What is the recommended approach for continuing or discontinuing bisphosphonates (BIS) prior to dental implants in a patient with a history of bisphosphonate use?

Management of Bisphosphonates Prior to Dental Implants

For patients requiring dental implants, complete all dental work and allow adequate healing time before initiating bisphosphonate therapy; for patients already on bisphosphonates, consider discontinuing treatment prior to invasive dental procedures to reduce the risk of osteonecrosis of the jaw (ONJ), with the decision based on duration of therapy and route of administration.

Risk Stratification by Bisphosphonate Type and Duration

Intravenous Bisphosphonates

• Dental implants are contraindicated in patients receiving IV bisphosphonates due to the substantially higher risk of ONJ compared to oral formulations 1
• IV bisphosphonate schedules show 0-1% incidence of ONJ with osteoporosis dosing, but monthly IV schedules demonstrate even higher rates 2

Oral Bisphosphonates: Duration-Based Approach

• For patients on oral bisphosphonates <3 years with no other risk factors: Dental implant placement may proceed with informed consent about ONJ risk, which remains low but present 3
• For patients on oral bisphosphonates ≥3 years: The American Association of Oral and Maxillofacial Surgeons recommends greater caution, and discontinuation should be strongly considered prior to and following surgery 1
• The risk of ONJ increases with cumulative bisphosphonate exposure duration, particularly beyond 5 years 2

Timing of Bisphosphonate Discontinuation

Before Initiating Therapy (Ideal Scenario)

• Patients who require dental work should have this completed and be given time to heal before bisphosphonate initiation 4
• This represents the optimal approach to prevent ONJ complications 5, 6

For Patients Already on Therapy

• For invasive dental procedures including implant placement, discontinuation of bisphosphonate treatment may reduce the risk for ONJ 5, 6
• The FDA labels for both alendronate and risedronate explicitly state this recommendation 5, 6
• Clinical judgment should guide the management plan based on individual benefit/risk assessment 5, 6

Key Risk Factors for ONJ

The most consistent risk factor for developing ONJ is recent dental surgery or extraction 4, 2

Additional risk factors include:

• Invasive dental procedures (tooth extraction, dental implants, boney surgery) 5, 6
• Poor oral hygiene 5, 6
• Concomitant therapies (chemotherapy, corticosteroids, angiogenesis inhibitors) 5, 6
• Pre-existing dental disease, periodontal disease 5, 6
• Duration of bisphosphonate exposure 2, 5, 6

Clinical Algorithm for Decision-Making

Step 1: Assess Current Bisphosphonate Status

• Not yet on bisphosphonates: Complete all dental implant work first, allow healing, then initiate therapy 4
• On IV bisphosphonates: Dental implants are contraindicated 1
• On oral bisphosphonates <3 years: May proceed with caution and informed consent 1, 3
• On oral bisphosphonates ≥3 years: Strongly consider discontinuation 1

Step 2: Evaluate Fracture Risk vs. ONJ Risk

• High fracture risk patients (history of fragility fractures, very low BMD): The decision to discontinue becomes more complex, requiring careful weighing of fracture risk against ONJ risk 5, 6
• Moderate-to-low fracture risk patients: Discontinuation is more favorable given the lower consequence of temporary cessation 7
• Consider that bisphosphonates have prolonged skeletal retention, providing residual antifracture protection even after discontinuation 8

Step 3: Duration of Drug Holiday

• No specific duration is established in guidelines, but bisphosphonates continue to provide bone protection for months to years after stopping due to skeletal accumulation 8
• Studies suggest persisting antifracture efficacy for 1-2 years after stopping treatment 8
• The drug holiday should be individualized based on the specific bisphosphonate's half-life in bone 2

Step 4: Informed Consent Requirements

• All patients treated with bisphosphonates must have the risk of possible implant loss and ONJ explained and provide informed consent prior to dental implant surgery 1
• Document the discussion of risks, benefits, and alternatives 1

Critical Pitfalls to Avoid

• Do not assume oral bisphosphonates are safe for dental implants simply because ONJ incidence is "rare" - the devastating nature of the complication requires preventive action 9, 1
• Do not place implants without knowing bisphosphonate history - screening all patients for bisphosphonate use is essential 3
• Do not rely on screening tests to predict ONJ risk - current diagnostic tests are unreliable for predicting individual patient risk 3
• Ensure all patients on long-term bisphosphonates have oral examination and maintain good oral hygiene 2

Evidence for ONJ with Dental Implants

• Case reports document severe periimplant infection, exposed bone, and osteonecrosis persisting for months in patients on oral bisphosphonates for ≥3 years 9
• Histologic examination shows osteonecrosis, severe inflammatory osteolysis, and heavy bacterial colonization associated with failed implants in bisphosphonate users 9
• The overall incidence remains very rare (<1 case per 100,000 person-years), but the severity of complications justifies preventive measures 4

When Bisphosphonate Continuation is Necessary

If bisphosphonates cannot be discontinued due to very high fracture risk:

• Optimize oral hygiene before and after implant placement 5, 6
• Use prophylactic antibiotics (though evidence is limited) 9
• Ensure close monitoring for early signs of ONJ (exposed bone, delayed healing, pain) 5, 6
• Consider alternative osteoporosis therapies that do not carry ONJ risk (e.g., teriparatide, though this has its own considerations) 10