Is dental clearance required before starting osteoporosis treatment in patients with dental cavities or those needing dental work or dental implants, especially with medications like bisphosphonates (e.g. alendronate, zoledronic acid)?

From the Guidelines

Dental clearance is recommended before starting bisphosphonate therapy for osteoporosis, particularly for patients with active dental disease, pending dental work, or planned implants, to minimize the risk of medication-related osteonecrosis of the jaw (MRONJ). This recommendation is based on the guidelines from the American Society of Clinical Oncology and Cancer Care Ontario, which suggest that a dental assessment is recommended prior to commencement of bisphosphonates, and any pending dental or oral health problems should be dealt with prior to starting treatment, if possible 1. The risk of MRONJ is relatively low with oral bisphosphonates used for osteoporosis, but increases with longer duration of therapy, concurrent steroid use, and invasive dental procedures.

Some key points to consider include:

• Patients should inform their dentist about bisphosphonate therapy and maintain excellent oral hygiene 1
• Dental work can typically be completed first, followed by medication initiation for oral bisphosphonates like alendronate 1
• For higher-potency intravenous medications like zoledronic acid, dental evaluation is more strongly advised beforehand 1
• Patients with suspected MRONJ should be referred to a dental practitioner with expertise in treating this condition 1

It is essential to weigh the benefits of bisphosphonate therapy against the potential risks, particularly for patients with a history of dental problems or those requiring invasive dental procedures. By prioritizing dental clearance and maintaining good oral hygiene, patients can minimize their risk of developing MRONJ and ensure the safest possible treatment outcome 1.

From the FDA Drug Label

Advise patients to have a dental examination prior to treatment with zoledronic acid injection and to avoid invasive dental procedures during treatment. Inform patients of the importance of good dental hygiene, routine dental care, and regular dental check-ups Advise patients to immediately tell their doctor about any oral symptoms such as loosening of a tooth, pain, swelling, or non-healing of sores or discharge during treatment with zoledronic acid injection [see Warnings and Precautions (5.4)]. Known risk factors for osteonecrosis of the jaw include invasive dental procedures (e.g., tooth extraction, dental implants, boney surgery), diagnosis of cancer, concomitant therapies (e.g., chemotherapy, corticosteroids, angiogenesis inhibitors), poor oral hygiene, and co-morbid disorders (e.g., periodontal and/or other pre-existing dental disease, anemia, coagulopathy, infection, ill-fitting dentures).

Dental Clearance is Recommended before starting osteoporosis treatment with medications like bisphosphonates (e.g. alendronate, zoledronic acid) in patients with dental cavities or those needing dental work or dental implants.

• Patients should have a dental examination prior to treatment.
• Invasive dental procedures should be avoided during treatment.
• Patients should be informed of the importance of good dental hygiene and regular dental check-ups.
• The risk of osteonecrosis of the jaw (ONJ) may increase with duration of exposure to bisphosphonates, and patients with a history of dental problems or invasive dental procedures are at higher risk 2, 3.

From the Research

Dental Clearance Before Osteoporosis Treatment

• Dental clearance is often recommended before starting osteoporosis treatment, especially with medications like bisphosphonates, in patients with dental cavities or those needing dental work or dental implants 4, 5, 6, 7.
• The risk of osteonecrosis of the jaw (ONJ) is a significant concern in patients taking bisphosphonates, and dental clearance can help prevent this complication 5, 6, 7.
• A maxillofacial examination before treatment with bisphosphonates can help identify patients at risk of ONJ and prevent this complication 7.
• Patients with osteoporosis can still receive dental implants, but they must be informed about the possibility of ONJ and give informed consent 8.
• Ceasing to use bisphosphonates before implant placement does not seem to be necessary, but patients should be closely monitored for signs of ONJ 8.

Considerations for Dental Work and Implants

• Dental work, including implants, should be completed before starting bisphosphonate therapy to minimize the risk of ONJ 4, 6.
• Patients with dental cavities or needing dental work should have these issues addressed before starting osteoporosis treatment 4, 5.
• The decision to place dental implants in patients taking bisphosphonates should be made on a case-by-case basis, taking into account the patient's overall health and the potential risks and benefits of the procedure 6, 8.

Prevention and Management of ONJ

• Prevention of ONJ is crucial, and patients should be educated about the risks and signs of this complication 5, 6, 7.
• A multidisciplinary approach to prevention and management of ONJ is recommended, involving dentists, oral surgeons, and other healthcare professionals 5, 6.
• Patients taking bisphosphonates should be closely monitored for signs of ONJ, and any dental problems should be addressed promptly to prevent this complication 5, 6, 7.