Bisphosphonate Use and Your Oral Health

Your eyes are the gateway to the soul, but your mouth is the gateway to the body. In recent years, Physicians have started to take a more careful look at the correlation oral health has on overall health. In a recent study by the American Dental Association, of persons with serious gum disease, 40% were more likely to have additional chronic conditions such as diabetes or heart disease. The results of this study makes it apparent that a lack of oral care dramatically increases the risk of additional overall health problems. In reaction to this we should try and take care of ourselves by visiting our Physicians regularly, eating healthy and taking necessary, sometimes prescription, medications. But who would have expected that these certain medications could be one of the main contributing factors to one of the most serious oral health conditions. Osteonecrosis of the jaw, or ONJ, is a serious condition that has become all too common. The cause of this influx of persons effected by this condition is due to the use of a class of drug called bisphosphonates. For us here at WYOMS, we have seen a steady increase of patients plagued by ONJ. We are wanting to spread awareness of the increased use of this class of drug and more importantly inform those who are faced with its use, the proper protocol to follow before beginning treatment.

Bisphosphonates were originally used solely for the treatment of osteoporosis. Prescribed as both preventative and therapeutic, they come in two forms; oral and intravenous. The job of a bisphosphonate is to dramatically decrease the break down or degeneration of bone, and they are good at their job. Some may be thinking, ok, if the drug is doing its job, isn’t that a good thing? And yes it is, however, the breakdown of bone is a natural process the body needs in order to reproduce new bone. With bisphosphonate use, this breakdown process is halted and without this necessary trigger, the body, in situations of surgery or trauma, does not know to reproduce and heal bone. So what about drug fasting? Bisphosphonate medications cannot be fasted from. Their effects are long lasting and, once taken, they immediately concentrate in the bones and remain there unaltered for decades. Even after full discontinuance, bisphosphonate medications are always present and cannot be fully metabolized out of the system. With such a systemic effect, it is incredible to note that complications because of their use have only been documented in the upper and lower jaws. So why the increase in cases of Osteonecrosis of the Jaw? In 2013 at the Annual San Antonio Breast Cancer Symposium, it was announced that bisphosphonate use should be added to the standard of treatment of post menopausal women diagnosed with breast cancer. In a series of studies, it was found that adjunct bisphosphonate use with the already core standard of treatment dramatically reduced bone metastases and significantly increased the survival rate. 34% was the over all reduction of bone recurrence and a 17% or 1 in 6 reductions of the risk of breast cancer related death. Those statistics are incredible, and we are not denying that bisphosphonates are beneficial and a necessary treatment protocol, however, we would like to stress that before starting any new medication regiments, it should be encouraged to follow the correct pre-dose protocol.

In the case of bisphosphonate use, the correlation of spontaneous Osteonecrosis of the Jaw is staggering. This condition can be the outcome from simple procedures such as routine dental cleanings or the unassuming situation of an ill-fitting partial or denture, to the more invasive procedures such as tooth extraction. ONJ does not differentiate and results in the chronic sometimes recurring exposed areas of dead bone.  We at WYOMS highly suggest following the outlined protocol below before starting any of the listed bisphosphonate medications. Your future oral health depends on it.

Oral Bisphosphonates: Actonel, Boniva, Fosamax, Skelid,  & Didronel

Proper Protocol

  • Complete dental exam including a panoramic radiograph
  • Definitive comprehensive treatment to include oral hygiene instruction and education to maintain excellent oral health
  • Eliminate dental and periodontal pathology
  • Allow healing following invasive procedures before therapy begins
  • Regular follow up care to maintain excellent oral health

Intravenous Bisphosphonates: Aredia, Zometa, Reclast & Bonefos

Proper Protocol

  • Complete dental exam including a panoramic radiograph
  • definitive comprehensive treatment to include oral hygiene instruction and education to maintain excellent oral health.
  • COMPLETE elimination of dental and periodontal pathology. This includes crowns on teeth susceptible to fracture, extraction of non-restorable teeth, and creation of an oral environment that the patient can efficiently maintain in a high state of health.
  • Allow adequate healing time (2-3 weeks) before initiation of IV therapy
  • Avoid orthodontic treatment