What are the considerations for tooth extraction in patients taking bisphosphonates?

Management of Tooth Extraction in Patients Taking Bisphosphonates

Patients taking bisphosphonates who require tooth extraction should undergo a comprehensive dental assessment prior to starting bisphosphonate therapy, with any pending dental issues addressed before treatment begins to minimize the risk of osteonecrosis of the jaw (ONJ). 1

Risk Assessment

The risk of developing ONJ after tooth extraction varies based on:

• Type of bisphosphonate therapy:

  • Intravenous bisphosphonates (1-10% risk of ONJ in cancer patients) 1
  • Oral bisphosphonates (0.01-0.06% risk in osteoporosis patients) 2

• Duration of therapy:

  • 5 years of oral bisphosphonate use significantly delays extraction socket healing 3

  • Longer duration increases ONJ risk 2

• Additional risk factors:

  • Concurrent chemotherapy or corticosteroid use 2
  • Poor oral hygiene with periodontal disease 2
  • Asian ethnicity 2

Pre-Extraction Protocol

1. Dental evaluation:

   • Comprehensive assessment of hard and soft tissues 1
   • Radiographic examination to identify potential infection sources

2. Laboratory assessment:

   • Serum calcium measurement prior to starting treatment 1
   • Vitamin D level assessment and correction of deficiency 2
   • Renal function evaluation (especially for IV bisphosphonates) 1

3. Medication considerations:

   • For patients on bisphosphonates >5 years, consider temporary discontinuation in consultation with prescribing physician 2
   • Some experts recommend stopping bisphosphonate treatment 2 months prior to oral surgery 1

Extraction Protocol

1. Infection control:

   • Antibiotic prophylaxis before extraction 4, 5
   • Chlorhexidine mouthwash before and after procedure 4

2. Surgical technique:

   • Atraumatic extraction to minimize bone trauma 6
   • Consider using ultrasonic surgical devices for extraction 5
   • Primary wound closure when possible 4
   • Alternative approach: nontraumatic avulsion with closure by secondary intention 6

3. Post-extraction care:

   • Continue antibiotic coverage post-extraction 4, 5
   • Regular follow-up to ensure proper healing 3
   • Calcium and vitamin D supplementation (calcium should be taken at least 2 hours after oral bisphosphonate) 1

Special Considerations

• For IV bisphosphonate patients: Higher risk requires more aggressive preventive measures and closer follow-up 4, 5

• For oral bisphosphonate patients: Generally lower risk, but increased caution with longer duration of therapy 3, 6

• For patients with existing ONJ: Refer to dental practitioners with expertise in treating this condition 1

Monitoring for Complications

• Monitor for signs of ONJ: pain, swelling, exposed bone in the jaw 2
• Watch for delayed healing, especially in long-term bisphosphonate users 3
• Monitor for inflammatory eye conditions (uveitis, scleritis) which may require ophthalmological evaluation 1

Important Caveats

1. Despite concerns, evidence suggests tooth extraction can be performed safely in bisphosphonate patients with proper protocols 6, 7

2. It is not the extraction itself but prevailing infectious conditions that may be the key risk factor for ONJ development 7

3. Healing time may be prolonged in patients on long-term bisphosphonate therapy, but this doesn't necessarily lead to ONJ 3

4. The decision to temporarily discontinue bisphosphonates should balance the risk of ONJ against the risk of osteoporotic fractures 2