What are the considerations for using bisphosphonates in patients with complete tooth loss (edentulism)?

From the Guidelines

Bisphosphonates can be safely continued in patients who have had all their teeth removed, as the risk of medication-related osteonecrosis of the jaw (MRONJ) is significantly reduced without teeth. According to the guidelines from the Journal of Clinical Oncology 1, a dental assessment is recommended prior to commencement of bisphosphonates, and any pending dental or oral health problems should be dealt with prior to starting treatment. However, in the case of edentulous patients, the risk of MRONJ is lower, and bisphosphonates can be maintained at their standard dosing regimens for osteoporosis or other conditions.

Key Considerations

• The primary concern with bisphosphonates in dentate patients is the risk of MRONJ following dental extractions or other invasive dental procedures, which is mitigated in edentulous patients.
• Patients should still maintain good denture hygiene if they wear prosthetics, as ill-fitting dentures can cause mucosal irritation.
• Patients should be advised to have dentures checked regularly for proper fit and to report any persistent sore spots promptly.
• While the risk is lower, patients should still inform any dental professional about their bisphosphonate therapy if they require procedures involving the jawbone.

Medication Regimens

• Typical regimens for osteoporosis include alendronate 70mg weekly or zoledronic acid 5mg IV yearly.
• Common bisphosphonates like risedronate (Actonel), ibandronate (Boniva) can also be maintained at their standard dosing regimens. It is essential to note that patients should be informed of the risk of developing ONJ, especially with tooth extractions and other invasive dental procedures, although this risk is lower in edentulous patients, as stated in the guidelines from the Journal of Clinical Oncology 1.

From the FDA Drug Label

1. 4 Osteonecrosis of the Jaw Osteonecrosis of the jaw (ONJ), which can occur spontaneously, is generally associated with tooth extraction and/or local infection with delayed healing, and has been reported in patients taking bisphosphonates, including alendronate sodium. Known risk factors for osteonecrosis of the jaw include invasive dental procedures (e.g., tooth extraction, dental implants, boney surgery), diagnosis of cancer, concomitant therapies (e.g., chemotherapy, corticosteroids, angiogenesis inhibitors), poor oral hygiene, and co-morbid disorders (e.g., periodontal and/or other pre-existing dental disease, anemia, coagulopathy, infection, ill-fitting dentures).

The use of bisphosphonates, such as alendronate, is not directly contraindicated in patients who have had all their teeth removed. However, osteonecrosis of the jaw (ONJ) is a potential risk associated with bisphosphonate therapy, and this risk may be increased with invasive dental procedures, including tooth extraction.

• Since the patient has already had all their teeth removed, the risk of ONJ due to tooth extraction is no longer a concern.
• However, poor oral hygiene and co-morbid disorders, such as ill-fitting dentures, can still increase the risk of ONJ.
• The decision to use bisphosphonates in these patients should be based on individual benefit/risk assessment 2.

From the Research

Bisphosphonates in Patients with No Teeth

• The use of bisphosphonates in patients who have had all their teeth removed is a topic of interest due to the potential risk of osteonecrosis of the jaw (ONJ) 3, 4.
• Bisphosphonates tend to accumulate in bone, subject to remodeling, and can affect osteoclast-mediated bone resorption and osteoclast formation, leading to the osteonecrotic phenomenon 3.
• The overall incidence of bisphosphonate-related ONJ is low, ranging from 0.7% to 12%, mainly observed in those patients receiving intravenous treatment 4.
• Practical approaches in the prevention of ONJ include thorough pre-treatment evaluation and performing any preventative procedures, such as treating periodontal conditions and extracting loose teeth 3.
• However, there is no direct evidence in the provided studies that specifically addresses the use of bisphosphonates in patients who have had all their teeth removed.
• The studies mainly focus on the general use of bisphosphonates in patients with osteoporosis and the risk of ONJ in patients receiving bisphosphonates or denosumab 5, 6, 7.
• Further research would be needed to determine the specific risks and benefits of using bisphosphonates in patients who have had all their teeth removed.

Key Considerations

• The type of bisphosphonate used, length of treatment, and route of administration are important factors to consider when assessing the risk of ONJ 3, 4.
• Patients with co-morbidities and/or treatment with immune-suppressing drugs may be at higher risk of developing ONJ 3.
• A preventive dental surgery visit and examination of the case would be advisable prior to beginning treatment with bisphosphonates, especially in oncological patients currently in treatment with receiving intravenous bisphosphonates 3.