Should patients with postmenopausal osteoporosis on bisphosphonate therapy be referred to specialized dental clinics?

Dental Referral for Patients on Bisphosphonates for Postmenopausal Osteoporosis

Yes, patients with postmenopausal osteoporosis should receive a dental assessment before starting bisphosphonates, and those with suspected osteonecrosis of the jaw (ONJ) should be referred to a dental practitioner with expertise in treating this condition. 1

Pre-Treatment Dental Assessment

Before initiating bisphosphonate therapy, a dental assessment is recommended where feasible, and any pending dental or oral health problems should be addressed prior to starting treatment. 1 This preventive approach is critical because:

• The risk of ONJ increases with frequency, dose, and duration of bisphosphonate administration 1
• The most consistent risk factor for ONJ is recent dental surgery or tooth extraction 1
• Patients with dental or periodontal abscess are significantly more likely to develop bisphosphonate-related ONJ (odds ratio 2.9) 2
• The incidence of ONJ in osteoporosis patients receiving bisphosphonates is approximately 9% in some studies, particularly when active infectious processes are present 2

Patient Education Requirements

Patients must be informed of the risk of developing ONJ, especially with tooth extractions and other invasive dental procedures, and should inform their dental practitioner of their bisphosphonate treatment. 1

When to Refer to Specialized Dental Care

Patients with suspected ONJ should be referred to a dental practitioner with expertise in treating this condition. 1 The following guidelines should be consulted for management:

• International Task Force on Osteonecrosis of the Jaw 1
• American Association of Oral and Maxillofacial Surgeons 1
• American Dental Association 1

Risk Context for Osteoporosis Treatment

The risk of ONJ with bisphosphonates administered for osteoporosis is lower than for patients receiving higher doses or more frequent administration as used for cancers with bone metastasis. 1 However, the risk remains present and increases with:

• Longer treatment duration 1
• Higher cumulative doses 1
• Presence of active dental infections 2

Timing Considerations

If dental work is required, patients should have this work completed and be given adequate time to heal before bisphosphonate initiation. 1 Some organizations recommend dental assessment and care as soon as possible after osteoporosis diagnosis to allow time for dental procedures and adequate healing prior to treatment. 1

Practical Implementation

For patients already on bisphosphonates who require dental procedures, close coordination between the prescribing physician and dental practitioner is essential. The dental practitioner should be aware of the bisphosphonate therapy to modify dental care appropriately and reduce ONJ risk. 1