The Role of Bisphosphonates in Oral and Maxillofacial Surgery
The medical field has been studying the effects of bisphosphonates in the context of oral and maxillofacial surgery, particularly in relation to dental implant placement, bone grafting and their role in osteodistraction, which is utilized to correct skeletal defects like cleft lip and cleft palate.
Bisphosphonates (BPs) are bone-seeking biological compounds that have been shown to decrease bone resorption through two separate mechanisms, thanks to their ability to attach to bone minerals. The biological effects of bisphosphonates, which have been synthesized for decades, were not appreciated until the late 1960s, when it was found that the compounds inhibited vascular calcification and stopped bone resorption.
This class of drugs has been successfully used to help treat diseases like osteoporosis, osteopenia, Paget’s disease, multiple myeloma and metastatic cancer of the bone. Oral and IV bisphosphonate medications are an effective treatment for thousands of people, but reports of bisphosphonate-induced osteonecrosis of the jaw (ONJ) have surfaced in the past 10 years, raising concerns.
Osteonecrosis of the Jaw (ONJ)
Osteonecrosis of the jaw occurs when the bone begins to die due to insufficient blood flow. In patients who are taking bisphosphonate drugs, this complication manifests as exposed, necrotic bone involving the maxillofacial features. It is believed that this condition results from injury/trauma to dentoalveolar structures that have minimal bone healing abilities from bisphosphonate therapy.
With bisphosphonate associated osteonecrosis of the jaw, the bone’s metabolism is altered since the compound interferes with the effectiveness of osteoclasts (the cells that absorb bone tissue during growth).
The incidence of MRONJ (Medication-related Osteonecrosis of the Jaw) depends on whether the medication is taken orally or intravenously. Studies show that IV use may result in an incidence of jaw osteonecrosis approaching 20 percent, whereas oral administration of bisphosphonates or RANKL inhibitors Xgeva and Prolia yields a much lower risk of ONJ, ranging from 1 to 4 percent.
Once ONJ is diagnosed, it can be challenging to treat. Those who are taking IV bisphosphonates are encouraged to refrain from elective procedures like dental implant placement/tooth extraction until they consult an oral and maxillofacial surgeon.
Alternatively, some patients may temporarily halt bisphosphonate therapy before and after dental implant surgery to promote better healing. This decision will be made with your oral surgeon and prescriber of the medication.
Who Is Most at Risk for Developing ONJ?
- Patients who are receiving IV bisphosphonate therapy
- Patients taking oral bisphosphonate drugs for prolonged periods (3 years or more)
- Patients currently on bisphosphonate therapy who have gum disease, tooth decay and/or abscesses
- Patients on bisphosphonate drugs who undergo invasive dental surgery that entails manipulation of the bone
- Patients who smoke
- Diabetic patients
- Patients taking corticosteroid medications
Keep in mind that osteonecrosis of the jaw, although rare, can occur spontaneously as a result of dental decay or invasive procedures. Researchers continue to study the risk factors for patients taking bisphosphonates, as ONJ induced by the medication is still a comparatively rare adverse event.
Oral & Maxillofacial Surgeons in Feasterville, Newtown, and Jenkintown, PA
At Innovative Oral Surgery & Dental Implants, our practice is staffed with highly trained professionals who are dedicated to providing superior patient care in a friendly, warm environment. If you are receiving bisphosphonate therapy and would like to know more about your candidacy for tooth extraction, dental implants, or other procedures, we invite you to arrange an appointment by calling our office. Our clinic serves residents throughout Bucks County and Montgomery County, PA.
Additional Resources on Bisphosphonates in Oral and Maxillofacial Surgery:
- National Institutes of Health, Osteonecrosis and bisphosphonates in oral and maxillofacial surgery https://www.ncbi.nlm.nih.gov/pubmed/18088878
- Wiley Online Library, Advantages and disadvantages of the use of bisphosphonates in oral and maxillofacial surgery https://onlinelibrary.wiley.com/doi/pdf/10.1922/IDJ_2519Pierotti06
- Science Direct, Bisphosphonate https://www.sciencedirect.com/topics/medicine-and-dentistry/bisphosphonate