What is the effect of stopping Fosamax (alendronate) for nine months in a 69-year-old female with osteoporosis prior to dental surgery?

From the Guidelines

Stopping Fosamax (alendronate) for nine months in a 69-year-old female with osteoporosis for dental surgery is generally not recommended unless absolutely necessary. A temporary discontinuation of 2-3 months before major dental surgery like tooth extraction or implant placement may be sufficient to reduce the risk of medication-related osteonecrosis of the jaw (MRONJ), a rare but serious complication 1. For routine dental work, stopping Fosamax is typically unnecessary. After nine months without treatment, there could be a gradual loss of bone mineral density and increased fracture risk, as the protective effects of bisphosphonates diminish over time. Fosamax works by inhibiting bone resorption by osteoclasts, and while some medication remains in bone for years, its active effects decrease progressively after discontinuation.

Some key points to consider:

• The risk of MRONJ increases with frequency, dose, and duration of bisphosphonate administration, but can be reduced with appropriate screening prior to treatment and modification of dental care 1.
• The decision to stop Fosamax should always be made jointly between the patient's dentist, oral surgeon, and the physician managing the osteoporosis treatment, weighing the risks of MRONJ against the risks of worsening osteoporosis and potential fractures.
• Bisphosphonates, such as alendronate, are first-line treatment for osteoporosis and have been shown to reduce the risk of vertebral, non-vertebral, and hip fractures 1.
• If the medication has been stopped for dental work, it should be resumed as soon as possible after adequate healing has occurred, typically 2-3 months post-procedure.

It's essential to prioritize the patient's overall health and consider the potential consequences of stopping Fosamax for an extended period. The most recent and highest-quality study recommends bisphosphonates as first-line treatment for osteoporosis, highlighting their effectiveness in reducing fracture risk 1. Therefore, stopping Fosamax for nine months is not recommended unless absolutely necessary, and a temporary discontinuation of 2-3 months may be sufficient to reduce the risk of MRONJ.

From the FDA Drug Label

In patients with postmenopausal osteoporosis treated with alendronate sodium 10 mg/day for one or two years, the effects of treatment withdrawal were assessed. Following discontinuation, there were no further increases in bone mass and the rates of bone loss were similar to those of the placebo groups

The effect of stopping Fosamax (alendronate) for nine months in a 69-year-old female with osteoporosis prior to dental surgery is that bone loss will occur at a rate similar to that of the placebo group. After discontinuation of alendronate, there will be no further increases in bone mass. 2

From the Research

Effect of Stopping Fosamax (Alendronate) on Osteoporosis

• The effect of stopping Fosamax (alendronate) for nine months in a 69-year-old female with osteoporosis prior to dental surgery is not directly addressed in the provided studies.
• However, the studies suggest that the risk of bisphosphonate-related osteonecrosis of the jaw (BRONJ) is associated with the duration of bisphosphonate use, and that stopping the medication may not completely eliminate the risk 3, 4, 5, 6, 7.
• A case report found that a patient developed BRONJ after receiving mandibular dental implants 5 months after discontinuing alendronic acid (Fosamax) 3.
• Another study reported a case of a patient showing osteonecrosis of the jaw associated with the use of oral bisphosphonates after tooth extractions, and the patient was treated through the suspension of the alendronate with the removal of the necrotic tissue and the foci of infection 5.
• A nationwide user-only cohort study found that long-term and compliant use of alendronate are associated with an increased risk of surgically treated osteonecrosis of the jaw (ONJ) 7.

Risk Factors for BRONJ

• The studies identify several risk factors for BRONJ, including:
  • Duration of bisphosphonate use 4, 7
  • Route of administration (oral vs. intravenous) 4
  • Oral surgical procedures performed 4, 5, 6
  • History of rheumatoid disorders 7
  • Use of proton pump inhibitors 7
• The American Association of Oral and Maxillofacial Surgeons protocols for suspension of presurgical oral bisphosphonates were followed in one case, but the patient still developed BRONJ after implant surgery 3.