What are the considerations for using bisphosphonates (e.g. alendronate, risedronate, zoledronic acid, pamidronate) in patients undergoing dental procedures?

Bisphosphonates in Dentistry: Critical Considerations and Management

Primary Risk: Osteonecrosis of the Jaw (ONJ)

All patients on bisphosphonates require comprehensive dental evaluation before starting therapy, and invasive dental procedures should be completed prior to bisphosphonate initiation whenever feasible. 1, 2, 3

The most serious dental complication of bisphosphonate therapy is medication-related osteonecrosis of the jaw (ONJ), which presents as exposed bone in the maxillofacial region that fails to heal after 8 weeks. 4, 5, 6 This condition occurs most commonly following invasive dental procedures, particularly tooth extractions. 1, 2

Risk Stratification by Route and Indication

Intravenous Bisphosphonates (Highest Risk)

• Zoledronic acid and pamidronate carry substantially higher ONJ risk than oral formulations. 1, 2
• In cancer patients receiving IV bisphosphonates, ONJ incidence ranges from 6.7% to 11% in multiple myeloma patients. 1
• Zoledronic acid demonstrates 9.5 times higher relative risk compared to pamidronate alone and 4.5 times higher risk compared to sequential pamidronate/zoledronic acid. 1
• The cumulative hazard increases from 1% at 12 months to 11-13% at 4 years of treatment. 1

Oral Bisphosphonates (Lower Risk)

• Oral bisphosphonates (alendronate, risedronate) carry very low ONJ risk: <1 case per 100,000 person-years. 2
• Risk remains significantly lower than IV formulations even with prolonged use. 2
• Despite low absolute risk, preventive measures remain essential. 2, 4

Pre-Treatment Dental Protocol (Mandatory)

Before initiating any bisphosphonate therapy: 1, 3

• Perform comprehensive dental evaluation including radiographic examination of hard and soft tissues 1, 3
• Complete all necessary invasive dental procedures (extractions, implants, periodontal surgery) before starting bisphosphonates 1, 2, 3
• Treat all active oral infections and eliminate sites at high risk for infection 1
• Correct vitamin D deficiency to prevent hypocalcemia 2
• Ensure patients understand ONJ risk and the importance of informing dental practitioners about bisphosphonate use 1

Management During Active Bisphosphonate Therapy

Preventive Measures

• Maintain excellent oral hygiene with regular dental check-ups every 6 months. 1, 3
• Avoid invasive dental procedures whenever possible 1, 3
• Ensure proper denture fit, as ill-fitting dentures increase ONJ risk 2

When Invasive Dental Procedures Are Necessary

The decision to discontinue bisphosphonates before dental surgery remains controversial: 1, 2, 3

Option 1: Drug Holiday Approach

• Some experts recommend stopping bisphosphonates 2 months prior to oral surgery, with resumption delayed until complete osseous healing occurs 1, 2, 3
• This approach hypothesizes that temporary discontinuation allows better bone healing 1, 2

Option 2: Continue Therapy

• Alternative view holds that short breaks have no effect since bisphosphonates remain in bone for years after discontinuation 1
• The decision must balance ONJ risk against fracture risk during the drug holiday 3

For patients requiring extraction while on bisphosphonates: 2

• Use prophylactic antibiotics 2
• Suspend bisphosphonate until tooth socket healing appears complete 2
• Schedule follow-up every 6-8 weeks until complete mucosal healing 3

Risk Factors for ONJ Development

High-risk factors include: 1, 2, 4, 5

• Recent tooth extraction or invasive dental surgery (present in at least 60% of ONJ cases) 2
• Poor oral hygiene and pre-existing periodontal disease 2, 4
• Concurrent chemotherapy or corticosteroid use 2, 4, 5
• Longer duration of bisphosphonate exposure 1
• Higher doses and more frequent administration 1
• Cancer diagnosis (higher risk than osteoporosis patients) 2
• Ill-fitting dentures 2

Management of Established ONJ

If ONJ develops: 1

• Refer immediately to a dental practitioner or oral surgeon with expertise in treating ONJ 1
• Consult recent guidelines from the International Task Force on Osteonecrosis of the Jaw, American Association of Oral and Maxillofacial Surgeons, or American Dental Association 1
• Consider discontinuing bisphosphonate therapy based on individual benefit/risk assessment 4, 5, 6
• Note that extensive dental surgery may exacerbate ONJ in affected patients 4, 5

Additional Monitoring Requirements

For all patients on bisphosphonates: 1, 4, 6

• Measure serum calcium before starting treatment 1
• Monitor renal function before each IV bisphosphonate dose 1, 6
• Monitor serum calcium and creatinine throughout IV treatment 1
• Provide calcium and vitamin D supplementation unless contraindicated 1
• Separate oral bisphosphonates from calcium supplements by at least 2 hours 1

Critical Pitfalls to Avoid

• Never assume oral bisphosphonates carry no ONJ risk—while rare, ONJ can occur with oral formulations 2, 7
• Do not perform elective invasive dental procedures without considering drug holiday or prophylactic measures 2, 3
• Avoid starting bisphosphonates in patients with active dental infections or pending dental work 1, 3
• Do not ignore prodromal symptoms—patients may report jaw pain or loose teeth before frank ONJ develops 8
• Remember that ONJ risk increases with duration of therapy—vigilance must continue throughout treatment 1, 9