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 are Bone Density Drugs?
Bone density drugs are given by medical providers to patients who usually have bone deficiencies like osteoporosis or cancer that has metastasized to the bone. These may include bisphosphonates or denosumabs and can be taken by either pill or injection. The mechanism of these drugs work by inhibiting osteoclasts (cells that break bone down) thus minimizing the bone from resorbing at a faster rate.
What's the Big Deal?
Patients taking these medications coupled with a tooth extraction, have a greater propensity in developing osteonecrosis of the jaw (ONJ)—where the jaw bone dies. Though the risk of having ONJ is currently rare: 1 in 500 for IV bone density drugs and 1 in 2,000 for those taking them in pill form, the risk is great enough where the consequences are very drastic and destructive if you did get ONJ.
How Does One Get Osteonecrosis of the Jaw?
ONJ can occur mainly from tooth extraction(s) but can also be caused from dental cleanings or other invasive dental procedures. ONJ can occur weeks or even years after treatment and even in that waiting period the smallest form of trauma like from a toothbrush, chewing hard foods, or a denture sore spot can aggravate ONJ to initiate the destructive process.
What are the Signs and Symptoms?
ONJ begins in the bone near a tooth extraction site and is either asymptomatic or has an intermittent dull toothache type of pain deep into the bone. This can progress to bone exposed in the mouth with the gingiva unable to close over it, and can be nearly impossible to reverse without aggressive surgery. Destruction can be asymptomatic or painful, never seal, lead to a wider opening, and introduce more infection.
Treatment Options
Treatment may be long and difficult. Palliative treatment entails 1) applying Peridex to the site 3x/day 2) taking penicillin 4x/day and 3) daily doses of vitamin E. These need to be done daily for life or until the site heals. We highly suggest monthly visits at our or an oral surgeon’s office to monitor the size of the exposure. A hyperbaric chamber of 16+ visits ($1,000+) post dental treatment can be encouraged but the jury is still out on its effectiveness. If the site fails to heal, surgery or hospitalizations would be the next step. The surgeon would likely remove the compromised bone, which often means cutting out most of the jaw and placing metal plates in lieu of bone, screws, and grafts for reconstructive surgery.
Who is Vulnerable to Getting ONJ?
We do not have the means yet to predict who will and won't acquire ONJ, but there are increased risk factors if you have any of the following conditions when taking bone density drugs:
Cancer, especially when it metastasizes to bone
Comorbidities (2-plus ailments)
Immunocompromised
IV bisphosphonate use for at least 2 years
Older than 65-years old
Poor oral hygiene
Smoking
Wear dentures
Dental Recommendations
Dr. Nelson is not saying whether to take bisphosphonate drugs--this is outside of our scope of practice. 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 ONJ can still occur even after mild dental treatment. If a tooth extraction is needed, leaving the compromised tooth is a weighed decision. In the meantime, just take better care of your teeth while on bone density drugs and let's avoid removing teeth if you can.
**If you are about to begin bone density drugs, make sure ALL pending dental treatment gets completed beforehand.
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.