Why should Fosamax (alendronate) be stopped before dental procedures and for how long?

Stopping Fosamax (Alendronate) Before Dental Procedures

Fosamax (alendronate) should be temporarily discontinued before invasive dental procedures at the discretion of the treating physician in consultation with the dental provider, though evidence supporting this practice is insufficient. 1

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

• Bisphosphonates like Fosamax (alendronate) are associated with medication-related osteonecrosis of the jaw (MRONJ), a serious complication characterized by exposed bone in the maxillofacial region 1, 2
• Risk factors for MRONJ include:
  • Duration of bisphosphonate therapy (higher risk with longer use) 3, 4
  • Invasive dental procedures, particularly tooth extractions 1, 3
  • Poor oral health and periodontitis 1
  • Concurrent use of corticosteroids 3

Recommendations for Dental Procedures

Before Starting Bisphosphonate Therapy

• Comprehensive dental evaluation including radiographic examination should be performed before starting bisphosphonate therapy 1
• Necessary dental procedures should be completed before initiating bisphosphonate treatment 1
• Allow for adequate healing of any invasive dental procedures before starting bisphosphonate therapy 1

For Patients Already on Bisphosphonate Therapy

• Elective dentoalveolar surgical procedures (extractions, implants) should be avoided during active therapy with bisphosphonates when possible 1
• If dental procedures are necessary:
  • The decision to temporarily discontinue bisphosphonate therapy should be made jointly between the treating physician and dental provider 1
  • There is insufficient evidence to definitively support or refute the need for discontinuation 1
  • Some experts suggest stopping oral bisphosphonates 2 months prior to oral surgery and delaying restart until osseous healing has occurred 1
  • Morning fasting serum C-terminal telopeptide (CTX) test may help assess risk and guide treatment decisions 4

Duration of Drug Holiday

While there is no definitive consensus on the optimal duration for stopping Fosamax before dental procedures:

• Some clinicians recommend a 2-month drug holiday before invasive dental procedures 1
• Resumption of therapy should be delayed until adequate healing has occurred, typically when there is complete mucosal coverage of the surgical site 1
• For patients on long-term therapy (>5 years), longer healing times may be necessary as healing can be significantly delayed 5

Important Considerations and Caveats

• The risk of MRONJ with oral bisphosphonates like Fosamax is lower than with intravenous bisphosphonates used for cancer treatment 1, 6
• The decision to discontinue therapy must balance the risk of MRONJ against the risk of fractures or other skeletal events that might occur during the drug holiday 1
• Patients should maintain excellent oral hygiene and receive regular dental check-ups (every 6 months) while on bisphosphonate therapy 1
• Post-procedure follow-up should be scheduled every 6-8 weeks until complete mucosal healing has occurred 1
• The longer the duration of bisphosphonate use, the higher the risk of complications, with exponential relationship between exposed bone size and duration of use 4

Remember that while a drug holiday may be beneficial, the evidence supporting this practice is limited, and decisions should be made on a case-by-case basis considering the patient's overall health, fracture risk, and the invasiveness of the planned dental procedure 1.