What are the recommendations for stopping Fosamax (alendronate) prior to a tooth extraction?

Management of Fosamax (Alendronate) Before Tooth Extraction

For patients taking Fosamax (alendronate) for osteoporosis, there is insufficient evidence to support or refute the need for discontinuation before tooth extraction, and administration may be deferred at the discretion of the treating physician in conjunction with discussion with the patient and oral health provider.

Risk Assessment for Medication-Related Osteonecrosis of the Jaw (MRONJ)

Bisphosphonates like Fosamax (alendronate) are associated with MRONJ, a serious complication that can occur following invasive dental procedures such as tooth extractions. The risk varies based on several factors:

Key Risk Factors

• Duration of therapy: Longer treatment duration increases risk
• Dosage: Oncologic doses carry higher risk than osteoporosis doses
• Route of administration: IV bisphosphonates pose greater risk than oral formulations
• Concurrent medications: Especially corticosteroids or immunosuppressants
• Comorbidities: Diabetes, poor oral health, tobacco use

Recommendations for Dental Management

For Patients on Oral Bisphosphonates for Osteoporosis

1. Preoperative assessment:

   • Evaluate duration of bisphosphonate therapy
   • Assess oral health status
   • Identify modifiable risk factors (poor oral hygiene, ill-fitting dentures, uncontrolled diabetes, tobacco use) 1

2. Management options:

   • For patients on oral bisphosphonates <4 years with no additional risk factors:

     • Proceed with extraction without interruption of bisphosphonate therapy
     • Implement preventive measures (antibiotic prophylaxis, antiseptic mouthwash)

   • For patients on oral bisphosphonates >4 years OR with additional risk factors:

     • Consider temporary discontinuation of bisphosphonate 1-3 months before extraction if medically feasible
     • Consult with prescribing physician regarding risks/benefits of discontinuation 1

Drug Holiday Considerations

While some clinicians advocate for a "drug holiday" before invasive dental procedures, evidence supporting this practice is limited. The 2019 MASCC/ISOO/ASCO guidelines state there is "insufficient evidence to support or refute the need for discontinuation of the BMA before dentoalveolar surgery" 1.

Perioperative Protocol

1. Preoperative measures:

   • Antimicrobial mouth rinse (chlorhexidine 0.12%)
   • Prophylactic antibiotics starting 1 day before procedure
   • Consider pentoxifylline 400mg twice daily and tocopherol 1000 IU daily starting 1 week before extraction 1

2. Surgical considerations:

   • Minimize trauma during extraction
   • Primary closure when possible
   • Consider removing adjacent alveolar bone to ensure healthy bleeding bone margins

3. Postoperative care:

   • Continue antibiotics for 7-14 days
   • Continue antimicrobial mouth rinse until complete mucosal healing
   • Close follow-up every 6-8 weeks until complete mucosal healing 1
   • Consider continuing pentoxifylline and tocopherol for 1-3 months post-extraction 1

Important Caveats

1. Risk vs. benefit assessment: The risk of MRONJ with oral bisphosphonates is relatively low (estimated at 0.1%), but increases with duration of therapy 1.

2. Rebound bone turnover: Discontinuing bisphosphonates may lead to increased bone turnover, potentially compromising bone health, especially in high-risk patients 1.

3. Healing time: Even with continued bisphosphonate therapy, extraction socket healing may be delayed, but this doesn't necessarily lead to MRONJ 2.

4. Communication: Coordination between the dentist and prescribing physician is essential to develop an appropriate management plan 1.

Practical Algorithm for Decision-Making

1. Low risk: <4 years on oral bisphosphonate, no additional risk factors

   • Proceed with extraction without interruption
   • Implement preventive measures

2. Moderate risk: >4 years on oral bisphosphonate OR presence of additional risk factors

   • Consider drug holiday if medically appropriate (consult physician)
   • Implement comprehensive preventive protocol
   • Close follow-up

3. High risk: Oncologic doses or IV bisphosphonates

   • Drug holiday if possible (consult physician)
   • Consider alternative dental treatments if feasible
   • Implement aggressive preventive protocol
   • Very close follow-up

Remember that the decision to discontinue Fosamax before tooth extraction should be made collaboratively between the dentist, prescribing physician, and patient, weighing the risks of MRONJ against the risks of compromised bone health.