Should osteoporosis treatment be postponed in patients with multiple dental caries?

Osteoporosis Treatment in Patients with Multiple Dental Caries

Osteoporosis treatment should be postponed in patients with multiple dental caries until dental treatment is completed and oral health is stabilized to reduce the risk of osteonecrosis of the jaw. 1

Rationale for Postponing Treatment

Dental caries represent a potential risk factor for developing osteonecrosis of the jaw (ONJ), a serious complication associated with antiresorptive medications used to treat osteoporosis. The presence of multiple dental caries indicates poor oral health that should be addressed before initiating osteoporosis treatment for several important reasons:

1. Risk of ONJ: Dental caries can lead to infections, abscesses, and the need for invasive dental procedures such as extractions, which significantly increase the risk of developing ONJ when on antiresorptive therapy 1, 2

2. Medication-specific concerns:

   • Bisphosphonates: The risk of ONJ increases with frequency, dose, and duration of bisphosphonate administration 1
   • Denosumab: The risk of ONJ is approximately 2.3% in patients undergoing dental extractions while on denosumab, which is 7.7 times higher than for oral bisphosphonates 2

Pre-Treatment Dental Protocol

Before initiating osteoporosis treatment:

1. Complete dental evaluation including examination of both hard and soft tissues 1
2. Treat all active dental disease:
   • Restore all carious lesions
   • Perform necessary endodontic treatments
   • Extract non-restorable teeth
   • Treat any periodontal disease 1
3. Allow adequate healing time before starting osteoporosis medication, particularly for any invasive dental procedures 1

Treatment Algorithm

1. Refer for comprehensive dental assessment and treatment

   • Complete all necessary dental procedures
   • Allow for complete healing of oral tissues (typically 2-3 weeks for simple procedures, longer for extractions)

2. Once dental health is stabilized:

   • Initiate osteoporosis treatment with appropriate medication
   • Ensure calcium and vitamin D supplementation unless contraindicated 1
   • Schedule regular dental follow-ups every 6 months 1

3. For urgent osteoporosis treatment (e.g., very high fracture risk):

   • Consider using medications with lower ONJ risk temporarily
   • Complete urgent dental care first
   • Transition to standard osteoporosis therapy once dental health is stabilized

Special Considerations

• Medication timing: If dental extractions are needed while on denosumab, consider timing them between 6-7 months after the last injection, as this timing showed no ONJ development in studies 2

• Maintenance during treatment: Patients on osteoporosis medications should maintain excellent oral hygiene and undergo regular dental check-ups 1, 3

• Risk stratification: The risk of ONJ varies by medication:

  • Denosumab: Higher risk (2.3% with extractions) 2
  • IV bisphosphonates: Moderate risk
  • Oral bisphosphonates: Lower risk (0.1-0.3%) 2

Pitfalls to Avoid

1. Do not start osteoporosis treatment without dental clearance in patients with multiple dental caries, as this significantly increases ONJ risk 1

2. Do not discontinue ongoing osteoporosis treatment without consulting the prescribing physician, as this could increase fracture risk 3

3. Avoid assuming all osteoporosis medications carry the same risk - denosumab carries a significantly higher risk of ONJ than oral bisphosphonates when dental extractions are needed 2

4. Do not delay dental treatment once osteoporosis therapy has begun, as the risk of ONJ increases with the duration of antiresorptive therapy 1

By addressing dental caries and establishing good oral health before initiating osteoporosis treatment, the risk of developing serious complications like ONJ can be significantly reduced while still providing effective treatment for osteoporosis.