Osteoporosis and Dental Health 

How serious is Osteoporosis and Bone Fracture?

Bisphosphonate-Related Osteonecrosis of the Jaw  ( BRONJ ) is a failure of exposed bone to heal after a trauma in the mouth such as extraction of a tooth. BRONJ is 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. Bisphosphonates are also widely used for the treatment of postmenopausal osteoporosis

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. Since their introduction into the global marketplace, over 190 million prescriptions for these medications have been dispensed. The more potent intravenous bisphosphonates appear to be significantly more problematic than the oral prescriptions. 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.

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.

Why are the Jaws at increased risk?

Bisphosphonates 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 inhibited. Unfortunately, in some rare circumstances, this can result in diminished new bone formation and 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.

What are the signs and symptoms of BRONJ?

Following extraction of a tooth, a BRONJ  site in the mouth may remain painless for weeks or months and may only be recognized when the site becomes secondarily infected or when 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.

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. The drug is concentrated 8X in areas of active remodeling, such as the jaws; therefore, taking a "drug holiday" can go a long way in minimizing the long-term gnathic effects.  THUS, temporarily stopping the med at the time of an invasive procedure is prudent (3-months either side of the event).  Only consider this after consultation with your doctors. 

One more item: I also found that osteonecrosis in very rare circumstances can occur spontaneously without mouth trauma. This may be because the character and  quality of bone in any given area is established over a very long period of time as it is constantly being remodeled, perhaps without proper circulation.

*** But remember, usually BRONJ develops 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.

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 oral 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.

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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 CHALLANGING FOR LAYPERSONS TO INTERPRET.  I HAVE TAKEN THE LIBERTY TO PUT SOME OF THE KEY IMFORMATION FROM THAT ARTICLE IN LAYMENS’ LANGUAGE HERE SO THAT YOU MIGHT BETTER UNDERSTAND THIS COMPLICATED MATTER