What precautions should be taken for a patient taking bisphosphonates (e.g. alendronate, risedronate) who needs a dental procedure?

Precautions for Dental Procedures in Patients Taking Bisphosphonates

Patients taking bisphosphonates who require dental procedures should undergo comprehensive dental assessment prior to the procedure, with minimally invasive surgical techniques used when necessary to reduce the risk of osteonecrosis of the jaw (ONJ). 1

Risk Assessment

The risk of developing ONJ after dental procedures varies based on:

• Type of bisphosphonate therapy:

  • Intravenous bisphosphonates: 1-10% risk in cancer patients 1
  • Oral bisphosphonates (e.g., alendronate, risedronate): 0.01-0.06% risk 1

• Duration of treatment:

  • Risk appears to be time and dose-dependent 2
  • Patients on bisphosphonates for >5 years have higher risk 1

• Additional risk factors:

  • Concurrent chemotherapy or corticosteroid use 1
  • Poor oral hygiene with periodontal disease 1
  • Dentures 2
  • Asian ethnicity 1

Pre-Procedure Protocol

1. Comprehensive dental assessment:

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

2. Laboratory assessment:

   • Serum calcium measurement 1
   • Renal function evaluation (especially for IV bisphosphonates) 1

3. Medication considerations:

   • For high-risk patients (IV bisphosphonates for cancer), consider temporary discontinuation of bisphosphonate therapy until healing of invasive dental surgery 2
   • Some experts recommend stopping oral bisphosphonate treatment 2 months prior to oral surgery 1
   • Note: The necessity of bisphosphonate discontinuation remains controversial, as one study showed that while healing was delayed with longer bisphosphonate use, ONJ did not develop even with continued therapy 3

4. Prophylactic measures:

   • Antibiotic prophylaxis before invasive dental procedures 1
   • Ensure good oral hygiene 2
   • Treat active oral infections before procedure 2
   • Eliminate sites at high risk for infection 2

Procedure Recommendations

1. Use minimally invasive surgical techniques 1

   • Choose the least invasive dental treatment option 2

2. For tooth extractions:

   • Preoperative antibiotic prophylaxis 3
   • Complete wound closure may not be necessary in all cases 3
   • Be aware that healing time may be prolonged in patients on long-term bisphosphonate therapy (>5 years) 3

3. For dental implants:

   • Contraindicated in patients being treated with intravenous bisphosphonates 4
   • Exercise caution in patients on oral bisphosphonates for >3 years 4
   • Obtain informed consent explaining the risk of implant failure and ONJ 4

Post-Procedure Care

1. Close monitoring:

   • Watch for signs of ONJ: pain, swelling, exposed bone in the jaw 1
   • Be aware that healing may be delayed, especially in patients on bisphosphonates for >5 years 3

2. Continued oral care:

   • Maintain good oral hygiene 2
   • Regular dental follow-up 1

3. Management of complications:

   • If ONJ develops, refer to dental practitioners with expertise in treating this condition 1
   • Long-term antibiotics may be necessary for established ONJ 5

Special Considerations

1. For patients on oral bisphosphonates (e.g., alendronate, risedronate):

   • Take medication with at least 4 ounces of plain water 6
   • Remain upright for at least 30 minutes after taking the medication 6
   • Take calcium supplements at least 2 hours after oral bisphosphonate 1

2. For patients with cancer and bone metastases:

   • Continue bisphosphonate therapy throughout the course of the disease 1
   • Exercise greater caution with dental procedures 2

3. For patients on long-term therapy:

   • Consider reevaluating the need for continued bisphosphonate therapy after 5 years 1
   • Patients at very high risk of fracture may need to continue treatment 1

By following these precautions, the risk of ONJ can be minimized while still allowing necessary dental procedures to be performed in patients taking bisphosphonates.