Do you usually hold Fosamax (alendronate) before dental work?

Management of Fosamax Before Dental Work

You do not routinely need to hold Fosamax (alendronate) before most dental procedures, but you should complete a comprehensive dental evaluation and necessary invasive dental work before starting bisphosphonate therapy whenever possible. 1, 2

Pre-Treatment Dental Assessment (Ideal Scenario)

• Complete all necessary invasive dental procedures before initiating Fosamax, as this eliminates the osteonecrosis of the jaw (ONJ) risk entirely 2, 3
• Perform a comprehensive dental evaluation of both hard and soft tissues, including radiographic examination, before starting bisphosphonate therapy 1, 3
• Treat all active oral infections and eliminate high-risk sites before bisphosphonate initiation 2
• Correct vitamin D deficiency prior to bisphosphonate therapy to avoid hypocalcemia 1, 2

Risk Stratification for ONJ

The risk of ONJ with oral Fosamax is extremely low compared to intravenous bisphosphonates used in cancer treatment:

• Oral bisphosphonates for osteoporosis: <1 case per 100,000 person-years 1, 2
• Intravenous bisphosphonates for cancer: 6.7-11% incidence 2
• The most consistent risk factor is recent dental surgery or extraction 1, 2

Management When Dental Work is Needed During Treatment

The Drug Holiday Controversy

The evidence regarding stopping Fosamax before dental procedures remains controversial and lacks strong support:

• Some experts hypothesize that stopping bisphosphonates 2 months prior to oral surgery may allow better bone healing, with resumption delayed until adequate healing occurs 1, 2, 3
• However, 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 1
• The decision to discontinue therapy must balance the risk of ONJ against the risk of fractures that might occur during the drug holiday 3

Practical Approach for Routine Extractions

For patients already on oral Fosamax requiring tooth extraction, the procedure can be performed safely without stopping the medication:

• A prospective study of 1,480 extractions in 700 patients on oral bisphosphonates showed 100% success with zero cases of ONJ using atraumatic surgical technique 4
• Use prophylactic antibiotics perioperatively 2, 3
• Employ atraumatic surgical technique with minimal trauma to soft and hard tissues 4
• Ensure complete mucosal healing before resuming normal activities 3

Ongoing Dental Care During Treatment

• Maintain excellent oral hygiene and receive regular dental check-ups every 6 months 2, 3
• Inform your dental practitioner of your bisphosphonate treatment 1, 2
• Avoid elective invasive dental procedures (implants, complex extractions) when possible during active therapy 3
• Schedule post-procedure follow-up every 6-8 weeks until complete mucosal healing has occurred 3

Critical Caveats

• The fracture prevention benefits of continued Fosamax therapy in osteoporosis patients generally outweigh the minimal ONJ risk, especially when proper dental protocols are followed 2
• Patients with suspected ONJ should be referred to a dental practitioner or oral surgeon with expertise in treating this condition 1, 2
• Risk of ONJ increases with frequency, dose, and duration of bisphosphonate administration 1, 2
• Concurrent chemotherapy, corticosteroid use, poor oral hygiene, and pre-existing dental infections increase ONJ risk 2