increase with the duration of exposure to bisphosphonates.
• Discontinuation of bisphosphonate treatment may reduce the risk for ONJ in patients requiring invasive dental procedures, such as tooth extraction.
• Clinical judgment should guide the management plan, considering individual benefit/risk assessment.
• Patients who develop ONJ while on bisphosphonate therapy should receive care by an oral surgeon.
• Extensive dental surgery to treat ONJ may exacerbate the condition, and discontinuation of bisphosphonate therapy should be considered based on individual benefit/risk assessment 2.

From the Research

Considerations for Tooth Extraction

• For a 41-year-old patient on Risedronate (bisphosphonate) and steroid (corticosteroid) undergoing tooth extraction, several considerations must be taken into account 3, 4, 5, 6, 7.
• The patient's use of bisphosphonates, such as Risedronate, increases the risk of osteonecrosis of the jaw (ONJ), a condition characterized by the death of bone tissue in the jaw 3, 6, 7.
• Corticosteroid intake, in combination with bisphosphonate use, may further increase the risk of ONJ 4.
• The risk of ONJ is higher in patients with multiple risk factors, such as older age, longer duration of bisphosphonate therapy, and presence of comorbidities 5, 6, 7.

Risk Factors and Complications

• Multi-rooted teeth are at higher risk for ONJ than single-rooted teeth 4.
• Bone sequestrum is a radiographic indicator of osteonecrosis 4.
• Delayed healing of the surgical wound is a possible complication in patients treated with oral bisphosphonates 7.
• The duration of exposure to oral bisphosphonates influences the onset of complications, with longer treatment durations associated with higher risk 7.

Management and Prevention

• Meticulous oral hygiene and surgical procedures prior to commencing bisphosphonate treatment are important for preventing ONJ 6.
• A standardized surgical extraction protocol and antibiotic therapy may help reduce the risk of ONJ in patients undergoing tooth extraction while on bisphosphonate therapy 5.
• The use of antibiotics and antiseptics, as well as a surgical procedure as little traumatic as possible, can help manage ONJ and promote healing 5.