ADA resources answer bisphosphonate questions

Treating patients who take bisphosphonates continues to raise questions not only in dentistry, but in medicine as well.

Dentists may have questions about managing patients on bisphosphonates鈥攁 class of drugs used primarily for the prevention and treatment of osteoporosis that have been associated with a rare side effect called bisphosphonate-associated osteonecrosis of the jaw.

For those dentists with questions, the ADA developed “Dental Management of Patients Receiving Oral Bisphosphonate Therapy: Expert Panel Recommendations.” The recommendations apply to patients taking oral bisphosphonates, specifically, and not intravenous bisphosphonate medications, where the risk for developing BON is higher.

Dr. Peter Jacobsen, vice chair of the ADA Council on Scientific Affairs and a member of the expert panel that developed the recommendations, advises dentists to read the recommendations and also urges them to openly communicate with physicians when treating these patients.

“Knowledge about bisphosphonates and osteonecrosis is still evolving,” Dr. Jacobsen said. “We still don’t really know the incidence of osteonecrosis of the jaw in dental patients nor how to most effectively manage it. But research and treatment experience is moving quickly and the ADA is closely monitoring all publications on this topic to ensure our panel recommendations are current and accurate.”

He added that cancer patients being treated with intravenous bisphosphonate drugs are “clearly at risk for developing BON” and “should have a dental evaluation, ideally before, but certainly within the first several months of beginning IV therapy.”

The incidence of BON in patients taking the oral form of bisphosphonates is much lower.

In January, an alert from the Food and Drug Administration warned of additional side effects from bisphosphonates, including the “possibility of severe and sometimes incapacitating bone, joint, and/or muscle (musculoskeletal) pain.” The alert indicated “bisphosphonate use might be responsible for severe musculoskeletal pain in patients who present with these symptoms” and asked health care professionals “to consider temporary or permanent discontinuation of the drug[s].”

“Bisphosphonates have a history of coming up with unexpected things,” said Robert Recker, M.D., in a Jan. 28 article of the American Medical News鈥攏ewspaper of the American Medical Association. Dr. Recker, director of the Creighton University School of Medicine Osteoporosis Treatment Center, added he was frustrated that dentists have told patients to get off the drugs.
“The truth is bisphosphonates are among the safest drugs we prescribe in osteoporosis,” he said.

In a letter to the AM News, ADA Executive Director James Bramson says the ADA recommendations do not suggest patients should stop taking these drugs prior to dental procedures, but instead that “dental treatment should not generally be modified solely on the basis of bisphosphonate therapy.

“The ADA recommendations stress that the incidence of bisphosphonate-associated osteonecrosis of the jaw is very low,” Dr. Bramson wrote, and “patients may also benefit from having a dental exam prior to beginning oral bisphosphonate therapy.”

Dr. Bramson concluded that the ADA recognizes that discontinuation of these drugs is a serious medical decision and that “the ADA recommends that dentists encourage patients to consult with their treating physician about any health risks associated with use of these drugs.”

The ADA Council on Scientific Affairs released the recommendations in 2006 for practitioners to consult when treating patients taking oral bisphosphonates. The recommendations encourage dentists to talk with a patient’s treating physician about any health risks and recommend that patients have a dental exam prior to beginning oral bisphosphonate therapy. In some cases, patients may want to schedule dental treatments before starting bisphosphonate therapy.

“The use of these drugs is a serious medical decision,” Dr. Jacobsen said. “They provide a very real and measurable benefit by decreasing bone fractures in patients with osteoporosis. All drugs have side effects and any drug has a risk-to-benefit balance that needs to be considered.

“We do know that the older a patient gets,” he continued, “there is a higher risk of a broken hip or fractured spinal vertebra. The risk of osteonecrosis of the jaw is much lower than the risk of such fractures.”

The medications listed in the FDA warning are: Fosamax and Fosamax Plus D (alendronate); Didronel (etidronate); Boniva (ibandronate); Aredia (pamidronate); Actonel and Actonel with Calcium (risedronate); Skelid (tiludronate); and Reclast and Zometa (zoledronic acid.)

To see the ADA recommendations for bisphosphonates online,聽click here聽or call the ADA toll-free, Ext. 2878.

The August 2006 issue of The Journal of The American Dental Association also published the ADA bisphosphonate recommendations and the January 2008 Journal of the American Dental Association contained the cover story, “Bisphosphonate Use and the Risk of Adverse Jaw Outcomes: A medical claims study of 714,217 people.”

A patient information page may be accessed at by clicking here.