Osteoporosis is a very serious condition that affects about 10 million Americans;8 million of them women. It affects more women than cancer, heart disease and stroke combined. Fracture of the hip and the spinal column are the most common and they can be life threatening. The National Osteoporosis Foundation reports that an average of 24 percent of patients over 50 and older with hip fractures die within one year of their injury. One in five patients with a hip fracture ends up in a nursing home. Six months after a hip fracture, only 15 percent of patients are able to walk across the room without help. I think those are fairly sobering statistics and I've started there because it can help us put the 'dental component' in perspective.

The link between dental health and osteoporosis came up when oral surgeons (dentists who extract teeth) found that a' small percentage of people taking bone density medicines did not heal well after routine tooth removal. Apparently, in a very' small minority, the bone in the jaw did not have a healthy enough system of veins and arteries to heal the exposed bone after a trauma in the mouth such as extraction of a tooth.'  This condition is called BRONJ in dental circles: Bisphosphonate-Related Osteonecrosis of the Jaw,' ' BRONJ is considered to be a very rare condition that can only occur in people who have had previous or current treatment with a bisphosphonates; drugs commonly taken to reduce skeletal complications of bone cancer treatments.'  Even rarer yet, it could happen to folks taking bisphosphonates for the treatment of postmenopausal osteoporosis.

So are osteoporosis medications worth taking? It is estimated that these medications may reduce the risk of hip fracture by 40%. Thus, it is possible that the drug could prevent more than 100,000 hip fractures and tens of thousands of deaths each year. Given this risk/benefit ratio, you should never stop taking these medications before discussing the matter fully with your physician.' In addition' you must understand that there are two basic types of bisphosphonates; one type is a potent intravenous forms administered monthly for patients with bone cancer, and the second type are dosed orally on a daily or weekly basis for the treatment of osteoporosis.

The medicine taken by cancer patients is' that which' most concerns dentists and oral surgeonsis a kind of Bisphosphonates that is given' in larger loading dose.' Since their introduction into the global marketplace, over 190 million prescriptions for these medications have been dispensed.'  The incidence of BRONJ in patients with a history of intravenous bisphosphonates ranges from .8% to 12 %.'  The incidence in patients who have taken oral bisphosphonates is far less.

The jaws seem to be at greater risk for this type of poor wound healing than any other part of the body and here's why: Bisphosphonate medicines are designed to impair a type of bone cell called an 'osteoclast'. These are the cells that take away and remodel bone. With significant reduction in their activity, normal bone turnover and resorbtion is reduced. Unfortunately, in some rare circumstances, this can result in poor blood circulation in areas where bone remodeling has occurred. The mechanism is not well understood, but we do know that bisphosphonates are preferentially deposited in bone that has a high remodeling rate like the jaws because of the forces that you exert on your mouth chewing and talking day in and day out.

You might have BRONJ if your mouth remains painless for weeks or months after an extraction, but the'  site becomes secondarily infected or the tongue becomes painful via repeated contact with the sharp edges of exposed bone.'  Failure to heal properly can be a side effect of having had radiation therapy to the jaws, but this type of delayed healing is not technically diagnosed as BRONJ.

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How can you avoid BRONJ?'  The potential risk factors associated with BRONJ include: 1. The length of time you have been taking bisphosphonates and' ' 2. the type of bisphosphonate you have taken. Again, the intravenous forms of the drug are the most potent and most likely to produce this particular side effect. Unfortunately, it appears that stopping daily oral doses of bisphosphonates will not reduce your risk significantly. This may be because the character and'  quality of bone in your jaw is established over a very long period of time as it is constantly being remodeled, so things can't improve overnight.However remember that you can only develop BRONJ if you experience some mouth trauma like an extraction of a tooth or complex gum surgery involving the bone following advanced gum disease.'  This underscores the importance of maintaining good oral health in order to avoid extractions or oral surgery.

So, where do you go from here? We do not understand the mechanism of this condition enough to calculate the probability of BRONJ in people taking daily bisphosphonates, (Although BRONJ is obviously very, very rare if 190 million prescriptions have been taken and so few BRONJ cases have been diagnosed). First, you should talk to your dentist about how you can try to eliminate any dental related risk factors that could lead to extractions such as gum disease, decay, and/or a diet that would promote decay.'  If you have dental risk factors that are eminent, then you may need to ask your physician about the risk/benefit ratio of your continued bisphosphonate therapy.' 

If my mother' were on these medications daily, I would counsel her to be meticulous about her dental health and avoid ever having to face the need for extractions. Just another reason to become a 'frequent flyer' in your dental' hygienist's chair!

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THE PREVIOUS INFORMATION HAS BEEN TAKEN FROM vol. 20, issue 2 of the Journal of the American Association of Oral and Maxillofacial Surgeons' '  www.aaoms.org .'  THAT JOURNAL IS WRITTEN FOR PROFESSIONALS AND THEREFORE CONTAINS VOCABULARY THAT WOULD BE CHALLENGING FOR LAYPERSONS TO INTERPRET.'  I HAVE TAKEN THE LIBERTY TO PUT SOME OF THE KEY' IFOOATION FROM THAT ARTICLE IN LAYMENS' LANGUAGE HERE SO THAT YOU MIGHT BETTER UNDERSTAND THIS.