How long should alendronate (bisphosphonate) be held prior to a deep dental procedure?

Timing of Alendronate Discontinuation Before Deep Dental Procedures

For patients taking alendronate (bisphosphonate), it is recommended to consider stopping the medication 2 months prior to deep dental procedures and resuming after adequate osseous healing has occurred to reduce the risk of osteonecrosis of the jaw (ONJ). 1

Rationale for Temporary Discontinuation

Bisphosphonates like alendronate have been associated with medication-related osteonecrosis of the jaw (MRONJ), particularly with invasive dental procedures. The risk factors include:

• Duration of bisphosphonate therapy
• Concomitant use of dentures
• Poor oral hygiene
• Presence of active oral infections 1

Pre-Procedure Protocol

1. Dental Assessment:

   • Comprehensive dental evaluation of both hard and soft tissues before starting bisphosphonate treatment 2
   • Complete any invasive dental procedures before initiating bisphosphonate therapy when possible 2

2. Timing of Discontinuation:

   • Stop alendronate 2 months prior to oral surgery 1
   • This "drug holiday" may allow better bone healing during invasive dental procedures 2

3. Resumption of Therapy:

   • Delay restarting until osseous healing has occurred 2
   • Ensure complete healing of the surgical site before resuming treatment

Risk Assessment

The risk of ONJ appears to be dose and duration dependent:

• Lower risk with osteoporosis dosing (weekly alendronate) compared to cancer treatment dosing
• ONJ rates with 6-monthly zoledronic acid range from 0.45% to 2.1% 2
• ONJ rates with oral bisphosphonates for osteoporosis are significantly lower

Additional Preventive Measures

1. Oral Health Optimization:

   • Maintain good oral hygiene 2
   • Treat any active oral infections before the procedure 1
   • Eliminate sites at high risk for infection 1

2. Adjunctive Therapy:

   • Consider pentoxifylline (400 mg twice daily) and tocopherol (1,000 IU once daily) for patients undergoing teeth extraction while on bisphosphonates 1
   • Start 1 week before and continue for 4 weeks after extraction or until socket healing 1

3. Calcium and Vitamin D Management:

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

Special Considerations

For patients with cancer and bone metastases, the approach may differ:

• These patients should continue bisphosphonate therapy throughout the course of their disease 1
• The benefit of preventing skeletal-related events may outweigh the risk of ONJ in these cases

Monitoring After Procedure

• Follow up for at least 6 months after the procedure for surveillance of bisphosphonate-related osteonecrosis 3
• Monitor for signs of delayed healing, exposed bone, or infection

Caveats and Pitfalls

1. There is some controversy regarding the effectiveness of temporary discontinuation, as bone effects of bisphosphonates are maintained for years after treatment stops 2

2. The decision to discontinue should consider the patient's fracture risk versus the risk of ONJ

3. Patients with very high fracture risk (T-score ≤ -3.5, history of osteoporotic fracture while on treatment) may need alternative approaches 1

4. Attempts should be made to achieve primary wound closure of any surgical site in patients who have taken bisphosphonates 3