Is the decision to stop alendronate (bisphosphonate) before a dental procedure made by the oral surgeon or the primary care physician (PCP)?

Decision to Stop Alendronate Before Dental Procedures: Oral Surgeon or PCP?

The decision to stop alendronate before a dental procedure should be made collaboratively between the oral surgeon and the primary care physician, with the oral surgeon taking the lead on the final decision as they are performing the invasive procedure and evaluating the specific MRONJ risk. 1, 2

Decision-Making Framework

Oral Surgeon's Role:

• Performs comprehensive dental evaluation before invasive procedures
• Assesses specific risk factors for medication-related osteonecrosis of the jaw (MRONJ)
• Determines the invasiveness and bone manipulation involved in the planned procedure
• Makes the final recommendation regarding bisphosphonate discontinuation based on:
  • Type of dental procedure (extraction, implant, etc.)
  • Patient's oral health status
  • Presence of other MRONJ risk factors (dentures, poor oral hygiene, etc.)

PCP's Role:

• Provides medical history and context for bisphosphonate therapy
• Evaluates the patient's fracture risk if bisphosphonate is discontinued
• Discusses alternative osteoporosis management during any drug holiday
• Determines timing for safe resumption of therapy after dental healing

Evidence-Based Recommendations

According to the MASCC/ISOO/ASCO clinical practice guideline 1, there is "insufficient evidence to support or refute the need for discontinuation of the bisphosphonate before dentoalveolar surgery." However, the guideline states that "administration of the bisphosphonate may be deferred at the discretion of the treating physician, in conjunction with discussion with the patient and the oral health provider."

The FDA drug label for alendronate 3 acknowledges that "for patients requiring invasive dental procedures, discontinuation of bisphosphonate treatment may reduce the risk for ONJ" and that "clinical judgment of the treating physician and/or oral surgeon should guide the management plan of each patient based on individual benefit/risk assessment."

Risk Stratification Approach

1. Low-Risk Procedures:

   • Routine cleanings, fillings, crown preparations without significant bone manipulation
   • Generally no need to discontinue alendronate

2. Moderate to High-Risk Procedures:

   • Extractions, implant placement, periodontal surgery with bone manipulation
   • Consider temporary discontinuation based on:
     • Duration of bisphosphonate therapy (longer duration = higher risk)
     • Route of administration (IV > oral)
     • Presence of other risk factors

Timing Considerations

If discontinuation is deemed necessary:

• The American Society of Clinical Oncology recommends stopping alendronate 2 months prior to oral surgery 2
• Delay restarting until osseous healing has occurred (typically when full mucosal coverage of the surgical site is achieved) 1, 2
• Follow-up by the dental specialist should occur on a systematic basis (e.g., every 6-8 weeks) until full healing 1

Common Pitfalls to Avoid

1. Failing to communicate between providers: The decision should never be made in isolation by either the oral surgeon or PCP.

2. Overlooking patient-specific risk factors: Both providers should consider:

   • Duration of bisphosphonate therapy
   • Concomitant medications (especially corticosteroids)
   • Comorbidities (diabetes, poor oral hygiene)
   • History of radiation therapy to the head and neck

3. Unnecessary discontinuation: For minor dental procedures without bone manipulation, discontinuation may introduce unnecessary fracture risk without providing benefit.

4. Inadequate follow-up: After dental procedures, patients should be evaluated systematically until complete healing occurs 1.

Research shows that with proper protocols, dental extractions can be performed safely in patients on oral bisphosphonates. A 2013 study of 700 patients on oral bisphosphonates undergoing 1,480 extractions reported no cases of MRONJ with appropriate surgical technique and antibiotic coverage 4.