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Oral Bisphosphonates, Osteonecrosis, and Dental Implants
Dr. Gold submits:
About 80 million people in the US alone take bisphosphonates for cancer, osteoperosis, etc. It is clear that patients who have received IV bisphosphonates are at high risk for osteonecrosis in the mandible and maxilla.
What is not clear is the situation for patients who have taken bisphosphonates via the oral route. Not as much data has been collected on oral bisphosphonates and osteonecrosis and dental implant failure. However, the evidence for is mounting daily that orally administered forms of bisphosphonates may lead to osteonecrosis. What does this imply for dental implant placement in these cases?
Are you familiar with any anecdotal case reports of patients who have take oral bisphosphonates and experienced osteonecrosis associated with dental implant failure? What are your thoughts on the connection between Oral Bisphosphonates, Osteonecrosis, and Dental Implants? Please leave your comments below.
Note: For additional discussion on this topic, please also see Dental Implant Contraindications where we discuss IV bisphosphonates in greater length.
February 19, 2006 in Dental Implant Contraindications, Oral Bisphosphonates | Permalink
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Comments
As a periodontist, I have performed several hundred surgical procedures on osteoporotic and osteopenic patients. In the past year, I treated one patient taking Fosamax, with extractions and sinus graft procedures. The clinical healing was representative of the published cases of osteonecrosis. When I contacted the patients physician for medical approval to discontinue Fosamax for about one month, she informed me that all patients in her office are told to discontinue oral or injected bisphosphonates when treated for fractures. Their rationale is to prevent impaired healing related to bisphosphonates. I just thought that this case was worth reporting to Osseonews readers.
Posted by: Barry P. Levin, DMD | Feb 21, 2006 1:53:29 PM
I have treated many many osteoporotic patients with implants, and in fact lectured and published on the subject. I saw no contraindications to treating them as long as they were treated with care. Now I am very concerned about placing them in patients who have been taking these medications. Certainly these patients must be given proper informed consent. The scary thing is these drugs are being marketed to practically every aging woman in the world. I think there needs to be a way to get the word out on this side effect that dentistry seems to know about before medicine does.
Posted by: Dr. Crystal Baxter | Feb 21, 2006 2:14:57 PM
I have experienced the same with a patient taking Fosamax on mandibular implants. She has since lost the 2 implants for the molar and premolar areas. She is finally on the road to healing, but had to combat a superinfection with Actinomycosis as well. If a case comes up, doing debridement is not the treatment, nor is hyperbaric oxygen. You need to get rid of the oral bisphosphonate for about 1 to 2 months and treat with clindamycin 150 mg tid for a month. This combination really works well. No research, but it's worked!!
Posted by: Robin D. Henderson, DMD | Feb 21, 2006 2:18:39 PM
I have now seen 12 patients in my OMFS practice that have experienced Osteonecrosis either due to recent extractions, periodontal surgery, and three that have had spontaneously exposed tori or alveolar bone (one denture wearer). This has been over the course of the last year. I can recall however, the placement of bone grafts in advance of dental implants in several patients. It has been my experience that the graftd sites had type I bone that was great for primary stability, but went on to have failed integration.
In talking with a Hematologist/Oncologist regardign the bisphosphonate dilemma we are experiencing, it has been her recommendation to have patients that have been on these medications for more than two years consecutively to either go to a monthly maintenance dose, alternate months, or discontinue entirely depending on the patient's clinical situation.
Having tried to debride the areas in some of the patients, only to have soft tissue breakdown, to follow, I have discontinued this procedure six months ago. Two of the patients went on to have hyperbaric oxygen therapy, yet continued to have bone exposure. It is my opinion that Osteoblast/Osteoclast axis is shifted so far to the right as to generate bone that no longer has the vascular capacity for repair or remodeling and hence becomes necrotic with no forseeable end in sight. JOMS Vol 63, Number 11, Nov 2005 has a great review article on the subject for those who would like more information.
DAS
Posted by: Dave Salmassy, DMD | Feb 21, 2006 2:47:35 PM
At this time it appears from published studies in peer reviewed journals and many anecdotal reports that ALL patients receiving oral bisphosphonates are at risk for developing osteonecrosis of the maxilla and mandible. Originally the focus was on bisphosphonates delivered via IV. However the mechanism of action of oral bisphosphonates is the same as those delivered via IV.
Posted by: | Feb 21, 2006 4:29:15 PM
Having read thoroughly the articles penned by Dr Robert Marx from Miami, I will not place implants in individuals taking the drugs until further evidence shows evidence they will not cause the necrosis. I trained under Dr Marx, and his opinion is good enough for me. At this time, I have seen delayed healing with the oral forms, and I have seen one case with the IV form. According to current information, stopping the drug does not help as it remains in the body for at least 10 years. Until this is resolved, I believe the implant market for these individuals is hindered. All it takes is one case of total necrosis to wipe out a thousand successes.
Posted by: | Feb 21, 2006 5:03:24 PM
Oral bisphosphonates may actually emerge as a more siginifcant problem simply because of the vast number of people taking them. Now that we are all more aware of the complications of bisphosphonates maybe we will have more cases being reported yielding more data for analysis.
Posted by: | Feb 22, 2006 3:06:12 AM
Latest information from peer discussions relative to word from Harvard oncologist is that while Fosamax is a Bisphosphonate, there is a chemical structural difference and a shorter half life. Recommendation is that Fosamax is discontinued for 3 months after which oral surgery can be done with relative safety. Probably good to use prophylatic antibiotic coverage. After "healing" Fosamax is continued. How this relates to implants is a matter of speculation. I'm unaware of literature relative to this at this time. I'd certainly be interested in more information regarding this anectdotal posting before doing implants.
Posted by: L. V. Franz | Feb 23, 2006 5:19:04 PM
I had upper and lower dental implants a year ago. Today my doctor prescribed Fosamax plus D...NOW I'm worried about taking the medicine..I don't want all my implants to fall out! Input please ! I'm 58 and have osteopenia in the hips..just diagnosed.
Posted by: Linda Thompson | Feb 25, 2006 8:27:02 PM
Emory School of Medicine CE course last month provided me with enough information that would NOT have me consider any implants for these patients. I think we're about to see a major problem grow even bigger.
Posted by: | Feb 26, 2006 8:16:40 AM
Double trouble;
I have a patient who had a carcinoma of the base of the tongue treated with radiation successfully in 1997. In the last year he started Fosamax. He presented with a large necrotic area in an edentulous space distal to a lower first molar with a periodontal pocket. I've referred him to an endodontist for treatment of the first molar. We've (his ENT, internist and I) discontinued the Fosamax and have the patient irrigating with chorhexidine and have had him on Clindimicin. Could this have started as a mucositis on the lingual side of the mandible? (Fosamax is noted for esophogitis) Time will tell on the success of our treatment plan.
Posted by: Robert P. Marier, DDS, FAGD | Feb 27, 2006 7:58:05 AM
As an Implantologist/General Dentist I am very concerned with the bisphosphonate attention. I do my best to educate my patients of the risks of osteonecrosis of the jaws. However, when the pts consult their attending physicians the pts are being told that dentists are being overdramatic and there is no need to be concern. What do DDS' know that MD's don't?
Posted by: | Feb 27, 2006 9:39:41 PM
I had a single case of osteonecrosis with implant placement. Implants had to be removed, bone debrided and closed. Patient was taking Fosamax and methotrexate.
Posted by: Steve Wallace | Mar 1, 2006 6:39:09 AM
Anyone have any idea why bisphosphonate related osteonecrosis appears to be limitted to the maxilla and the mandible? The general population that is taking the oral bisphosphnates, such as Fosamax, mostly AARP eligable people, certainly includes many who have had knee or hip replacement surgery. Why wouldn't we be getting reports of osteonecrosis complicatons with these procedures?
Posted by: Joseph S. Towbin, DDS | Mar 1, 2006 7:30:04 AM
Is it possible that the incidence of O.N. seen in the facial skeleton may be that these bones are intramembranous versus the rest of the skeleton being endochondral bone? It might be an excellent literature review to see if there has been incidents of O.N. at the interface of prosthetic joints, especially those made of titanium as are our beloved dental implants. Perhaps it is a specific interaction with titanium and the facial osseous tissue altered by bisphosphonates.
Posted by: Joseph Margarone III DDS | Mar 1, 2006 6:30:40 PM
In my old publications I stated that osteoporosis is seen in the maxilla and mandible even before it is the rest of the body (especially in edentulous patients). We may just be seeing the tip of the iceberg.
Regarding MD's they are not omnipotent, we are the ones who find the most oral cancer, and I have had MD's refer me pizza burns for biopsy. Dentists know far more about oral disease than MD's, and this is as it should be.
Posted by: Dr. Crystal Baxter | Mar 2, 2006 7:40:25 AM
Dr. Baxter, I agree that dentists should know more about oral disease than MD's, as an Internist should know more about hypertension. The truth is far from that, as most dentists have tried to make their practices more profitable by acting as specialists without the proper technical training, knowledge and most importantly they fail to recognize their limitations.
Remember, failure to diagnose is a very common allegation against General Dentists and this a trend that worsens daily.
Posted by: | Mar 4, 2006 12:49:29 AM
Iam an OMF Surgeon from Brisbane, Australia. I have recently seen a case of Fosamax-induced ONJ of the anterior maxilla, which was initiated just by the wearing of a partial upper denture. The frightening thing about it was that the elderley patient had been on oral Fosamax only, and had been off the drug for at least 3 months, before the ONJ set in. My colleagues are coming around to the conclusion that there may not be any real "safe" period to be off Fosamax before doing any Oral Surgery.
Posted by: Dr Frank Moloney | Mar 4, 2006 3:51:42 PM
I have seen some interesting comments and questions posted regarding Bisphosphonate induced Osteonecrosis of the Jaws. Most clinicians only see a few of these patients in their practices and aren't sure how to treat them. I invite the readers to review our article published in JOMS, Nov.2005 for a thorough review of our findings in 119 patients. I would be happy to e-mail the article to those without access to the JOMS.
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
E-mail: vbrouma1@newssun.med.miami.edu
Posted by: Vishtasb Broumand DMD MD | Mar 6, 2006 8:25:47 PM
As an Oral Surgeon from Sydney Australia I have been referred three cases of Bis-Phossy Mouth -- two in the maxilla and one mandibular one in the 3rd molar region. It would appear that the reason why the Bisphosphonate Osteonecrosis occurs only in the maxilla or mandible is because they hold teeth (and implants) in an interface of periodontium (or peri-implantium) which is prone to inflammation and contamination. Nowhere else in the body does such an interface occur. It makes one think about the placement of implants for patients who are yet to be diagnosed at osteoporotic.
Posted by: Dr Evan Godfrey | Mar 7, 2006 11:58:14 AM
In the last 3 years, I have seen about 4 patients in which my referring dentist took out periodontally involved teeth and they did not heal. All of them were taking Fosamax. I extensively followed two patients and performed multiple debridements on them. One of them finally healed 18 months later. The other one is still not healed. After the first two patients, I refer all osteonecrosis post extraction to the university. Not sure if they can do much either. In these cases, doing less maybe better! I would not place implants in a Fosamax patient.
Posted by: Victor Ho DMD (oral surgeon) | Mar 7, 2006 4:52:09 PM
Go to www.powelllaw.com - they know about the problem and will help YOUR? patient!
This is posted on Drug.com but nothing in side effect of the biophos's lists bone issues.
Posted by: R. Menke, DDS | Mar 8, 2006 6:05:27 AM
My wife has been taking fosamax over a year for early osteoporosis. She is 56 yrs old. She has pretty good teeth; but after reading all these coments I'm concerned for the future. Should she discontue using this drug? Are there any other treatments to prevent or reverse osteoporosis that do not have this potentially serious side affects?
Posted by: Dr. Lawrence Lizzack | Mar 8, 2006 3:04:12 PM
Lawrence, besides being a Prosthodontist, I am getting to the age that bone loss is an issue with me, especially with a family history of osteoporosis. Personally I won't be touching these drugs witha 10 foot pole.
Posted by: Dr. Crystal Baxter | Mar 10, 2006 2:32:31 PM
Crystal, Good to see you still can deliver that "sharp" commentary. This problem is new to most of us and will only become more visible with time. Thanks to everyone for posting their experiences and comments-it has been very helpful. Herm D.
Posted by: H. Donatelli | Mar 14, 2006 8:51:13 PM
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