What is the relationship between Alendronate (bisphosphonate) and periodontitis?

From the Guidelines

Alendronate should be used with caution in patients with periodontitis due to the potential risk of osteonecrosis of the jaw, as highlighted in the 2018 American Society of Clinical Oncology clinical practice guideline update 1. When considering the use of alendronate for periodontitis, it is essential to weigh the benefits against the potential risks. The mechanism of action of alendronate, which involves inhibiting osteoclast activity to reduce bone resorption, may be beneficial in preserving alveolar bone and maintaining tooth attachment. However, the potential for complications such as osteonecrosis of the jaw, as noted in the 2018 guideline update 1, must be carefully considered.

Some key points to consider when using alendronate for periodontitis include:

• The typical dosage of alendronate for periodontitis patients is 70 mg once weekly as an oral tablet, although lower doses of 10 mg daily may also be used.
• Treatment duration usually ranges from 6 months to several years, depending on the patient's response and underlying bone health.
• Alendronate should be used as an adjunct to standard periodontal therapy, such as scaling and root planing.
• Patients should be aware of potential side effects, including esophageal irritation, musculoskeletal pain, and rare complications like osteonecrosis of the jaw.
• Proper administration is crucial, with patients taking alendronate with a full glass of water while sitting upright and remaining upright for at least 30 minutes afterward to prevent esophageal irritation.

It is also important to note that a 2024 narrative review on drug-induced atrial fibrillation found an increased risk of atrial fibrillation associated with alendronate use, with an odds ratio of 1.86 (1.09-3.15) 1. However, this risk must be balanced against the potential benefits of alendronate in preserving alveolar bone and maintaining tooth attachment in patients with periodontitis. Ultimately, the decision to use alendronate for periodontitis should be made on a case-by-case basis, taking into account the individual patient's risk factors and medical history, as well as the potential benefits and risks of treatment 1.

From the Research

Alendronate and Periodontitis

• Alendronate is a nitrogen-containing bisphosphonate that inhibits bone resorption by osteoclasts 2
• A study found that alendronate sodium had a positive effect on bone density in patients with periodontitis, with a statistically significant difference in bone density observed in the alendronate group 3
• However, alendronate sodium had no effect on clinical parameters such as pocket depth, attachment level, and gingival index in patients with periodontitis 3

Risks Associated with Alendronate

• Osteonecrosis of the jaw (ONJ) is a rare but potential side effect of alendronate treatment, with an incidence rate of 2.53 per 10,000 patient-years 4
• Recent, long-term, and compliant use of alendronate are associated with an increased risk of surgically treated ONJ 4
• Tooth extraction is a significant risk factor for ONJ in patients taking alendronate, with a 9.6-fold increased risk 5
• Concomitant rheumatoid arthritis and drug duration exceeding 3 years are also independent predictors of ONJ 5

Management and Prevention

• Preventive measures should be taken to avoid ONJ, including careful dental evaluation and necessary dental treatment before starting alendronate therapy 6
• Patients with periodontitis should be closely monitored while taking alendronate, and tooth extraction should be performed with caution 5