Should an older adult on Fosamax (alendronate) for osteoporosis, taken for less than three years without additional risk factors, stop the medication before a routine dental extraction?

Fosamax Does Not Need to Be Stopped Prior to Routine Dental Extractions in Low-Risk Patients

For an older adult taking Fosamax (alendronate) for less than three years without additional risk factors, routine dental extraction can proceed without stopping the medication. The risk of medication-related osteonecrosis of the jaw (MRONJ) is extremely low in this population, and there is insufficient evidence to support routine drug holidays before dental procedures in patients on oral bisphosphonates for osteoporosis. 1

Risk Stratification: Who Can Proceed Safely

Low-risk patients who do NOT require bisphosphonate discontinuation include those with:

• Oral bisphosphonate use for osteoporosis (not oncologic dosing) 1
• Duration < 3 years of therapy 2, 3
• No history of prior MRONJ 1
• Good oral health and no active dental infection 1
• No concurrent glucocorticoid use 1
• No diabetes mellitus 1
• Non-smoker status 1

The incidence of MRONJ with osteoporosis-dose oral bisphosphonates is less than 1 case per 100,000 person-years, making it an extremely rare complication. 4, 5 This risk is dramatically lower than the oncologic-dose intravenous bisphosphonate population where MRONJ guidelines were originally developed. 1

Evidence Against Routine Drug Holidays

The 2019 MASCC/ISOO/ASCO Clinical Practice Guideline explicitly states there is insufficient evidence to support or refute the need for discontinuation of bisphosphonates before dental surgery, even in cancer patients receiving higher oncologic doses. 1 For osteoporosis patients on lower doses, the evidence is even weaker for requiring drug holidays.

A prospective study of 132 patients undergoing tooth extraction while continuing oral bisphosphonates found that BRONJ did not develop in any patient, regardless of treatment duration, though healing was delayed in those on therapy > 5 years. 3 This demonstrates that continued therapy during extraction is safe, even if healing may be slightly prolonged.

When Bisphosphonate Discontinuation Should Be Considered

Higher-risk scenarios where temporary discontinuation (2-3 months before and after surgery) may be discussed include:

• Duration > 5 years of bisphosphonate therapy 3, 6
• Concurrent glucocorticoid use (> 7.5 mg prednisone daily) 1
• History of prior MRONJ 1
• Planned extensive dentoalveolar surgery (multiple extractions, alveoloplasty, implants) 1
• Active dental infection or poor oral health 1
• Sjögren's syndrome or other autoimmune conditions 7
• Diabetes mellitus 1
• Tobacco use 1

However, even in these scenarios, the decision to stop bisphosphonates must weigh the fracture risk during the drug holiday against the small absolute risk of MRONJ. 1

Critical Pre-Extraction Preventive Measures

Rather than stopping Fosamax, focus on these evidence-based preventive strategies:

• Complete comprehensive dental examination before initiating bisphosphonates when possible 1, 4
• Optimize oral hygiene and treat any active infections before extraction 1
• Use prophylactic antibiotics perioperatively 3
• Achieve primary wound closure when feasible 3
• Ensure adequate calcium (1000-1200 mg/day) and vitamin D (800 IU/day) supplementation 4, 8
• Avoid unnecessary invasive procedures (elective implants, alveoloplasties) while on therapy 1, 5

Post-Extraction Monitoring Protocol

After dental extraction in patients continuing Fosamax:

• Evaluate healing every 6-8 weeks until complete mucosal coverage occurs 1
• Watch for delayed healing (more common with duration > 5 years but not indicative of MRONJ) 3
• Monitor for exposed bone, pain, swelling, or purulent discharge as signs of potential MRONJ 1, 7
• Maintain communication between dentist and prescribing physician 1

Common Pitfalls to Avoid

Do not automatically stop bisphosphonates for routine dental work in low-risk osteoporosis patients, as this exposes them to unnecessary fracture risk without proven benefit. 4 The vertebral fracture reduction benefit of alendronate (49-53% reduction) far outweighs the extremely rare MRONJ risk in this population. 5

Do not confuse osteoporosis-dose oral bisphosphonates (alendronate 70 mg weekly) with oncologic-dose intravenous bisphosphonates (zoledronic acid monthly), which carry a 100-fold higher MRONJ risk. 1, 6 Guidelines developed for cancer patients do not directly apply to osteoporosis management.

Do not delay medically necessary dental extractions in patients on bisphosphonates, as untreated dental infections themselves increase MRONJ risk. 1 Prompt treatment of dental disease is more important than drug holidays.