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Osteoporosis Medications and Oral Health

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Overview

There are approximately 10 million Americans aged 50 years or older with osteoporosis and an additional 34 million with low bone mass or “osteopenia,” which puts them at risk for osteoporosis.1 Due to related fractures, osteoporosis is responsible for considerable morbidity and mortality.2-7  An estimated 1.8 million individuals suffer a bone disease-related fracture each year.8,9

Antiresorptive agents, like bisphosphonates and denosumab, often are used to treat osteoporosis, lowering the risk of related fractures.  In rare cases, use of antiresorptive agents has been associated with osteonecrosis of the jaw. However, the risk of developing antiresorptive agent-induced osteonecrosis of the jaw (ARONJ) is low, with the highest prevalence estimated at 0.10% in a large sample of patients (n=952) who had taken oral bisphosphonates.10

Although osteonecrosis can occur spontaneously, more commonly ARONJ has been reported after dental treatments—most often invasive procedures like tooth extractions—in patients treated with antiresorptive agents.11

While it is not possible to identify who will develop ARONJ and who will not, research suggests the following risk factors exist12-15:

  • Age older than 65 years;
  • Periodontitis
  • Prolonged use of antiresorptive agents (more than two years)
  • Smoking
  • Denture wearing
  • Diabetes

Clinical Presentation
The typical clinical presentation of ARONJ includes pain, soft-tissue swelling and infection, loosening of teeth, drainage and exposed bone.  Patients also may complain of numbness, heaviness and dysesthesias of the jaw.  However, ARONJ may remain asymptomatic for weeks or months and may only become evident after bone in the jaw is exposed.16

Dental Management
NOTE: The recommendations discussed here apply only to patients who are prescribed antiresorptive agents to prevent or treat osteoporosis. 

An expert panel assembled by the ADA’s Council on Scientific Affairs developed recommendations for dental management of patients receiving medications for the prevention and treatment of osteoporosis.17 Because there currently is no data from clinical trials evaluating dental management of patients on antiresorptive therapy, the recommendations are based on expert opinion alone. The report contains recommendations related to general dentistry, periodontal disease management, implant placement and maintenance, oral and maxillofacial surgery, endodontics, restorative dentistry and prosthodontics, and orthodontics.  The panel also discusses C-terminal telopeptide (CTX) testing and drug “holidays.”

The panel advises that clinicians ask questions about osteoporosis, osteopenia and the use of one of the various antiresorptive agents, during the health history interview process.  However, routine dental treatment generally should not be deferred solely due to use of antiresorptive agents as the risks and consequences of no treatment likely outweigh the risk of developing ARONJ. 

All patients should receive routine dental examinations.  Patients who are prescribed antiresorptive agents and are not receiving regular dental care would likely benefit from a comprehensive oral examination before or early in their treatment.  While neither the physician nor the dentist can eliminate the possibility of ARONJ development, regular dental visits and maintaining excellent oral hygiene are essential parts of risk management.

Endnotes

1. National Osteoporosis Foundation. Osteoporosis review of the evidence for prevention, diagnosis and treatment, and cost effectiveness analysis. Osteoporos Int 1998;Suppl 4:S7-S80. PubMed 

2. Abrahamsen B, van Staa T, et al. Excess mortality following hip fracture: a systematic epidemiological review. Osteoporos Int 2009;20(10):1633-50. PubMed 

3. Braithwaite RS, Col NF, Wong JB. Estimating hip fracture morbidity, mortality and costs. J Am Geriatr Soc 2003;51(3):364-70. PubMed

4. Browner WS, Pressman AR, Nevitt MC, Cummings SR. Mortality following fractures in older women: the study of osteoporotic fractures. Arch Intern Med 1996;156(14):1521-5. PubMed

5. Caliri A, De Filippis L, Bagnato GL, Bagnato GF. Osteoporotic fractures: mortality and quality of life. Panminerva Med 2007;49(1):21-7. PubMed 

6. Cauley JA, Thompson DE, Ensrud KC, et al. Risk of mortality following clinical fractures. Osteoporos Int 2000;11(7):556-61. PubMed 

7. Ensrud KE, Thompson DE, Cauley JA, et al. Prevalent vertebral deformities predict mortality and hospitalization in older women with low bone mass: Fracture Intervention Trial Research Group. J Am Geriatr Soc 2000;48(3):241-9. PubMed 

8. Riggs BL, ed Epidemiology of Osteoporosis. In: Riggs BL, Melton LJ III (eds.) Osteoporosis: Etiology, Diagnosis, and Management. Philadelphia: Lippincott-Raven Publishers; 1995.

9. Chrischilles EA, Butler CD, Davis CS, Wallace RB. A model of lifetime osteoporosis impact. Arch Intern Med 1991;151(10):2026-32. PubMed 

10. Lo JC, O'Ryan FS, Gordon NP, et al. Prevalence of osteonecrosis of the jaw in patients with oral bisphosphonate exposure: Predicting Risk of Osteonecrosis of the Jaw with Oral Bisphosphonate Exposure (PROBE) Investigators. J Oral Maxillofac Surg 2010;68(2):243-53. PubMed

11. Migliorati CA. Bisphosphanates and oral cavity avascular bone necrosis. J Clin Oncol 2003;21(22):4253-4. PubMed 

12. Yarom N, Yahalom R, Shoshani Y, et al. Osteonecrosis of the jaw induced by orally administered bisphosphonates: incidence, clinical features, predisposing factors and treatment outcome. Osteoporos Int 2007;18(10):1363-70. PubMed 

13. Ruggiero SL, Mehrotra B, Rosenberg TJ, Engroff SL. Osteonecrosis of the jaws associated with the use of bisphosphonates: a review of 63 cases. J Oral Maxillofac Surg 2004;62(5):527-34. PubMed 

14. Mavrokokki T, Cheng A, Stein B, Goss A. Nature and frequency of bisphosphonate-associated osteonecrosis of the jaws in Australia. J Oral Maxillofac Surg 2007;65(3):415-23. PubMed 

15. Khamaisi M, Regev E, Yarom N, et al. Possible association between diabetes and bisphosphonate-related jaw osteonecrosis. J Clin Endocrinol Metab 2007;92(3):1172-5. PubMed 

16. Damato K, Gralow J, Hoff A, et al. Expert Panel Recommendations for the Prevention, Diagnosis, and Treatment of Osteonecrosis of the Jaws: June 2004 (PDF).

17. Hellstein JW, Adler RA, Edwards B, et al.; for the American Dental Association Council on Scientific Affairs Expert Panel on Antiresorptive Agents. Managing the Care of Patients Receiving  Antiresorptive Therapy for Prevention and Treatment of Osteoporosis: Recommendations from the American Dental Association Council on Scientific Affairs. Nov. 2011 (PDF)

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Additional ADA Resources

The Journal of the American Dental Association

For the Dental Patient

For the Dental Patient is a JADA column that is geared toward patient education and intended to facilitate discussion between dentists and patients.

ADA Catalog

The materials listed below can be ordered online through the ADA Catalog:

  • Osteoporosis Medications and Your Dental Health (W418) 

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Other Resources

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