Oral Health Topics
Osteoporosis Medications and Oral Health
Overview
Because some medications can affect your oral health or your dental treatment plan, your dentist should know about all the medications that you take. For example, antiresorptive agents (which include bisphosphonates), can influence dental treatment decisions. These types of medications may be used to prevent or treat osteoporosis (a thinning of the bones) or as part of cancer treatment. They also are used to treat Paget’s disease of the bone.
Some antiresorptive agents (such as Fosamax, Actonel, Atelvia, Didronel, Boniva) are taken orally (swallowed) to help prevent or treat osteoporosis and Paget's disease of the bone. Others, such as Boniva IV, Reclast or Prolia, are administered by injection. Higher and more frequent dosing of these agents are given as part of cancer therapy to reduce bone pain and hypercalcemia of malignancy (abnormally high calcium levels in the blood) associated with metastatic breast cancer, prostate cancer and multiple myeloma.
How do these medications affect dental treatment plans?
These medications have been associated with a rare but serious condition called osteonecrosis (OSS-tee-oh-ne-KRO-sis) of the jaw (ONJ) that can cause severe damage to the jawbone.
While osteonecrosis of the jaw can occur spontaneously, it more commonly occurs after dental procedures that affect the bone or associated tissues (for example, pulling a tooth). Your dentist can tell you if the proposed treatment involves these tissues.
Am I at risk?
It’s not possible to say who will develop osteonecrosis and who will not. Most people (94 percent) diagnosed with ONJ associated with these medications are patients with cancer who are receiving or have received repeated high doses through an infusion. The other 6 percent of people with ONJ were receiving much lower doses of these medications for treatment of osteoporosis.
It may be beneficial for anyone who will be starting osteoporosis treatment with antiresorptive agents to see their dentist before beginning treatment or shortly after. This way, you and your dentist can ensure that you have good oral health going into treatment and develop a plan that will keep your mouth healthy during treatment.
Should I cancel or postpone dental treatments?
Patients who take antiresorptive agents for the treatment of osteoporosis typically do not need to avoid or postpone dental treatment. The risk of developing osteonecrosis of the jaw is very low. By contrast, untreated dental disease can progress to become more serious, perhaps even involving the bone and associated tissues, increasing the chances that you might need more invasive treatment.
People who are taking antiresorptive agents for cancer treatment should avoid invasive dental treatments, if possible. Ideally, these patients should have a dental examination before beginning therapy with antiresorptive agents so that any oral disease can be treated. Let your dentist know that you will be starting therapy with these drugs. Likewise, let your physician know if you recently have had dental treatment.
Should I stop taking my medication?
It is not generally recommended that patients stop taking their osteoporosis medications. The risk of encountering bone weakness and a possible fracture are higher than those of developing osteonecrosis.
You should talk to your physician before you stop taking any medication.
What are the symptoms of osteonecrosis of the jaw?
Symptoms include, but are not limited to:
- pain, swelling, or infection of the gums or jaw
- injured or recently treated gums that are not healing
- loose teeth
- numbness or a feeling of heaviness in the jaw
- exposed bone
Contact your dentist, general physician or oncologist right away if you develop any of these symptoms after dental treatment.
Additional ADA Resources
ADA.org
For the Dental Patient
For the Dental Patient is a column in the Journal of the American Dental Association that offers a basic overview on topics of interest to patients and can be a helpful source of information to refer to when talking with your dentist about your oral health.
- Osteoporosis Medications and Your Dental Health (November 2011) (PDF)
Other Resources
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.
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)
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.
- Osteoporosis Medications and Your Dental Health (November 2011) (PDF)
ADA Catalog
The materials listed below can be ordered online through the ADA Catalog:
- Osteoporosis Medications and Your Dental Health (W418)
Other Resources
- U.S. Food & Drug Administration MedWatch Program. If a practitioner suspects a patient to have ARONJ, they should contact the FDA’s MedWatch program online or by calling 800-FDA-1088
- The National Osteonecrosis Foundation
