Fosamax, Boniva, and Dentistry

Are you taking or do you know someone who is taking bisphosphonates? Bisphospho-what? Well, you probably have heard of bisphosphonates, but you know them as Fosomax, Actonel, or Boniva. These drugs are commonly prescribed for osteoporosis. While men are prescribed these medications it is mostly Caucasian women with slight builds who take these bisphosphonates. These drugs are advertized widely on television and in magazines and people are led to believe they are safe and effective drugs for osteoporosis with no real risk. Most patients have not been told of any oral health risks associated with the use of bisphosphonates when these drugs are prescribed. However, even short term use of bisphosphonates poses a dental risk of which many people are unaware.

Before I started this I thought I’d do a search on Google to see what comes up when you enter “Fosamax dental”. The very first site to come up was a link to a lawyers office. As I looked through the list half of the sites on the first page that came up were links to attorney offices. Yikes! I guess that should be a warning sign right there.

Bisphosphonates are used to treat osteoporosis and osteopenia and some cancers involving the bone. Osteoporosis is the thinning of bone tissue and loss of bone density over time while osteopenia is the term for thin bones. Some bisphosphonates are taken orally, and others are taken intravenously (IV).

The dental risk that we must be aware of is a rare disorder called osteonecrosis of the jaw (ONJ), or death of the jawbone. Sounds pretty awful, doesn’t it? Since 2003, there have been reports of a possible link between bisphosphonates and ONJ. The death of the jawbone is a condition marked by pain, swelling, infection and exposed bone. The majority of cases of ONJ involved people with cancer who were receiving chemotherapy and had been given IV bisphosphonates to treat cancer that had spread (metastasized) to the bone.

However, in January 2009, USC School of Dentistry reported in the Journal of the American Dental Association that a small but growing number of cases of ONJ have been reported in people taking oral bisphosphonates — such as Fosamax, Actonel, and Boniva — for osteoporosis. These have occurred primarily where a person has active dental disease or has had a recent dental procedure, such as a tooth extraction. The USC study reported that 4% (9 of 208) of the healthy patients in the group who were evaluated for ONJ had been taking bisphosphonates orally. This was startling!! It had previously been believed that only those receiving IV bisphosphonates were at risk, that the risks to those taking this drug orally was negligible.

In theory bisphosphonates are supposed to strengthen bone, however interrupting the natural process of bone recycling is proving to be very dangerous in some cases. Here’s a quick little lesson on how these drugs work:

Bisphosphonate medications act as bone strengtheners and increase bone density by binding to the bone and slowing down osteoclastic (bone-destroying) activity which increases osteoblastic (bone-building) effectiveness.

This helps prevent fractures in the hip, spine, and other skeletal regions, but it may disrupt the osteoclast and osteoblast activity in the jaws, impairing the bone destroying osteoclasts’ ability to remove and repair or contain diseased bone. Bone healing requires the breakdown of diseased bone to replace it with healthy bone. This impairment causes bone building osteoblasts to overbuild or wall off diseased bone. As osteoblasts build new bone, the failure of bone destroying osteoclasts to remove contaminated bone interferes with the development of the necessary structure on which to lay down healthy bone.

Bisphosphonates irreversibly alter the metabolism of the bone destroying osteoclasts, so there is little or no bone resorption, even if the blood supply is good. This is what dental professionals are concerned about because once the osteoclasts are destroyed there is no bone healing.

Symptoms of ONJ can include loose teeth, pain in the jaw, swelling, exposed bone, and/or recurring infection. Keep in mind that the risk of developing ONJ due to bisphosphonate use is very low in people without cancer or dental problems.

Recent studies have also shown that bisphosphonates may actually cause the exact thing they are supposed to prevent – bone fractures. A study was published in The Journal of Orthopaedic Trauma (JOT) in May 2008 that reported 20 patients with fractures in their thigh bones (femur). 19 of those patients had been taking Fosamax. Patients stated that after weeks or months of unexplained aching their thigh bones simply snapped while they were walking or standing!!

If your doctor prescribes a bisphosphonate for you be sure and talk to your doctor about the risks associated with this drug. Ask about options. Maybe you would respond to weight bearing exercises and diet changes. If you are already taking bisphosphonates you should be sure to have routine dental exams and maintain excellent oral hygiene. If you have a dental infections you should pursue aggressive nonsurgical treatment where possible. You should have root canal treatment done if needed rather than having the tooth extracted. You should not have dental implants as they may result in ONJ.

After reading this you might think that stopping the medication would be a good thing, however, stopping the medication is not thought to make any difference in the outcome. Bisphosphonates accumulate in the bones for up to 30 years making a patient who once received bisphosphonate therapy to be at significantly increased risk for ONJ, and dental treatment must be carefully considered. If extractions are needed referral to the oral surgeon may be recommended.

If your doctor recommends and you decide to take a bisphosphonate for osteoporosis, consider getting any needed dental work done before starting this medication. If you currently take an oral bisphosphonate and need a dental procedure, you should discuss this with your doctor and dentist, don't just stop taking the medication without first talking to your doctor.

You can see how important it is to let your dentist know if you are taking a bisphosphonate or if you have ever taken this drug. We aren’t just being nosey when we ask what medications you are taking. The fact is, your health may be vitally affected if we proceed with dental treatment without this knowledge.

Here is a list of the different Bisphosphonate Medications:

Generic: Alendronate, Risedronate, Etidronate, Tiludronate, Pamidronate, Ibandronate, Zoledronate.

Trade Name: Fosamax, Fosamax Plus D, Actonel, Actonel with Calcium, Didronel, Skelid, Aredia, Boniva, Zometa, Reclast.

ref: JADA, Jan 2009; JOT, May 2008; Science Daily www.sciencedaily.com