An unintended side effect of osteoporosis medications may include losing your dentist.
Osteonecrosis of the jaw (ONJ), a rare but challenging-to-treat complication that can occur after dental procedures such as extractions, is more common in patients on antiresorptive medication. Although the condition remains uncommon, the increased risk has deterred some dentists from treating patients who are on bisphosphonates or denosumab, an injectable treatment for bone loss.
When dental professionals initially became aware of this complication, some “decided to not treat these patients,” said Salvatore Ruggiero, DMD, MD, with the New York Center for Orthognathic and Maxillofacial Surgery, in New Hyde Park, New York. “That’s a decision that’s based on wrong data.”
In fact, good dental care may be key to preventing ONJ.
“If you can maintain a patient’s dental health in an optimum state, that is probably the most important thing that you can do to prevent this from happening,” Ruggiero said.
A 2011 report from an advisory committee for the American Dental Association (ADA) states osteoporosis medications need not derail dental care.
“Routine dental treatment generally should not be modified solely due to use of antiresorptive agents,” the committee wrote. “A patient with active dental or periodontal disease should be treated in spite of the risk for ARONJ [antiresorptive agent-induced ONJ] because the risks and consequences of no treatment likely outweigh the risks of developing ARONJ.”
Dentists should consider documenting discussions about the risks and benefits of treatment options and consider obtaining written consent for the chosen plan, according to the committee’s recommendations.
‘Aggressively Antiosteoporosis Meds?’
This year, a clinician sparked a spirited discussion in a family medicine forum on Reddit by asking: “What’s with dentists being aggressively antiosteoporosis meds?” Dozens of medical and dental professionals weighed in.
One dentist explained medication-related ONJ (MRONJ) is “among the most serious complications that can be associated with dentistry,” and lawsuits involving MRONJafter dental work may result in “huge settlements.”
“A lot of dentists are scared to touch patients on these medications,” they continued. “I understand why some dentists are excessively cautious about it. But clearly there are some of us who take it too far.”
ONJ can lead to infection, chronic pain, and facial disfigurement, and affect the ability to speak and eat.
Another dentist countered: “I’m not antiosteoporosis meds, I’m antiprescribing them without having a conversation with their dentist first.”
“I don’t want to be finding out that you put my patient on it when they need an emergency extraction,” they added.
The ADA advisory committee noted dentists should be informed when antiresorptive medication is going to be initiated. And if a patient has not regularly been seeing a dentist, they “would likely benefit from a comprehensive oral examination before or early in their treatment,” the panel noted.
In practice, however, some dentists might say things that discourage patients from starting osteoporosis medications or encourage them to stop taking the drugs, which could have catastrophic consequences such as spinal fractures if these decisions are not handled carefully, bone experts said.
High Stakes Decisions
Aliya Khan, MD, a professor of clinical medicine in the Divisions of Endocrinology and Geriatrics at McMaster University in Hamilton, Ontario, Canada, has been inundated with calls over the years from dental professionals asking about performing dental procedures in her patients on osteoporosis medications.
Now, she has written responses prepared.
Partly, her answers are designed to prevent dentists from giving misguided advice to patients about stopping denosumab, which the FDA approved in 2010.
The drug is typically given every 6 months. Soon after patients are due for their next injection, the risk for vertebral fractures increases, although a delay of between 4 and 6 weeks appears to be safe.
Telling patients they can discontinue the drug indefinitely could have catastrophic consequences, Khan said.
“These patients will end up in the hospital with multiple spine fractures, and the dentists don’t realize that,” she said. Patients “may even die as a result of those multiple vertebral fractures,” she said.
If the timing of a dental procedure is flexible, Khan advises dentists via fax: “Time the procedure to be done when the Prolia/Jubbonti [denosumab] dose is due. Delay Prolia/Jubbonti for up to 6 weeks after procedure, but no longer as risk of fracture will increase.”
Her office also emphasizes dental procedures should not be delayed in the case of an oral emergency, regardless of whether patients are taking a drug for osteoporosis.
“Any dental emergency — if they have got osteomyelitis, an abscess, whatever — go ahead and do the procedure,” Khan said. “Do not delay.”
More Likely in Oncology Patients
A position paper on MRONJ from the American Association of Oral and Maxillofacial Surgeons, authored by Ruggiero and colleagues, defines the condition as exposed bone in the maxillofacial region that has persisted for more than 8 weeks in someone who has received or is receiving antiresorptive therapy, and who has not had radiation therapy or metastatic disease to the jaws.
The association’s latest position paper was published in 2022. Earlier versions appeared in 2007, 2009, and 2014.
The updates reflect how it has become increasingly clear that the risk for ONJ from bisphosphonates and denosumab is far greater in patients who receive the medications to prevent cancer-related skeletal complications rather than for osteoporosis.
“Big difference. A hundred times more likely to happen in those patients taking these medications for cancer as opposed to those who are taking them for osteoporosis,” Ruggiero said.
While the cumulative risk for ONJ in patients taking medications for osteoporosis may be as low as 0.01%, it could be 4% in patients receiving them for cancer, he said.
Oncology patients receive significantly higher dosages on a much more accelerated schedule, Ruggiero said.
Dentist-Physician Collaboration
The Agency for Healthcare Research and Quality in May published a report that reviewed clinical practice guidelines about dental care for patients receiving drugs associated with MRONJ.
The authors identified 14 guidelines from professional organizations and international task forces.
“Overall, the guidelines consistently recommend integrative and collaborative care approaches with communication between dentists and prescribing physicians in deciding treatment plans,” the agency found.
But open questions remain.
“There is a lack of consensus on the discontinuation of antiresorptive treatments during MRONJ and the use of antibiotic prophylaxis for oral infections,” according to the report, which “may reflect the lack of strong evidence on these topics.”
When weighing treatment decisions, dentists might tend to focus on dental issues, while physicians may zero in on the risk for hip or vertebral fracture, said Chad Deal, MD, head of the Center for Osteoporosis and Metabolic Bone Disease at Cleveland Clinic in Cleveland.
“It’s always a balancing act,” Deal said. “And the dentists are typically much more worried about the oral health than the systemic bone health.”
In any case, the treatment decision “has to be a discussion with the patient,” he said. “It’s hard to be absolute about it.”
Deal reported being a consultant for Amgen. Khan reported receiving research funding from pharmaceutical companies.
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