What are the recommendations for managing a patient's Biz phosphates (phosphate supplements) regimen before a dental restoration procedure?

Managing Bisphosphonates Before Dental Restoration Procedures

Direct Recommendation

Complete a comprehensive dental evaluation and finish all necessary invasive dental work before starting bisphosphonate therapy whenever feasible; for patients already on bisphosphonates requiring dental restoration, proceed with the restoration while maintaining excellent oral hygiene, as routine restorative dentistry (fillings, crowns, bridges) does not require bisphosphonate discontinuation. 1, 2, 3

Risk Stratification by Procedure Type

Non-Invasive Dental Restorations (Fillings, Crowns, Bridges)

• Routine restorative dentistry does not penetrate bone and carries negligible osteonecrosis of the jaw (ONJ) risk, so bisphosphonates should be continued without interruption 1, 4
• Patients can proceed with standard restorative procedures while maintaining their bisphosphonate regimen 4

Invasive Procedures Requiring Bone Manipulation

• Tooth extractions, implant placement, periodontal surgery, and apicoectomies carry the primary ONJ risk and require specific protocols 1, 2, 5
• The most consistent risk factor for ONJ is recent dental surgery or extraction, with at least 60% of cases occurring after dentoalveolar surgery 2

Pre-Treatment Protocol (Before Starting Bisphosphonates)

This is the gold standard approach that eliminates ONJ risk entirely:

• Perform comprehensive dental evaluation of both hard and soft tissues, including radiographic examination 1, 3, 6
• Complete all necessary invasive dental procedures before initiating bisphosphonate therapy 1, 2, 3
• Treat all active oral infections and eliminate high-risk sites 2
• Correct vitamin D deficiency prior to bisphosphonate therapy to avoid hypocalcemia 2, 6

Management for Patients Already on Bisphosphonates

Drug Holiday Controversy

The evidence on bisphosphonate discontinuation before dental procedures remains equivocal:

Arguments for drug holiday:

• 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

Arguments against drug holiday:

• Bone effects of bisphosphonates persist for years after stopping, suggesting a short drug holiday may have no protective effect 2, 3
• The American Society of Clinical Oncology states there is insufficient evidence to support or refute the need for discontinuation before dentoalveolar surgery 2

Practical Algorithm When Invasive Procedures Are Necessary

For oral bisphosphonates (osteoporosis patients):

1. Assess treatment duration: risk increases with longer duration (>5 years significantly delays healing) 7
2. Ensure excellent oral hygiene and correct vitamin D deficiency 2, 6
3. Administer prophylactic antibiotics perioperatively 2, 3
4. Use atraumatic extraction technique with primary closure 2
5. Suspend bisphosphonate until complete mucosal healing occurs 2
6. Schedule follow-up every 6-8 weeks until complete healing 2, 3

For intravenous bisphosphonates (cancer patients):

• The decision to interrupt therapy must balance ONJ risk (6.7-11% incidence) against risk of pathologic fractures and spinal cord compression 2, 6
• Defer resumption until the dentist confirms complete healing 2

Risk Context by Bisphosphonate Type

Oral Bisphosphonates (Alendronate, Risedronate)

• ONJ incidence is very rare at <1 case per 100,000 person-years for osteoporosis treatment 2, 6
• Risk increases with frequency, dose, and duration of administration 1, 2

Intravenous Bisphosphonates (Zoledronic Acid, Pamidronate)

• ONJ incidence ranges from 6.7-11% in multiple myeloma or metastatic cancer patients 2, 6
• Substantially higher risk than oral formulations 2

Ongoing Monitoring Requirements

• Maintain excellent oral hygiene throughout bisphosphonate therapy 1, 2, 3
• Schedule dental check-ups every 6 months once therapy has commenced 2, 3
• Measure serum calcium before starting treatment and monitor renal function before each IV dose 1, 2
• Provide calcium (800-1000 mg/day) and vitamin D (800 IU/day) supplementation unless contraindicated 1, 2, 6

Critical Caveats

• Patients should inform their dental practitioner of their bisphosphonate treatment 1
• Do not confuse the low risk in osteoporosis patients with the much higher risk in cancer patients receiving high-dose intravenous bisphosphonates 2
• Patients with suspected ONJ should be referred to a dental practitioner or oral surgeon with expertise in treating this condition 1, 2
• Many patients lack knowledge about their bisphosphonate therapy and its oral complications, so dentists must be prepared to educate them 8