Osteoporosis is a condition that leads to the weakening of bones, making them fragile and more prone to fractures. To manage osteoporosis, bisphosphonates are commonly prescribed as a medication to slow down bone loss and strengthen bones.

These medications are widely used in the treatment of osteoporosis and are generally well-tolerated. However, when it comes to dental treatment, bisphosphonate therapy can have implications, particularly concerning the jawbone.

This article aims to explore how osteoporosis bisphosphonate therapy affects dental care, outlining the potential risks, dental considerations, and management strategies for dental professionals and patients undergoing bisphosphonate treatment in Australia.

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What Are Bisphosphonates?

Bisphosphonates are a class of drugs that inhibit bone resorption, meaning they slow the process by which osteoclasts (bone-resorbing cells) break down bone tissue. By reducing bone resorption, bisphosphonates help to maintain bone density and strength, which is crucial for individuals with osteoporosis. Some of the most commonly prescribed bisphosphonates include:

• Alendronate (Fosamax)
• Risedronate (Actonel)
• Ibandronate (Boniva)
• Zoledronic acid (Reclast)

Bisphosphonates are available in both oral and intravenous forms, with the intravenous formulations being typically used for more severe cases of osteoporosis or in patients who cannot tolerate oral bisphosphonates.

Risk Factors For Onj In Patients On Bisphosphonates

Several factors increase the likelihood of developing ONJ in patients taking bisphosphonates, particularly those receiving intravenous therapy. These factors include:

• Duration of Bisphosphonate Use: The longer a person has been on bisphosphonate therapy, the higher the risk of developing ONJ. The risk is generally considered to increase with use over 3–5 years, but it can also occur in patients who have only recently started treatment.
• Type of Bisphosphonate: Intravenous bisphosphonates (e.g., zoledronic acid) are associated with a higher risk of ONJ compared to oral bisphosphonates. This is due to the higher potency and more direct effect on bone turnover.
• Dental Procedures: Invasive dental procedures, such as tooth extractions, dental implants, or periodontal surgery, can trigger the onset of ONJ. The trauma from these procedures can lead to infection and delayed healing, which is problematic for patients with suppressed bone turnover.
• Cancer Treatment: Patients undergoing bisphosphonate therapy due to cancer (e.g., for bone metastases) have a significantly higher risk of ONJ compared to those treated for osteoporosis.
• Poor Oral Hygiene or Pre-existing Dental Infections: Patients with poor oral hygiene or ongoing dental infections are at a higher risk of developing ONJ. Proper oral care is crucial in reducing this risk.
• Corticosteroid Use: Patients taking corticosteroids in conjunction with bisphosphonates may have an elevated risk of developing ONJ due to their combined effects on bone density and immune function.

Preventing Onj In Patients On Bisphosphonates

Given the potential risk of osteonecrosis of the jaw, dental professionals should take extra precautions when treating patients who are on bisphosphonates. Some of the strategies that may help to prevent ONJ include:

Comprehensive Dental Examination:

Before starting bisphosphonate therapy, it is essential for patients to undergo a thorough dental examination to assess oral health. This includes identifying any pre-existing dental issues such as cavities, gum disease, or infections that could increase the risk of complications during treatment.

Treating Dental Infections Before Starting Therapy:

It is essential to treat any dental infections or periodontal issues before initiating bisphosphonate therapy. Infections, such as abscesses or gum disease, should be addressed and resolved to reduce the risk of complications, including ONJ.

Avoiding Invasive Dental Procedures:

Whenever possible, it is advisable to avoid invasive dental procedures such as tooth extractions or implants in patients receiving bisphosphonates. If such procedures are necessary, they should be planned carefully, with extra precautions taken to minimise trauma to the jawbone.

Regular Monitoring And Maintenance:

Patients on bisphosphonates should maintain regular dental check-ups, ideally every 6–12 months. This helps to monitor for early signs of ONJ, such as pain, swelling, or exposed bone in the mouth.

Good Oral Hygiene Practices:

Patients receiving bisphosphonate therapy must maintain excellent oral hygiene to minimise the risk of gum disease and infection. Brushing twice daily with fluoride toothpaste, flossing regularly, and using antimicrobial mouthwash can help prevent oral health issues.

Management Of Dental Treatment For Patients On Bisphosphonates

If a dental procedure is necessary for a patient on bisphosphonates, the dentist must take specific precautions to manage the procedure safely and minimise the risk of complications. These include:

Coordination With The Physician:

Before undertaking any invasive dental procedure, the dentist should liaise with the patient’s prescribing physician to discuss the necessity of the procedure, the risks, and whether adjustments in the bisphosphonate treatment are warranted. In some cases, the physician may recommend discontinuing bisphosphonates for a period before the procedure to allow the bone to recover.

Use Of Conservative Procedures:

For patients on bisphosphonates, dentists may opt for conservative treatment options that do not involve invasive surgery. For example, if a tooth extraction is necessary, the dentist may consider root canal therapy as an alternative to tooth extraction to avoid any disruption to the bone.

Localised Antibiotics And Chlorhexidine Rinses:

For patients undergoing dental procedures, the use of localised antibiotics and chlorhexidine mouth rinses before and after the procedure may help prevent infection. These measures reduce the chances of post-surgical complications and ONJ.

Monitoring For Early Signs Of Onj:

After any dental procedure, the dentist should closely monitor the patient for signs of ONJ. Early symptoms include pain, swelling, exposed bone, and difficulty in healing after a dental procedure. If these signs are present, immediate referral to a specialist may be required.

Dental Implants In Patients On Bisphosphonates

Dental implants are a common and effective way to replace missing teeth. However, in patients undergoing bisphosphonate therapy, particularly intravenous bisphosphonates, the use of implants may be complicated by the risk of ONJ. Research on the safety of dental implants in patients with bisphosphonates is ongoing, but the general approach is to avoid implant placement in these patients unless absolutely necessary.

If implants are required, careful planning and coordination between the dentist, oral surgeon, and prescribing physician are crucial. Some protocols suggest delaying the initiation of bisphosphonate therapy or temporarily discontinuing oral bisphosphonates prior to implant placement to reduce the risk of complications.

Conclusion

While bisphosphonates are effective in managing osteoporosis and other bone-related conditions, they present unique challenges when it comes to dental care. The most significant concern is the risk of osteonecrosis of the jaw (ONJ), which can occur following dental procedures, particularly in patients receiving intravenous bisphosphonates.

Dental professionals must carefully assess the risk factors and take appropriate precautions, such as pre-treatment dental evaluations, avoiding invasive procedures when possible, and ensuring good oral hygiene to minimise the risk of complications. By working closely with the patient’s physician and carefully planning dental procedures, dentists can provide safe and effective care for patients undergoing bisphosphonate therapy.

Frequently Ask Question

Should I Inform My Dentist If I’m On Bisphosphonate Therapy?

Absolutely. It is critical to inform your dentist if you are undergoing bisphosphonate therapy, as it can influence the treatment plan and risk assessment for certain procedures. This helps the dentist take appropriate precautions, such as coordinating with your prescribing doctor or considering alternative treatment methods that are safer for your bones. By sharing your medication history, your dentist can provide the best care while reducing potential risks.

How Long Should I Wait Before Undergoing Dental Surgery After Stopping Bisphosphonates?

The waiting period before undergoing dental surgery after stopping bisphosphonates varies depending on whether you’re taking oral or intravenous bisphosphonates. For oral bisphosphonates, it is typically recommended to wait for at least three to six months before undergoing invasive dental procedures.

For patients on intravenous bisphosphonates, the waiting period may be longer, and your dentist will coordinate with your physician to ensure optimal timing for surgery. The decision will depend on individual circumstances and the type of bisphosphonate therapy you’re receiving.

What dental treatments are considered safe for patients who use bisphosphonates?

Routine dental care, such as check-ups, cleanings, and cavity fillings, is generally considered safe for patients on bisphosphonates. Non-invasive treatments like these carry a lower risk of complications compared to surgeries or extractions.

However, your dentist will monitor your oral health closely and adjust treatments if necessary to prevent complications. Regular visits to your dentist for preventive care are crucial to maintaining good oral health while on bisphosphonate therapy.