Dental Concerns with Fosamax, Actonel and other Bisphosphonates

Fosamax, Actonel and other similar drugs prescribed to treat osteoporosis and Paget's disease are known as bisphosphonates.   There have been recent studies that indicate individuals using bisphosphonates should attempt to steer clear of tooth extractions and other major dental work while on the drugs.  It has been shown there is a connection between bisphosphonates and a serious bone disease called Osteonecrosis of the Jaw (ONJ). Osteonecrosis of the Jaw (ONJ) is also known as Dead Jaw. This finding was published in the Journal of Oral and Maxillofacial Surgeons, and prompted the US Food and Drug Administration (FDA) and the manufacturers of bisphosphonates to issue a warning to health care professionals concerning the possible effects.

Bisphosphonates are commonly used in tablet form to prevent and treat osteoporosis in post-menopausal women. Stronger forms of bisphosphonates are commonly used in the management of advanced cancers that have metastasized to the bone, where the disease often causes bone pain and possibly even fractures. Several cancers can involve or metastasize to the bone, including lung cancer, breast cancer, prostate cancer, multiple myeloma, and others. When bisphosphonates are given in cancer chemotherapy, the drugs are given intravenously and usually for longer periods of time.

A small number of patients taking bisphosphonates develop Osteonecrosis of the Jaw (ONJ).  While all forms of bisphosphonates, both oral and injectable, may increase the risk of ONJ, it is the injectable medications that appear to pose the greatest risk.   Osteonecrosis is a potentially disfiguring condition in which the bone tissue in the jaw fails to heal after minor trauma such as a tooth extraction, causing the bone to be exposed. Symptoms include jaw pain or inflammation, gums that don’t heal, loosening teeth, or a feeling of numbness or heaviness in the jaw. The exposure can eventually lead to infection and fracture and may require long-term antibiotic therapy or surgery to remove the dying bone tissue. Experts say prevention and early treatment of patients using bisphosphonates is extremely important in preserving the jawbone if dental procedures are indicated. 

The goal of bisphosphonates is to strengthen bone and prevent fractures. However, these medications may act somewhat differently on jaw bone, particularly in patients with active gum disease and compromised immune systems, such as cancer patients who have undergone chemotherapy.  Recent studies published in the Journal of Oral and Maxillofacial Surgery address the relationship between bisphosphonates and osteonecrosis and found it often results partly from a decrease in blood supply to specific areas of the bone.  Far from being a static substance, bone is constantly remodeling. Bone cells called osteoblasts create new bone, while bone cells called osteoclasts remove old bone. Normally, these two types of cells work in harmony, a balance known as the osteoclast/osteoblast axis. Bisphosphonates inhibit bone removal (resorption) by osteoclasts, thereby supporting the buildup of new bone. While this action may help prevent fractures in the hip, spine and other skeletal regions, it may disrupt the osteoclast/osteoblast axis in the jaws, impairing osteoclasts' ability to remove, and thus repair or contain, 'diseased' bone.  This impairment then causes osteoblasts to "overbuild" or "wall off" diseased bone. As osteoblasts build new bone, the failure of osteoclasts to remove contaminated bone interferes with the development of the necessary structure, or 'scaffolding,' on which to lay down healthy bone, thus creating potentially weak, non-healing infected bone - osteonecrosis. 

There is no doubt that bisphosphonate therapy will continue to show substantial clinical benefits and grow in use, but more study is needed to discover the ideal dosage, delivery route, and bisphosphonate for each patient to minimize the risk of concerns with dental procedures.  If you are taking Fosamax, Actonel or any of the other bisphosphonates, consult with your physician and dentist prior to having any dental procedures done.  Any questions?  E-mail me at This e-mail address is being protected from spambots. You need JavaScript enabled to view it and I will get back with you.  Have a blessed week!