Osteoporosis Drug Increases Risk of Dental Complications

Osteoporosis Drug Increases Risk of Dental Complications
By Michael Smith, North American Correspondent, MedPage Today
Published: January 02, 2009
Reviewed by Robert Jasmer, MD; Associate Clinical Professor of Medicine, University of California, San Francisco .


LOS ANGELES, Jan. 2 -- Even short-term use of oral alendronate (Fosamax) can increase the risk of osteonecrosis of the jaw as a complication of dental procedures, researchers here said.
Action Points
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■Explain to interested patients that osteoporosis is often treated with oral bisphosphonates, of which alendronate (Fosamax) is the most widely prescribed.


■Note that this study suggests that dental extractions or denture trauma can lead to osteonecrosis of the jaw among patients taking alendronate.
In a single-institution, retrospective study, 4% of patients taking oral alendronate developed osteonecrosis, compared with none of a large population of dental patients who didn't take the drug, according to Parish Sedghizadeh, D.D.S., of the dental school at the University of Southern California, and colleagues.


The finding contradicts claims that the rate of osteonecrosis in alendronate patients is about 0.7 cases per 100,000, or less than 0.00001%, the researchers said in the Jan. 1 issue of the Journal of the American Dental Association.


Indeed, that purported rate is so low that an expert panel selected by the dental association's scientific affairs council said in December that routine dental treatment should not be altered on the basis of oral bisphosphonate use, the researchers noted.


That position is incorrect, Dr. Sedghizadeh said in a statement. "We've been told that the risk with oral bisphosphonates is negligible, but 4% is not negligible," he said.


"Here at the school of dentistry we're getting two or three new patients a week who have bisphosphonate-related ONJ (osteonecrosis of the jaw)," he said, "and I know we're not the only ones seeing it."


Osteoporosis affects more than 10 million Americans, the researchers noted, and alendronate is the most widely prescribed oral bisphosphonate. In 2006 it was the 21st most prescribed drug overall.


But there is little epidemiological research to quantify the risk of osteonecrosis among dental patients taking the drug, the researchers said.


To help fill the gap, they queried the dental school's medical records system for long-term patients with a history of alendronate use.


Of the 208 they found, nine had stage two or three osteonecrosis of the jaw, four of them after an extraction and five as a consequence of denture trauma.


In contrast, the researchers found no cases of osteonecrosis among 13,522 patients without a history of alendronate use.


The proportion of those undergoing an extraction was similar in the two cohorts -- 31.7% among the alendronate users and 32.4% among those not using the drug.


Because all of the patients who used alendronate were long-term, there was no danger of referral bias, the researchers noted.


The findings have "important therapeutic and preventive implications," the researchers said.


Among other things, if patients are using bisphosphonates, dentists should consider alternate treatment options for non-necessary extractions and good oral hygiene should be achieved before extractions to minimize microbial load.


Also, follow-up should be more vigilant and a chlorhexidine rinse pre- and post-operatively "can be effective" in ensuring socket and wound healing and mucosal coverage of exposed bone, the researchers said.


In their institution, practice has already been changed. All patients have been actively screened and dental surgery consent forms now include a warning about the risk with oral bisphosphonates.


They also noted that the medical records system used at their dental school is also employed by 33 other institutions, making a broader epidemiological study possible.