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Dental Implant Contraindications
Dr. Nimchuk asks:
This week I have had three patients who have come in for consultations for dental implant placements but who are on bisphosphonates (Fosamax) for the treatment of osteoporosis.
Because of the potential for developing osteonecrosis of the jaws, oral surgery procedures are contraindicated in these cases. This means no extractions or dental implants.
Going off the drug will not make them better candidates for dental implants because the effects of bisphosphonates lasts for years. These drugs seem to be prescribed almost routinely for women over age 60 if there is any suspicion of osteoporosis. Right now there are quite a few class action lawsuits where persons on bisphosponates have had complications. Does anyone have any experience with this dilemma or a protocol for managing these patients?
January 30, 2006 in Treatment Planning & Complications | Permalink
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Comments
Let me preface my remarks by saying that this is not legal advice. I recently attended the International Associaation of OMFS meeting in Vienna and there was a symposia on management of the osteonecrosis patient on bisphosphonates. Fortunatly, almost all reported cases are due to the use of IV bisphosphonates (the exact number escapes me but I remember it being less than 50 worldwide on Fosamax and over 1500 reported on the IV drugs). The general consensus of that meeting (again NOT legal advise) was the routine dentoalveolar surgery including implant placement in patients on Fosamax was OK, but contraindicated in those on the IV meds. Obviously those on IV meds have significant medical problems including metastatic disease, lymphoma, ect. As an oral sureon, I don't really have much choice about extracting some teeth on patients on Fosamax, but I do have a "talk" first about risks/benefits.To put it in perspective, Fosamax has been used for years in millions of doses and ther are precious few reports of negative side effects. I think you have to discuss the situation in detail with the patient when you are doing elective surgery.
Posted by: Larry S. | Jan 31, 2006 3:06:34 PM
I agree with Larry S. Fosamax has not been shown to be much of a problem, but the I.V. bisphosphanates are. There is a good review of this subject in the Dec. issue of JADA.
Posted by: M. hunter | Jan 31, 2006 3:25:48 PM
I just inserted an abutment today on a patient who had the implant placed in June. The patient has lupus and is also on Fosamax. There was excellent tissue response and solid integration. This was done with a one-stage protocol. There is significantly less risk with Fosamax than with IV bisphosphonates. However, when performing elective procedures we do have to fully inform our patients of potential problems. Placing the complications in proper perspective.
Posted by: A Friedman,OMS | Jan 31, 2006 5:12:23 PM
I wouldn't. What is the difference b/n this case and premedicating for heart murmur ? Very low incident but still there. There is a good article by R. Marx in JOMS 2005.
Posted by: Matt L. | Jan 31, 2006 5:16:56 PM
Given the high #'s of pts. on fosomax (oral bisphonates), the high # of implants placed generally,the low # of pts on fosomax w/ concurrent reports of osteonecrosis, & finally ,the relatively low # of failures in postmenopausal women (most likley to be taking fosomax), I do not believe that its use is a contraindication. Certainly, i think of it as a possible risk factor (like smoking, etc.) and I think there must be a study going on someplace to give us further data, In the meantime, I do discuss w/ my patients. This drug has 1/2 life of 10 years, so we may be getting more news!
Posted by: F Lifshey OMS | Jan 31, 2006 5:36:45 PM
To respond to Matt L.: the AHA has significantly reduced the number of conditions for which prophylaxis is required simply because the evidence for it's efficacy was not there. Along the same lines, the evidence for substantial problems with Fosamax is not (currently) there. Another analogy is that there is a very real risk of anaphylaxis with oral antibiotics, yet we still utilize them. It's a risk/reward evauation we all make daily.
Posted by: Larry S. | Jan 31, 2006 5:49:39 PM
I had a consultation today regarding an extraction and the immediate placement of an implant with a patient on fosomax, The tooth must be extracted. I informed her of the risks and the reports we've all been reading as of late. I have placed implants for the last 22 years including patients on fosomax. I have never seen a complication in the fosomax patients I've treated. That does not mean I am blind to the risks. While we must be prudent I do not feel that we should be afraid to offer informed patients surgical care because of this apprantly rare occurance if that's what they really need and they are not in the higher risk IV treatment group.She decided to proceed with the above treatment.
Posted by: A. Prestup, Perio | Jan 31, 2006 6:24:40 PM
I've contacted Dr. Marx and he recommends discussing the remote possibility of problems with patients but still places implants in patients taking Fosamax. I've been doing the same but letting the fixtures integrate longer before restoring.
Posted by: Mike H. | Jan 31, 2006 6:25:16 PM
when i was doing my residency i had examined a patient who was on biphosphonate. she had very big lesions around all 4 lower implants that she had placed a few years ago. i think that there is initial osseointegation but at some point the patient presents with a big lesion around the implant. That was a single case. I have also seen one more case like this in my practice.
Posted by: yianni | Feb 1, 2006 12:48:16 AM
Please read our article out of the University of Miami, published regarding Bisphosphonates in the November Issue of JOMS 2005. I would be happy to e-mail the article to anyone if you'd like it.
Vishtasb Broumand, DMD, MD
Oral & Maxillofacial Surgery
Head and Neck Tumor and Reconstructive Surgery
Assistant Professor of Clinical Surgery
Division of Oral & Maxillofacial Surgery
University of Miami School of Medicine/ Jackson Memorial Hospital
9380 S.W. 150th Street, Suite 170
Miami, FL 33157
Cell: (305) 502-4117 Office: (305) 256-5270 Fax: (305) 256-5280
E-mail: vbrouma1@newssun.med.miami.edu
Posted by: Vishtasb Broumand DMD MD | Feb 1, 2006 10:52:07 AM
A complete discussion of risks and benifits withthe patient is essential. I have had patients elect coronectomy and root canals and have had patients elect extractions. I picked up a case of osteonecrosis prior to its publication in the literature and the patient subsequently died from what I felt was the draining effect of prolonged antibioitcs. There is no effective treatment. While the risks of occurance are extreemely low, the consequences are devastating. The decision is therefore in this office always on the conservativbe side. F Bonine
Posted by: F Bonine | Feb 2, 2006 7:30:05 AM
One of the toughest lower 1st molar extractions I've done was on a pt taking bisphosphonates long before we knew anything about the drug. It seemed as if the bone was denser than the root, which crumbled repeatedly. Patient stayed on the meds and I preped the site 5-6 months later for the implant. I looked down into the 4.5 x 10 mm drilled site and saw (in a post extraction case!) absolutely no cancellous bone and no bleeding. Type I - very unusual! That gave me a heads up to a potential problem. Secondarily, the talk of "spontaneous" osteonecrosis is probably due to decreased vascular perfusion and increased bacterial susceptibility. BTW, the 1st implant failed and the 2nd is still there.
Posted by: Roy Mintzer | Feb 7, 2006 4:43:02 PM
The complications may appear years later following the surgical procedure. Spontaneous cases of OJN have been reported in the complete absence of dental treatment. At this time all patients on oral or IV bisphosphonates have the potential for grave complications.
Posted by: | Feb 9, 2006 5:14:42 PM
I agree with the lack of current information to substantiate contraindication of dentoalveolar surgery including implants in Fosamax patients. Nearly all of the osteonecrosis complications are with IV bisphosphonates as stated with previous postings. Please see my article with my colleagues in Nov 2005 JADA.
Posted by: Joseph Margarone III DDS (OMS) | Feb 12, 2006 6:54:11 PM
Have patient, 76 year old African American come in for pain on #2, and #31. Was undergoing tx for multiple myeloma and recieving zometa as well. Did not know at the time the effects of bisphosphonates, especially IV. The bone was hard as a rock, but I thought it was due to the fact that he was African American. Saw him 6 months later, upper extraction site was healed on the panex but 31 site had little to no bone in the socket. Also the tissue had failed to cover over completely. Mild purulence noted. Spoke with the oncologist today, he said he would get back to me regarding future tx. Pt has multiple areas of decay on #'s 21-27. I will be interested to see what his recommendations are for future treatment. Seems to me he should have had all his teeth out prior to treatment for his cancer.
Posted by: Paul | Mar 16, 2006 12:01:38 PM
I am planning to have an implant in my missing lower left molar tooth. I know the positive sides but there aren't much comments on the negative sides. Could you please let me know about the after effects?
Many thanks,
Meri
Posted by: Meri | Apr 7, 2006 5:12:47 AM
I have been reading all on biphosphonates. On the last 3 years, I have routinely prescribed SodiumAlendronate 70 mg once a week + Calcium Carbonate 1200 mg with D Vitamin 400 UI daily to ALL my patients that underwent a major bone graft (ICBG for atrophic maxilla, ICBG as block, large sinus lifts). I start 15 days after surgery, and finish it 1 month after the prosthesis is placed. Usually then I discontinue the Sodium Alendronate, and keep a lower dose of the CaCarb+ D Vit. I have not done lab research, but the clinical evidence is amazing! Very little bone graft resorption. Very good bone density. I place implants (SLA Straumann SP or TE) 4-5 months after graft, and load them at 6-8 weeks. I am working on a retrospective report, 15 consecutive cases of total edentulous maxilla, 118 implants, 2 lost. My clinical impression is strong that it makes a difference. However, due to all this comments, on my last patient I prescribed only CaCarb+D Vit. Remember that I prescribed only for a maximum of 10 consecutive months, and then discontinued it. Comments?
Posted by: WP | Apr 12, 2006 9:49:53 PM
Fosamax, Actonel, Boniva, Zometa, and Aredia are all in a class of drugs called bisphosphonates and are commonly marketed as medications to help and prevent or treat bone loss in osteoporosis.
Unfortunately with women taking these drugs at an earlier age and for much longer time spans, they are at an increased risk of developing osteonecrosis of the jaw (ONJ).
There have been over 2,400 patients since 2001 that have reported bone death and jaw bone decay or osteonecrosis of the jaw. In addition, more than 120 patients have suffered from such severe pain and debilitation that they have become bedridden or in need of devices like crutches, walkers and wheelchairs.
Posted by: Robert H Hilley IV | May 10, 2006 12:11:38 PM
Am postmenopausal osteopenic 58 y.o. on Fosamax 2 yrs. this Aug. Recent bone scan shows increased density hip, decrease in femur. Very recent panex: very little change from '91. 22-plus y.o. fixed bridge spans anchoring back lower molar and eye tooth, where it's come loose. Must either replace bridge or retain anchor teeth and fill in teeth 19, 20 & 21 with implants. Seek advisability of implants. Basically healthy. On thyroid meds. Functional heart murmur/mild MVP. Prone to bruxism. Take cal/mag citrate w/extra D and occasional silica, which supposedly transmutates to calcium. Calcium carbonate kidney stone '92. Lithium carbonate intake '69-'81.
Posted by: Susan O. | Jun 1, 2006 9:06:13 PM
Have there been any reported cases of ONJ when patients who took fosamax wore a partial on the lower jaw? I am choosing not to get implants to replace three lower teeth that were extracted years ago, but I'm wondering if a removable partial would be okay.
Posted by: mbacin | Jun 12, 2006 5:37:44 PM
Has any one had experience with a patient having greatly increased pain during recuperation from periodontic reconstructive osseous surgery.
Posted by: gary gromet | Jun 26, 2006 1:10:05 PM
I am considering upper jaw split surgery for palatal expansion followed by extensive orthodontics and removal of pieces of lower jaw, all to correct a bad bite and improve my apprearance. I'm 50 and have been on 70 mg Fosamax for 1 year. My oral surgeon has expressed reservations about this course of action. Please advise.
Posted by: ssimatic | Jun 27, 2006 1:32:12 PM
I am considering upper jaw split surgery for palatal expansion followed by extensive orthodontics and removal of pieces of lower jaw, all to correct a bad bite and improve my apprearance. I'm 50 and have been on 70 mg Fosamax for 1 year. My oral surgeon has expressed reservations about this course of action. Please advise.
Posted by: ssimatic | Jun 27, 2006 1:32:19 PM
Have been on Fosamax and Actonel for a total of 9 years. Had a dental implant on tooth 3 last August. In February the tissue on the implant dissapeared, and after a CT scan, found major bone loss. I think as time goes on, long term use will present more and more negative results.
Posted by: GT | Jul 7, 2006 5:11:59 AM
I have several questions for you about your statement online on osseonews.blogs. What information do you have on the crippling of patients who have taken Fosamax? As I am experiencing side effects now, I am desperate for some help. Also, I have osteonecrosis of the lower jaw and I am scheduled for bone graft surgery Wednesday. I took Fosamax for four years so I have reservations about which is more dangerous, the surgery or the osteonecrosis.
Thanks!
Theresa
Posted by: Theresa | Jul 17, 2006 9:09:51 AM
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