Duration of Fosamax Discontinuation Before Dental Treatment
There is insufficient evidence to definitively support routine discontinuation of Fosamax (alendronate) before dental procedures, though some experts suggest a 2-month drug holiday may allow better bone healing, with resumption delayed until complete mucosal healing occurs. 1
Evidence-Based Risk Context
The risk of medication-related osteonecrosis of the jaw (MRONJ) with oral bisphosphonates like Fosamax for osteoporosis is extremely low at less than 1 case per 100,000 person-years. 2 This contrasts dramatically with intravenous bisphosphonates used in cancer treatment, which carry a 6.7-11% incidence. 1
The Drug Holiday Controversy
Arguments Against Routine Discontinuation
- Bisphosphonates have an extremely long bone half-life, persisting for years after stopping treatment, suggesting a short drug holiday may provide no protective benefit. 1
- The 2019 MASCC/ISOO/ASCO guideline explicitly states there is insufficient evidence to support or refute the need for discontinuation before dentoalveolar surgery. 1
Arguments Supporting Discontinuation
- Some experts hypothesize that stopping bisphosphonates 2 months prior to oral surgery may allow better bone healing. 1, 2
- A 2025 study of 152,299 osteoporotic patients found that risk of osteonecrosis was substantially lower when intravenous bisphosphonates were paused for more than 90 days, and lowest when the pause exceeded one year. 3
- One case report documented BRONJ development after implant surgery despite following a 5-month discontinuation protocol. 4
Recommended Clinical Algorithm
Before Initiating Fosamax (Highest Priority)
- Complete comprehensive dental evaluation including orthopantomography and intraoral radiographs before starting bisphosphonate therapy. 1
- Perform all necessary invasive dental procedures (extractions, periodontal surgery) before initiating Fosamax—this eliminates MRONJ risk entirely. 1, 2
- Correct vitamin D deficiency prior to therapy to prevent hypocalcemia. 2
During Active Fosamax Therapy
- Elective dentoalveolar surgical procedures (non-medically necessary extractions, implants) should not be performed during active therapy. 1
- Maintain dental check-ups every 6 months once therapy has commenced. 1
- Address modifiable risk factors: poor oral health, ill-fitting dentures, uncontrolled diabetes, and tobacco use. 1
When Dental Surgery is Necessary
For patients requiring invasive dental procedures while on Fosamax:
Consider a 2-month drug holiday before the procedure (based on expert consensus, though evidence is insufficient). 1, 2
Implement surgical protocol:
Post-operative management:
Critical Caveats
The decision to discontinue must balance MRONJ risk against the risk of osteoporotic fractures during the drug holiday. 1 For most osteoporosis patients, fracture prevention benefits generally outweigh the minimal MRONJ risk. 2
Long-term oral bisphosphonate therapy (>5 years) significantly delays healing of extraction sockets, though BRONJ may not develop. 5
At least 60% of MRONJ cases occur after dentoalveolar surgery, particularly tooth extractions, making the timing of dental procedures critical. 1
Recent dental surgery or extraction is the most consistent risk factor for MRONJ. 2
Common Pitfalls to Avoid
Do not confuse the low risk in osteoporosis patients (<1 per 100,000) with the much higher risk (6.7-11%) in cancer patients receiving high-dose intravenous bisphosphonates. 1, 2
Do not perform extractions without antibiotic prophylaxis, as infection is a key risk factor for MRONJ. 2
Do not assume a short drug holiday will be protective—bone effects persist for years after stopping. 1
Ensure adequate calcium (800-1000 mg/day) and vitamin D (800 IU/day) supplementation throughout treatment. 2