Should I stop taking risedronate (bisphosphonate) before a dental extraction?

Management of Risedronate Before Dental Extraction

For patients taking oral risedronate for osteoporosis, you do not need to routinely discontinue the medication before dental extraction, though some experts suggest a 2-month drug holiday may allow better bone healing—the decision should weigh the very low risk of osteonecrosis of the jaw (<1 case per 100,000 person-years with oral bisphosphonates) against the risk of fracture during the drug holiday. 1, 2

Risk Assessment for Osteonecrosis of the Jaw (ONJ)

The risk of ONJ with oral risedronate is extremely low compared to intravenous bisphosphonates:

• Oral bisphosphonates carry a very rare ONJ risk (<1 case per 100,000 person-years), making routine discontinuation questionable 1
• Intravenous bisphosphonates carry significantly higher ONJ risk than oral formulations 1
• The most consistent risk factor for ONJ is recent prior dental surgery or extraction 1
• Risk increases with frequency, dose, and duration of bisphosphonate administration 1
• Additional risk factors include concurrent chemotherapy or corticosteroid use, poor oral hygiene, and pre-existing dental infections 1

Pre-Extraction Protocol

Before any dental extraction in a patient on risedronate, implement these preventive measures:

• Complete a comprehensive dental evaluation before starting bisphosphonate treatment whenever possible 1
• Perform necessary invasive dental procedures before initiating bisphosphonate therapy when feasible 1
• Ensure good oral hygiene is maintained 3, 1
• Correct vitamin D deficiency prior to or during bisphosphonate therapy to avoid hypocalcemia 1
• The FDA label specifically warns that patients should inform their dental practitioner about risedronate treatment and that severe jaw bone problems may occur 4

Drug Holiday Considerations

The evidence on bisphosphonate discontinuation is conflicting:

• Some experts hypothesize that stopping bisphosphonates 2 months prior to oral surgery may allow better bone healing, with resumption delayed until adequate healing occurs 3, 2
• The alternative view is that a short break in bisphosphonate administration will have no effect, as bone effects of bisphosphonates are maintained for years after treatment stops 3
• The critical caveat: you must balance the risk of ONJ against the risk of fractures or skeletal events during the drug holiday 2
• Research shows that patients undergoing tooth extraction with continued oral bisphosphonate therapy showed delayed healing but BRONJ did not develop 5

Surgical Approach When Extraction is Necessary

If extraction cannot be avoided while on risedronate:

• Use prophylactic antibiotics 3
• Consider a surgical approach with removal of adjacent alveolar bone (alveolectomy) along with correct antimicrobial therapy 6, 7
• Suspend the bisphosphonate until healing of the tooth socket appears complete 3
• Schedule post-procedure follow-up every 6-8 weeks until complete mucosal healing has occurred 2
• Maintain excellent oral hygiene and regular dental check-ups (every 6 months) while on bisphosphonate therapy 2

Important Clinical Caveats

Key distinctions that affect your decision:

• Patients receiving bisphosphonates for cancer treatment are at substantially higher risk than those taking them for osteoporosis 1
• Long-term oral bisphosphonate therapy (>5 years) significantly delays healing of extraction sockets compared to <5 years of use 5
• The FDA label requires patients to inform dentists if they plan to have dental surgery or teeth removed 4
• Research on risedronate specifically shows that osteonecrosis of the jaw and atypical fractures are rare with oral administration 8

The most common dental cause of MRONJ is tooth extraction (69.6% of cases), with the mandible affected 2.7 times more than the maxilla 9