Treatment of Patients taking Bisphosphonates

Bisphosphonates are a group of drugs that are commonly prescribed in the prevention and treatment of resorptive bone conditions. These would include osteoporosis, bone metastasis associated with breast & prostate cancer, multiple myeloma, Paget's disease & other conditions that cause chronic bone fragility.

Some common bisphosphonates would include Aredia(pamidronate), Fosamax(alendronate), Zometa(zolendronate). These drugs work by inhibiting osteoclast formation. Osteoclasts are cells with the ability to break down bone. These drugs come in an oral form and IV form.

There has been recent concern regarding this class of drugs and the increasing awareness of a rare side effect known as osteonecrosis of the jaw (ONJ). ONJ is the inability of the bone to heal. Signs & symptoms may include gingival ulceration with exposure of the bone, pain or swelling in the jaw, infection of the jaw & altered sensation. ONJ occurs more frequently in the mandible than the maxilla.

Treatment of ONJ is very difficult. Treatments that have had limited success include surgical wound debridement, bone resection, antibiotics & hyperbaric oxygen. Prevention is the best treatment for ONJ.

Recognizing patients who are taking these drugs, and eliminating any treatment that would cause direct trauma/irritation to the bone is essential (extraction, implants or any type of surgical procedure). Patients who are taking or have taken the IV form of these drugs are at a higher risk of ONJ.

For additional information regarding recommendations and treatment guidelines for patients using bisphosphonates: click here

(Source: Endodontics Colleagues for Excellence, Winter 2007, Bisphosphonate-Associated Osteonecrosis of the Jaw. American Association of Endodontists)

CASE REVIEW



This patient came to my office after having broken the crown off of tooth #13. Recurrent decay was to the level of the crestal bone. The root was very short. The patient is currently being treated for multiple myeloma. Her past treatment have included IV bisphosphonates. Due to history of IV bisphosphonates, an extraction of #13 is contraindicated due to her high risk of ONJ.

Endodontic treatment is completed to remove any source of infection and the tooth is "banked". Banking indicates removing decay, completing RCT and placing a permanent access restoration with no intention of restoring the crown of the tooth.