BISPHOSPHONATE DRUGS--Must read if taking or considering taking!!!
Updated: Aug 18
Our recent patient had a tooth flapping in the wind and wanted it taken out. It could be plucked by pinching it with your finger and out of his mouth in a flash. Because this patient had been taking bisphosphonates (I.V. form) we referred him to the oral surgeon to remove the tooth and in turn the surgeon referred him to OHSU to have it extracted. What?! Why couldn't any of us dentists here in the Medford valley remove it???
What is this Drug?
In our latter years osteoporosis is the most common bone disease in America and this disease makes us vulnerable to increased fracture risks. Bisphosphonates et al. are commonly prescribed to slow the process of bone breaking down. Fosamax, Actonel, Boniva, and Reclast are all common bisphosphonates. There are two primary forms of administering the drug: pill and I.V.. Both are taken over long time periods but I.V. is definitely stronger and used in more dire conditions.
Note there are non-bisphosphonate medications that are also used like Denosumab (Prolia or Xgeva) or Romosozumabs; however, these too are associated with similar complications to bisphosphonates.
What's the Big Deal? Patients taking bisphosphonates have a dangerous risk of consequences with jaw-related procedures, predominantly tooth extractions. The major sequelae is "Medication-related osteonecrosis of the jaw" (MRONJ). This is jaw death and usually is treated by physically removing half of the jaw--not a good look. Those taking bisphosphonates in pill form have a 1 in a 1,000 chance of getting MRONJ. It's worse for those taking bisphosphonates in I.V. form, which is 1 in 100! This is a large enough concern that the majority of educated dentists typically will refer to a specialist every time a tooth is needing to come out on these patients. What complicates this even more is when you've taken the last bisphosphonate medication in your life, the risk still lingers for 7 years afterwards.
What is MRONJ?
Medication-related osteonecrosis of the jaw (MRONJ) occurs when the blood supply is syphoned from your bone. After a tooth extraction for example, the bone may get minimal blood supply to that area and thus dry out causing necrosis (bone death) in the extraction site. This can occur regardless if the tooth is needing to be drilled out or on the opposite spectrum is flapping in the wind prior to coming out. If necrosis does occur, treatment is to cut off the infected jaw to prevent the necrosis from spreading and prevent infection and death.
Who's at Risk?
We do not have the means yet to predict who will and won't acquire MRONJ, but there are increased risk factors if you have any of the following conditions:
Older than 65-years old
Poor oral hygiene
IV bisphosphonate use for at least 2 years
Dr. Nelson is not saying whether to take bisphosphonate drugs--this is outside of our scope of practice. This is a decision between you and your medical provider. What we do say is to be aware of consequences regardless if you take the pill or I.V. form. We obviously favor the pill form but know that either form will linger in your system for 7 years after the last medication taken. That is 7 years where a general dentist should not remove your tooth without proper palliative treatments. If a tooth extraction is needed while taking bisphosphonates or up to 7 years after your last dose, a hyperbaric chamber would be requisite with more than 16 visits (before and after treatment) costing more than $1,000. We recommend the hyperbaric chamber located at the Neuro Clinic in Grants Pass, Oregon.
There are other medications that can be a replacement for bisphosphonates (Forteo, Miacalcin, or Tymlos) that do not have the same MRONJ risks as bisphosphonates; however, they may not be as effective in treating osteoporosis and your prescribing physician may still recommend bisphosphonates.
In the meantime, take better care of your teeth and health and this may minimize the potential risk factors for MRONJ.
At Central Point Family Dentistry we care about you and your health and if you have further questions please reach out to us at (541) 664-8300.