Osteoporosis Medication & Dental Procedures
Osteoporosis Medication and Dental Procedures
As discussed in the introductory article “Medication and Dental Surgery: How your medical history influences treatment decisions” it is important that you are open and up to date with your dentist on the medications you are taking. Some medications, for specific treatments, can strongly impact upon your treatment plan so it is best to notify your dentist at any time a change is made. When considering your osteoporosis medication, it is not the osteoporosis that presents a problem to the dentist but rather it is the drugs used to treat osteoporosis that may cause problems after dental extractions or any surgical intervention involving the jaws.
One of the groups of drugs commonly used to treat osteoporosis by altering the balance of natural bone turnover is called Bisphosphonate medication. These drugs allow new bone to form but reduce the rate of removal of old bone and in this way the bone density increases. This is useful when treating Osteoporosis, Paget’s Disease and metastatic bone cancer.
With increased bone density, the bone of the jaws may become more sensitive to damage and appear to lack the ability to repair. As a result, the damage caused by a tooth extraction can be sufficient to lead to a localised lesion of bone destruction. This can be painful and an ulcer forms from which dead bone fragments are shed. This condition is referred to as Bisphosphonate-related Osteonecrosis of the jaw (BRONJ). This condition can be painful and difficult to treat. It can spread, leading to the loss of adjacent teeth, distortion of the bone and secondary infection is likely.
The aim of treatment for BRONJ is to prevent the lesion from becoming infected. It can take many months or even years to resolve the lesion and in some cases, it can become a chronic and long-standing condition.
The risk of suffering from this condition depends on the dose of Bisphosphonate and the route of administration. Low oral doses have been reported to cause BRONJ in 1 in approximately 1100 patients taking Bisphosphonates who undergo dental extraction.
Patients suffering from malignant tumours that have spread into the bone (metastatic bone cancer) may be given Bisphosphonate drugs intravenously in far higher doses, and in these patients, the risk of BRONJ is much higher having been estimated to be around 1 person in 10.
Dental extractions in all patients taking Bisphosphonates must be performed only after full discussion of the risks and after considering alternative treatment in order to try to avoid extractions whenever possible. Such alternatives may include root canal therapy or sectioning of the tooth and leaving uninfected roots in the bone covered by the gum.
Avoiding BRONJ is important and medical practitioners and dentists should be mindful that any patient who is being considered for Bisphosphonate treatment should be advised to visit their dentist for clinical and X-ray examination to determine if there are any teeth with a poor future that may be better removed prior to starting Bisphosphonate therapy.
If you are currently taking Bisphosphonate for Osteoporosis or any other illness and you are planning to undergo dental treatment please discuss this during your initial consultation with Dr Priestland. If you have recently been prescribed the medication and already have a treatment plan in place it is also important you raise this with our practice. Please call us to arrange a time for discussions.
CTX TESTING TO DETECT “BRONJ”
It is now possible to carry out a test on blood serum for patients medicated with Bisphosphonate in an attempt to assess the risk of Bisphosphonate-related osteonecrosis of the jaw (BRONJ) occurring after a surgical procedure in the jaw area. While this test helps identify those patients most at risk of BRONJ, it is not 100% sensitive and there will be patients who are identified as high risk but who fail to develop BRONJ. Likewise, there may be patients who according to the test are at low risk of developing the condition but after dental extractions or surgery go on to develop the condition. However, the availability of the test may be useful for those patients on higher doses of Bisphosphonates or who receive the drug intravenously.
How does CTX testing work?
Patients on Bisphosphonate will have a reduced turnover of their bone as the medication reduces the removal of old bone but allows the continued formation of new bone resulting in an increase in the density of the bone. With the reduced bone turnover, there are fewer breakdown products of bone found in the blood.
Carboxy-terminal telopeptide collagen crosslinks, known as “CTX”, is a breakdown product of bone released during bone turnover. It is therefore referred to as a “biomarker” detectable in serum. The test used to detect CTX is called Serum Cross Laps. This test was introduced in 2000.
The CTX result in a healthy patient not taking Bisphosphonate medication would be expected to be over 300 picograms per millilitre and often as high as 400-550 picograms/ml.
Osteoporotic patients taking Bisphosphonate who present for a dental extraction must be carefully managed to avoid causing BRONJ. This may occur following any procedure that causes even minor trauma to the bone supporting the teeth. While avoidance of extractions and any oral surgery is the ideal approach to the management of these patients, sometimes tooth removal is the only option likely to result in the elimination of pain and infection.
Arranging a drug holiday
In cases where extraction or surgery cannot be avoided, it has been the practice of some dentists and oral surgeons to discuss medical management with the patient’s general medical practitioner in order to investigate the withdrawal of the Bisphosphonate medication for a period of time, usually 3-6 months. This is often called a “drug holiday”.
CTX test results
After varying periods of time, the patient’s serum can be re-tested to assess their CTX level. After a drug holiday, the CTX level should increase reflecting an increase in bone turnover. This increase often appears to take place at the rate of 25-30 picograms per ml per month and therefore over a 6 month drug holiday it is possible to see the CTX increase by around 150picograms.
With the raised CTX level, indicating increased bone turnover, the risk of BRONJ appears to be reduced. This then suggests that any necessary surgery can proceed, albeit with the risk of BRONJ still being present, but reduced.
contact the friendly team at NQ Surgical Dentistry today on (07) 4725 1656 or call in to see us at 183 Kings Rd, Pimlico QLD 4812
Other posts in this series
- Medication and Dental Surgery: How your medical history influences treatment decisions – Click Here
- Osteoporosis medication influences dental extractions and dental surgery – Click Here
- Diabetes and dental treatment or surgery – Click Here
- Dental extractions and surgery after radiation therapy of the head and neck – Click Here
- Knee or hip replacement surgery influences future dental management – Click Here
- The influence of cardiac disease on dental management – Click Here
- Anticoagulant and antiplatelet medications influence management of dental extractions and dental surgery – Click Here
- Codeine sensitivity or allergy – Click Here
- Patients who routinely take steroid medications – Click Here
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