Bisphosphonates: Are you managing these patients correctly?

If you’ve been in practice for a while, you’ll notice that your patients are living longer. They’re becoming diabetic. They’re developing heart disease.

And often, they’re taking bisphosphonates for osteoporosis.

Seeing OSTEOPOROSIS on a medical history should immediately signal a red flag. We should immediately think Bisphosphonates and MRONJ (previously BRONJ): medication-related osteonecrosis of the jaw. BRONJ became MRONJ to include other medications like denosumab (monoclonal antibody) that can increase the risk of ONJ.

A common bisphosphonate used for osteoporosis management.

Ideally, we are advised to manage all dental needs before any of these medications are started — e.g. extract any teeth with poor prognosis .

But let’s be honest, how often does that really happen. Most of the time patients present having already taken the medication for many years.

So what do we do??? Fortunately, the American Association of Oral and Maxillofacial Surgeons has a very clear position on this.

Intravenous bisphosphonates or antiangiogenic drugs for cancer (e.g. multiple myeloma)

No extractions. No oral surgery. No implants.

Avoid procedures that involve direct osseous injury. So, in the event that there is apical periodontitis, perform endodontics — even if it is not restorable.

Oral bisphosphonates for less than 4 years

• Oral surgery can be performed. But always inform them of the <1% risk of MRONJ
• Are they suitable for dental implants ? Yes, but warn of long term implant failure and risk of ONJ.
• Consider: Alternating dose of bisphosphonates; Drug holidays or alternative medication than bisphosphonates.

Oral bisphosphonates less than 4 years, with corticosteroids or antiangiogenic medications

• Discontinue oral bisphosphonates (drug holiday) for at least two months prior to oral surgery, if systemic conditions permit.
• Do not restart medication until osseous healing has occurred (approximately 3 months).

Oral bisphosphonates for more than four years with or without any concomitant medical therapy

• Discontinue oral bisphosphonates (drug holiday) for at least two months prior to oral surgery, if systemic conditions permit.
• Do not restart medication until osseous healing has occurred (approximately 3 months).

HANG THIS MEDICATION LIST ON YOUR FRIDGE DOOR AND KEEP AN EYE OUT!

Antiresorptive Medications — *Keep note of IV bisphosphonates*

Antiangiogenic Medications

*Taken from AAOMS Medication-Related Osteonecrosis of the Jaw — 2014 Update

*AAOMS is still unsure whether systemic marker tests (e.g. CTX) of bone turnover is an effective method to determine ONJ risk.

• Drug holidays? Still no consensus that it helps prevent MRONJ — however “extrapolated data” has shown that drug holidays cause fluctuations in osteoclast function helping improve outcomes of MRONJ treatment.

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