Management of Alendronate Before Dental Extractions
For a patient on alendronate for a few months who requires dental extractions, proceed with the extraction without discontinuing the bisphosphonate, using prophylactic antibiotics and atraumatic surgical technique, as the risk of osteonecrosis of the jaw (ONJ) is extremely low (<1 case per 100,000 person-years) with short-duration oral bisphosphonate therapy. 1
Risk Stratification Based on Treatment Duration
Your patient's short duration of alendronate therapy (a few months) places them in the lowest risk category for ONJ:
- The incidence of ONJ with oral bisphosphonates for osteoporosis is very rare at <1 case per 100,000 person-years 2, 1
- Risk increases significantly only after 24 months of continuous therapy (adjusted odds ratio 2.07), and your patient falls well below this threshold 3
- Treatment duration <2 years shows no increased healing complications compared to non-bisphosphonate users 4
- The overall prevalence of ONJ in osteoporotic patients on alendronate is only 0.34%, rising to 2.16% after tooth extraction 5
Evidence-Based Surgical Protocol
Do NOT discontinue alendronate before the extraction. The evidence strongly supports continuing therapy:
- Drug holidays are not proven effective in preventing ONJ, as bisphosphonates' bone effects persist for years after stopping 1
- A prospective study of 1,480 extractions in 700 patients on oral bisphosphonates showed 100% success with zero ONJ cases when using proper surgical technique 6
- Another prospective study of 159 extractions in 45 patients showed only 0.6% ONJ incidence (1 case) with continued bisphosphonate therapy 7
Recommended Surgical Approach:
- Administer prophylactic antibiotics perioperatively 2, 1, 7
- Use atraumatic extraction technique with minimal trauma to soft and hard tissues 7, 6
- Ensure primary wound closure when possible 6
- Continue specific antibiotic and antiseptic therapy postoperatively 7
Critical Pre-Extraction Requirements
Before proceeding with extraction, verify the following:
- Ensure vitamin D deficiency has been corrected, as deficiency increases risk of bisphosphonate-related hypocalcemia and may attenuate efficacy 2, 1
- Confirm adequate calcium (800-1000 mg/day) and vitamin D (800 IU/day) intake 2
- Verify the patient can maintain upright position for 30 minutes post-dose to minimize esophageal complications 8
When Drug Holiday WOULD Be Considered (Not Applicable Here)
For context, drug interruption becomes relevant only in specific high-risk scenarios that do NOT apply to your patient:
- A 3-month drug holiday reduces ONJ risk (adjusted odds ratio 0.11) but is only recommended for patients on therapy ≥24 months 3
- The highest synergistic risk occurs with drug duration ≥24 months, <3 months interruption, and posterior mandibular extraction (adjusted odds ratio 80.29) 3
- Some experts hypothesize stopping bisphosphonates 2 months prior to surgery may help healing, but this applies to long-term users, not short-term patients like yours 2, 1
Post-Extraction Monitoring
- Monitor healing closely over the following weeks 1
- Instruct the patient to report any signs of delayed healing, exposed bone, pain, or infection 8
- Resume normal alendronate dosing schedule without interruption 6
Common Pitfalls to Avoid
- Do not unnecessarily discontinue alendronate in short-term users, as this provides no benefit and may compromise fracture protection 1, 6
- Do not perform the extraction without antibiotic prophylaxis, as infection is a key risk factor for ONJ 2, 7
- Do not use overly aggressive surgical technique, as trauma increases ONJ risk 7, 6
- Do not confuse the low risk in osteoporosis patients with the much higher risk (6.7-11%) in cancer patients receiving high-dose intravenous bisphosphonates 2, 1