What precautions are needed for a patient on Boniva (ibandronate) undergoing teeth extraction?

Precautions for Teeth Extraction in Patients on Boniva (Ibandronate)

Patients on Boniva (ibandronate) undergoing teeth extraction require special precautions to minimize the risk of medication-related osteonecrosis of the jaw (ONJ), including antibiotic prophylaxis, atraumatic surgical technique, and close post-operative monitoring. 1

Risk Assessment

• The risk of ONJ in patients taking oral bisphosphonates like Boniva for osteoporosis is relatively low (0.01-0.06%) compared to patients on intravenous bisphosphonates for cancer treatment (1-10%) 1
• Risk factors that increase ONJ probability:
  • Duration of bisphosphonate therapy (higher risk after 5+ years)
  • Concomitant use of dentures
  • Poor oral hygiene
  • Presence of active oral infections

Pre-Extraction Management

1. Comprehensive dental assessment:

   • Radiographic examination to evaluate bone status
   • Evaluation of hard and soft tissues
   • Serum creatinine measurement (especially important as ibandronate is contraindicated in severe renal impairment with creatinine clearance <30 mL/min) 2

2. Drug holiday consideration:

   • For patients who have been on Boniva for >5 years, consider temporary discontinuation of therapy
   • Some experts recommend stopping bisphosphonate treatment 2 months prior to oral surgery 1
   • Note: The FDA label for ibandronate states that patients at low risk for fracture should be considered for drug discontinuation after 3-5 years of use 2

3. Treat existing infections:

   • Address any active oral infections before extraction
   • Eliminate sites at high risk for infection

Extraction Protocol

1. Antibiotic prophylaxis:

   • Administer prophylactic antibiotics before and after the extraction procedure 1
   • Continue antibiotics until sufficient healing has occurred

2. Surgical technique:

   • Use minimally invasive, atraumatic extraction techniques 1, 3
   • Consider Protocol B from research evidence: nontraumatic avulsion and closure by secondary intention, which has shown 100% success rate in preventing ONJ 3
   • Avoid excessive trauma to both soft and hard tissues

3. Intraoperative considerations:

   • Ensure complete removal of infected tissue
   • Perform thorough debridement of the socket
   • Consider primary closure of the extraction site

Post-Extraction Care

1. Antiseptic mouth rinses:

   • Prescribe chlorhexidine gluconate (0.12% or 0.2%) mouth rinses twice daily until healing is complete 1

2. Close monitoring:

   • Schedule regular follow-up appointments to monitor healing
   • Watch for signs of ONJ: pain, swelling, exposed bone in the jaw
   • First follow-up should be within 1-2 weeks after extraction

3. Oral hygiene instructions:

   • Maintain meticulous oral hygiene
   • Gentle brushing with ultra-soft toothbrush
   • Regular rinsing with prescribed antiseptic solution

Adjunctive Therapies

1. Consider pentoxifylline and tocopherol:

   • Pentoxifylline (400 mg twice daily) and tocopherol (1,000 IU once daily)
   • Start 1 week before and continue for 4 weeks after extraction or until socket healing 4

2. Calcium and vitamin D supplementation:

   • Continue calcium and vitamin D supplementation
   • Take calcium at least 2 hours after oral bisphosphonate 1

Warning Signs Requiring Immediate Attention

• Persistent pain beyond normal post-extraction discomfort
• Exposed bone in the extraction site
• Delayed healing (>2 weeks)
• Progressive swelling or inflammation
• Purulent discharge from the extraction site

Special Considerations

• For patients who have been on Boniva for less than 3 years and have no additional risk factors, the risk of ONJ is minimal 1
• For patients with multiple risk factors or longer duration of therapy, consider referral to an oral surgeon with experience in managing patients on bisphosphonates
• Hyperbaric oxygen therapy is not routinely recommended for prophylaxis but may be considered in high-risk cases 4

The evidence shows that with proper precautions, dental extractions can be safely performed in patients taking oral bisphosphonates like Boniva, with studies showing a 100% success rate in preventing ONJ when using appropriate protocols 3.