Management of Fosamax Prior to Dental Extraction
For patients who have taken Fosamax (alendronate) for more than 4 years, consider a 2-month drug holiday before dental extraction, though the American Dental Association does not recommend routinely stopping bisphosphonates for dental procedures.
Guideline Recommendations: Conflicting Approaches
The management of bisphosphonates before dental extraction remains controversial, with two major professional societies offering different guidance:
American Association of Oral and Maxillofacial Surgeons Position
- Recommends a 2-month drug holiday for patients who have taken bisphosphonates for more than 4 years before dental extraction 1
- This recommendation specifically applies to patients on long-term therapy (>4 years) 1
American Dental Association Position
- Does not recommend stopping bisphosphonates for dental procedures 1
- However, if tooth extraction or implant is planned, initiation of new bisphosphonate therapy could be deferred until the area has healed 1
Risk Context for Decision-Making
Understanding the actual risk helps frame this decision:
- Overall ONJ risk in osteoporosis patients: 1 in 10,000 to 1 in 100,000 (0.001% to 0.01%) 1
- Risk with long-term therapy (>4 years): Up to 21 in 10,000 (0.21%) 1
- Risk of ONJ specifically with tooth extraction in bisphosphonate-exposed patients: 0.5% 1
- Recent evidence suggests risk reduction: A 2025 study found that pausing bisphosphonates for more than 90 days substantially reduces ONJ risk, with the lowest risk when the pause exceeds one year 2
Practical Clinical Algorithm
For patients on Fosamax <4 years:
- Proceed with dental extraction without stopping Fosamax 1
- Ensure good oral hygiene and routine dental care 1
For patients on Fosamax ≥4 years:
- Consider a 2-month drug holiday before extraction 1
- Optimal pause duration: Evidence suggests >90 days provides substantial risk reduction, with >1 year showing the lowest risk 2
- Balance this against the patient's fracture risk during the drug holiday 1
For all patients:
- Maintain good oral hygiene before and after the procedure 1
- Use antibacterial mouth rinse 1
- Ensure adequate calcium and vitamin D supplementation 3
Important Caveats
The Bisphosphonate Reservoir Effect
Bisphosphonates accumulate in bone and are released for months or years after stopping 1, 4. This means:
- A short drug holiday may have limited biological effect on reducing ONJ risk 5
- The long half-life of alendronate means bone effects persist even after discontinuation 1, 4
- However, recent data suggests that longer pauses (>90 days, ideally >1 year) do correlate with reduced ONJ risk 2
Fracture Risk During Drug Holiday
- Bisphosphonates show residual antifracture efficacy for 1-2 years after stopping 4
- For patients at high fracture risk, the 2-month holiday poses minimal fracture risk 1
- Do not extend the drug holiday beyond what is necessary for the dental procedure 1
Case Report Evidence
- A 2019 case report documented BRONJ development after implant surgery despite following the 5-month discontinuation protocol 6
- This suggests that even recommended discontinuation periods may not completely eliminate risk in some patients 6
Type of Bisphosphonate Matters
- The 2-month recommendation is based primarily on oral bisphosphonates like alendronate 1
- For IV bisphosphonates (zoledronic acid), the risk profile and optimal discontinuation period may differ 2
Post-Extraction Management
If extraction proceeds: