Bisphosphonate Discontinuation and Osteonecrosis of the Jaw Risk

Risk Factors and Assessment

• The most consistent risk factor for Osteonecrosis of the Jaw (ONJ) is recent prior dental surgery or extraction, according to the American College of Physicians and the Infectious Diseases Society of America 1, 2
• Risk of ONJ increases with frequency, dose, and duration of bisphosphonate administration, as stated by the American Society of Clinical Oncology 3
• Intravenous administration of bisphosphonates carries a higher risk of ONJ than oral administration, as noted by the National Comprehensive Cancer Network 4
• Concurrent chemotherapy or corticosteroid use, as well as poor oral hygiene and pre-existing dental infections, also increase the risk of ONJ, according to the European Society for Medical Oncology 5

Pre-Extraction Recommendations and Management

• Complete a comprehensive dental evaluation before starting bisphosphonate treatment whenever possible, as recommended by the European Society for Medical Oncology 5
• Perform any necessary invasive dental procedures before initiating bisphosphonate therapy, as suggested by the Infectious Diseases Society of America 1, 2
• Correct vitamin D deficiency prior to bisphosphonate therapy to avoid hypocalcemia, as advised by the American College of Physicians and the Infectious Diseases Society of America 1
• Maintain good oral hygiene, as recommended by the European Society for Medical Oncology 6

Discontinuation Considerations and Outcomes

• Some experts hypothesize that stopping bisphosphonates 2 months prior to oral surgery may allow better bone healing, as discussed by the American Society of Clinical Oncology 7
• The incidence of ONJ is very rare with oral bisphosphonates (<1 case per 100,000 person-years), as reported by the American College of Physicians and the Infectious Diseases Society of America 1
• Intravenous bisphosphonates carry a higher risk of ONJ than oral formulations, as noted by the National Comprehensive Cancer Network 4
• Patients receiving bisphosphonates for cancer treatment are at higher risk than those taking them for osteoporosis, according to the National Comprehensive Cancer Network 4

Management of Risedronate Before Dental Extraction

Pre-Extraction Protocol

• Ensuring good oral hygiene is maintained is crucial for patients on risedronate, as recommended by the Annals of Oncology 8

Drug Holiday Considerations

• Some experts suggest that stopping bisphosphonates 2 months prior to oral surgery may allow better bone healing, with resumption delayed until adequate healing occurs, according to the Journal of Clinical Oncology 9

Surgical Approach When Extraction is Necessary

• Using prophylactic antibiotics is recommended for patients on risedronate undergoing tooth extraction, as suggested by the Annals of Oncology 8
• Suspending the bisphosphonate until healing of the tooth socket appears complete is advised for patients on risedronate, as recommended by the Annals of Oncology 8

Riesgo de Osteonecrosis Mandibular con Alendronato

Magnitud del Riesgo

• El riesgo de osteonecrosis mandibular (ONM) con alendronato oral es muy bajo, con una incidencia menor a 1 caso por 100,000 personas-año, según la American College of Physicians, significativamente menor que los bifosfonatos intravenosos utilizados en oncología 10
• La incidencia de ONM con bifosfonatos intravenosos en oncología es de 6.7-11% en pacientes con mieloma múltiple o cáncer metastásico, según la Society of Clinical Oncology 11, 12

Factores de Riesgo Principales

• La cirugía dental invasiva reciente es un factor de riesgo importante, con al menos 60% de los casos ocurriendo después de cirugía dentoalveolar, especialmente extracciones dentales, según la European Society for Medical Oncology 13, 14
• El uso de prótesis dentales mal ajustadas también representa un riesgo adicional cuando no hay cirugía previa, según la European Society for Medical Oncology 13

Estrategias de Prevención Obligatorias

• Antes de iniciar alendronato, se debe realizar un examen dental completo y completar cualquier tratamiento dental necesario, y tratar todas las infecciones orales activas, según la American Society of Clinical Oncology 14, 11, 12
• Durante el tratamiento con alendronato, se debe mantener excelente higiene oral y evitar procedimientos dentales invasivos cuando sea posible, según la American Society of Clinical Oncology 13, 14, 11, 12

Consideración de Riesgo-Beneficio

• A pesar del riesgo de ONM, los bifosfonatos siguen siendo el tratamiento de primera línea recomendado para osteoporosis primaria debido a su eficacia superior en la reducción de fracturas, según la American College of Physicians 10

Bisphosphonates and Osteonecrosis of the Jaw: Management Considerations

Primary Risk Factors and Prevention

• All patients on bisphosphonates require comprehensive dental evaluation before starting therapy, and invasive dental procedures should be completed prior to bisphosphonate initiation whenever feasible 15, 16
• The American College of Oncology recommends that patients on bisphosphonates maintain excellent oral hygiene with regular dental check-ups every 6 months 17, 18
• The decision to discontinue bisphosphonates before dental surgery remains controversial, with some experts recommending a drug holiday approach 15, 16

Risk Stratification and Management

• Zoledronic acid and pamidronate carry substantially higher ONJ risk than oral formulations, with an incidence of 6.7% to 11% in multiple myeloma patients 19, 18
• The International Task Force on Osteonecrosis of the Jaw recommends referring patients with ONJ to a dental practitioner or oral surgeon with expertise in treating ONJ 20, 15, 16
• Longer duration of bisphosphonate exposure increases the risk of ONJ, with a cumulative hazard of 1% at 12 months to 11-13% at 4 years of treatment 19, 18

Monitoring and Prevention

• The American Association of Oral and Maxillofacial Surgeons recommends measuring serum calcium before starting treatment and monitoring renal function before each IV bisphosphonate dose 15, 16
• Patients on bisphosphonates should be monitored for serum calcium and creatinine throughout IV treatment, and provided with calcium and vitamin D supplementation unless contraindicated 15, 16

Timing of Invasive Dental Procedures After Zoledronic Acid

Pre-Procedure Planning

• Complete all necessary invasive dental procedures before initiating zoledronic acid whenever possible, as this eliminates the osteonecrosis of the jaw (ONJ) risk entirely, according to the National Comprehensive Cancer Network 21, 22
• Treat all active oral infections and eliminate high-risk sites before bisphosphonate initiation, as recommended by the Journal of Clinical Oncology 22

Surgical Protocol When Procedure is Necessary

• Use prophylactic antibiotics perioperatively, as suggested by the Journal of Clinical Oncology 22
• Defer resumption of zoledronic acid until the dentist confirms complete healing from the dental procedure, according to the National Comprehensive Cancer Network 21

Critical Caveats

• For patients with active cancer and bone metastases, interrupting zoledronic acid therapy poses tangible risks of pathologic fractures and spinal cord compression, as noted by the National Comprehensive Cancer Network 21
• Maintaining excellent oral hygiene and avoiding invasive dental procedures during active therapy remains the strongest evidence-based recommendation, according to the National Comprehensive Cancer Network and the Journal of Clinical Oncology 21, 22

Management of Teeth in Bisphosphonate-Treated Patients

Risk Assessment and Treatment Options

• The American College of Physicians recommends that the incidence of BRONJ with oral bisphosphonates used for osteoporosis is very rare, with a rate of less than 1 case per 100,000 person-years, but extraction dramatically increases this baseline risk 23
• The risk of BRONJ is significantly lower in patients taking oral bisphosphonates for osteoporosis, such as alendronate or risedronate, compared to those receiving intravenous formulations for cancer treatment, with a risk magnitude that must be kept in perspective 23
• The fracture prevention benefits of continued bisphosphonate therapy in osteoporosis patients generally outweigh the minimal BRONJ risk, especially when proper dental protocols are followed, according to the American College of Physicians 23, 24

Management of Fosamax Before Dental Work

Pre-Treatment Dental Assessment

• Complete all necessary invasive dental procedures before initiating Fosamax, as this eliminates the osteonecrosis of the jaw (ONJ) risk entirely, according to the American College of Oncology 25
• Perform a comprehensive dental evaluation of both hard and soft tissues, including radiographic examination, before starting bisphosphonate therapy, as recommended by the American College of Oncology 25
• Correct vitamin D deficiency prior to bisphosphonate therapy to avoid hypocalcemia, as suggested by the Infectious Diseases Society of America 26

Risk Stratification for ONJ

• Oral bisphosphonates for osteoporosis have a very low risk of ONJ, with less than 1 case per 100,000 person-years, according to the Infectious Diseases Society of America 26
• Recent dental surgery or extraction is a consistent risk factor for ONJ, as noted by the Infectious Diseases Society of America 26

Management When Dental Work is Needed During Treatment

• Stopping bisphosphonates 2 months prior to oral surgery may allow better bone healing, with resumption delayed until adequate healing occurs, as hypothesized by the American College of Oncology 25
• However, a short break in bisphosphonate administration may have no effect on bone healing, as bone effects of bisphosphonates are maintained for years after treatment stops, according to the American College of Oncology 25
• The risk of ONJ increases with frequency, dose, and duration of bisphosphonate administration, as reported by the American College of Oncology 25
• Patients with suspected ONJ should be referred to a dental practitioner or oral surgeon with expertise in treating this condition, as recommended by the American College of Oncology 25

Timing of Tooth Extraction After Reclast (Zoledronic Acid)

Risk Context for Osteoporosis Patients

• Intravenous bisphosphonates like Reclast for cancer treatment have a 6.7-11% ONJ incidence, which is dramatically higher than osteoporosis dosing 27

Bisphosphonate Discontinuation Before Tooth Extraction

Introduction to Bisphosphonate Management

• The American College of Oncology recommends that drug holidays from bisphosphonates before tooth extraction are not proven effective in preventing osteonecrosis of the jaw (ONJ), as the long-term bone effects of bisphosphonates persist for years after stopping the medication 28
• Some experts hypothesize that stopping bisphosphonates 2 months prior to oral surgery may allow better bone healing, with resumption delayed until adequate healing occurs, according to the Journal of Clinical Oncology 28
• The alternative view is that a short break in bisphosphonate administration will have no effect, as bone effects of bisphosphonates are maintained for years after treatment stops, as stated by the Journal of Clinical Oncology 28

Evidence-Based Prevention Protocol

• The American College of Oncology suggests a complete comprehensive dental evaluation before starting bisphosphonate treatment whenever possible, and performing all necessary invasive dental procedures before initiating bisphosphonate therapy 28
• For patients on oral bisphosphonates for osteoporosis, some experts suggest not routinely discontinuing bisphosphonates, ensuring excellent oral hygiene and preoperative antibiotic prophylaxis, using atraumatic extraction technique with primary closure, and monitoring healing closely, although the specific guideline society is not mentioned 28

Management of Alendronate Before Dental Extractions

Risk Stratification Based on Treatment Duration

• The incidence of osteonecrosis of the jaw (ONJ) with oral bisphosphonates for osteoporosis is very rare at <1 case per 100,000 person-years, according to the National Comprehensive Cancer Network, with a strength of evidence based on multiple studies 29, 30

Evidence-Based Surgical Protocol

• Administer prophylactic antibiotics perioperatively, as recommended by the Annals of Oncology, to minimize the risk of infection and ONJ 31

Critical Pre-Extraction Requirements

• Ensure vitamin D deficiency has been corrected, as deficiency increases risk of bisphosphonate-related hypocalcemia and may attenuate efficacy, as suggested by the Clinical Infectious Diseases and the National Comprehensive Cancer Network 29, 30
• Confirm adequate calcium (800-1000 mg/day) and vitamin D (800 IU/day) intake, as recommended by the National Comprehensive Cancer Network 30

Common Pitfalls to Avoid

• Do not confuse the low risk in osteoporosis patients with the much higher risk (6.7-11%) in cancer patients receiving high-dose intravenous bisphosphonates, as highlighted by the National Comprehensive Cancer Network 30
• Do not perform the extraction without antibiotic prophylaxis, as infection is a key risk factor for ONJ, according to the Annals of Oncology 31

Stopping Bisphosphonates Prior to Oral Surgery

Evidence-Based Risk Stratification

• The American Society of Clinical Oncology notes that bone effects of bisphosphonates persist for years after stopping, suggesting a short drug holiday may have no protective effect, for patients with a history of bisphosphonate use for osteoporosis or cancer treatment 32
• At least 60% of osteonecrosis of the jaw (ONJ) cases occur after dentoalveolar surgery, making the timing of dental procedures critical, particularly for patients on intravenous bisphosphonates for cancer 33

Practical Clinical Algorithm

• Perform comprehensive dental evaluation of both hard and soft tissues before starting bisphosphonate treatment, to identify potential oral health issues that may increase the risk of ONJ 32
• The decision to interrupt intravenous bisphosphonate therapy must be individualized based on cancer status, bone metastasis burden, and fracture risk, and should be made in consultation with an oncologist 33

Critical Caveats

• Risk increases with frequency, dose, and duration of bisphosphonate administration, highlighting the need for careful consideration of treatment duration and dosing regimen 32

Evidence for Stopping Bisphosphonates Before Oral Surgery

Introduction to Bisphosphonate Therapy

• The American Society of Clinical Oncology (ASCO) guideline states that there is insufficient evidence to support or refute the need for discontinuation of bisphosphonates before dentoalveolar surgery, with only a weak strength of recommendation 34, 35

Risk Stratification

• The incidence of medication-related osteonecrosis of the jaw (MRONJ) is very rare at <1 case per 100,000 person-years for patients taking oral bisphosphonates for osteoporosis 36
• The incidence of MRONJ ranges from 6.7-11% in multiple myeloma patients receiving monthly high-dose intravenous bisphosphonates 36

Prevention and Management

• The strongest recommendation is to complete all necessary dental work before initiating bisphosphonate therapy, which eliminates MRONJ risk entirely 34, 35, 36
• Patients on bisphosphonates should have dental check-ups every 6 months once therapy has commenced 34, 36
• The American College of Clinical Oncology recommends maintenance of excellent oral hygiene and adequate calcium and vitamin D supplementation for patients on bisphosphonates 34, 36

Post-Surgery Management

• Schedule follow-up every 6-8 weeks until complete mucosal healing for patients who have undergone dental surgery while on bisphosphonates 34, 35