You visit your dentist for a dental extraction, and before the procedure begins, your dentist asks you a series of questions: Do you have any medical conditions? Are you taking any medications? Have you undergone any medical treatment?
These questions may seem routine, but they can be extremely important. One medication that deserves a dentist’s attention is Alendronate. Alendronate belongs to the class of Bisphosphonates, commonly used to treat osteoporosis in post-menopausal women and other bone-related diseases. Despite their benefits in bone health, they have an important implication for dental treatment: Bisphosphonate-related osteonecrosis of the jaws (BRONJ)
What are Bisphosphonates?
Bisphosphonates are a group of drugs that slow bone loss by inhibiting the cell responsible for breaking down bone (osteoclast). They can be administered orally or intravenously.
| Mode of administration | Drugs | Conditions |
| Oral | Alendronate, Risedronate | Paget’s disease, bone pain, and malignant tumours |
| Intra Venous | Pamidronate, Zoledronate | Osteoporosis |
How do Bisphosphonates work?
In normal bone, there is a process called remodelling which takes place; this is balanced formation and resorption of bone. This happens due to the coordination between the bone-forming and bone-resorbing cells. Bisphosphonates effectively decrease osteoclast activity and numbers. This makes them highly effective in reducing bone loss.
Bisphosphonates and dental treatment
Certain dental treatments such as tooth extraction and implant placement are invasive in nature. That is, these procedures create a wound that requires coordinated soft-tissue and bone healing. What acts as a nightmare for the dental fraternity is BRONJ (Bisphosphonate-related osteonecrosis of the jaws).
BRONJ typically occurs after invasive dental procedures. Bisphosphonates interfere with healing by inhibiting the actions of osteoclasts (bone-eating cells), osteoblasts (bone-forming cells), inhibiting angiogenesis (formation of new blood vessels) and reducing the body’s immune function.
Understanding the clinical presentation of BRONJ
According to the American Association of Oral and Maxillofacial Surgeons’ (AAOMS) Position Paper, four stages can be observed:
Stage 0: Characterised by nonspecific symptoms such as pain and swelling, lacking clinical evidence of exposed bone or necrotic tissue.
Stage 1: Asymptomatic but exhibit exposed and necrotic bone within the mouth, persisting for more than eight weeks without signs of infection.
Stage 2: Fistulae that can be probed down to the bone. This condition is associated with pain and infection, indicating a more advanced level of tissue involvement.
Stage 3: Additional complications such as pathological fractures of the jaw, representing a critical and challenging clinical scenario.
Prevention of BRONJ: The most important step
Patients who are about to start Bisphosphonate therapy should undergo a comprehensive dental evaluation. This decision requires collaboration among the treating physician, dentist, and specialists.
- Retaining restorable teeth and completing necessary surgeries 4 to 6 weeks before initiating bisphosphonate treatment, allowing adequate time for bone healing;
- Patients should actively cooperate with regular evaluations and promptly report any symptoms potentially related to BRONJ.
What if the patient is already taking Bisphosphonates?
The next stage involves patients already receiving bisphosphonates, but without evidence of osteonecrosis.
- Maintaining excellent oral hygiene remains crucial.
- If tooth extraction becomes necessary, retaining the tooth root is recommended.
- Patients exposed to bisphosphonates like zoledronic acid and pamidronate should avoid dental implant procedures to minimise the risk of complications.
Management of Established BRONJ
The final stage pertains to patients diagnosed with established BRONJ.
- In these cases, panoramic and tomographic imaging are essential for accurate assessment.
- The primary objectives at this stage include pain elimination and infection control, highlighting the critical importance of comprehensive and personalised management strategies.
Conclusion
Bisphosphonates have transformed the therapeutic landscape of osteoporosis. However, their impact on bone turnover makes awareness of BRONJ particularly important in dental practice. The key is not fear of bisphosphonates, but recognising the risk, identifying susceptible patients, maintaining excellent oral health, and adopting a unified dental and medical approach.
A simple question about medications during dental appointments can therefore make a significant difference.
MBH/PS