Fosamax and Dental Implant Treatment

Bisphosphonates have been the buzz for the last few years in the dental and oral surgery literature because of the risk of osteonecrosis of the jaws. The cases are certainly not isolated, and frankly I'm seeing an alarming increase in the # of patients with this problem. The greatest risks for this osteonecrosis are associated with IV bisphosphonates, but there is a growing consensus and case-load of oral bisphosphonate patients who are developing the same problems as those related to the IV form. In brief, the guidelines being published now and recommended by the American Association of Oral & Maxillofacial Surgery (the specialty to first identify the problem and the specialty which will deal with and manage almost 100% of the problems in the future)recommends a "drug holiday" in consultation with the patient's primary physician. Also our latest tool in the screening process of patients is a lab test called the CTX (C-Telopeptide). Any patient who has been taking an oral bisphosphonate for greater than 3 years should have this test prior to any dental surgery, perio surgery or oral surgery. This test measures osteoclastic activity, and if the results come back as >150 pg/ml, then it is deemed safe to proceed with extractions/oral surgery. The drug holiday is used to hopefully get the CTX value over 150 pg/ml. Mary, the bisphosphonates are EXCELLENT DRUGS when it comes to helping protect women from harmful effects of osteoporosis, and they are excellent drugs for patients with bone cancers and those patients who have calcium problems related to their cancers. However, as with all medications there are risks. The risks, statistically speaking, are VERY SMALL in comparison with the # of patients taking these drugs, but the MORBIDITY can be TREMENDOUS if you are the unlucky one. The best thing you could do for yourself is consult with your general dentist, his/her preferred oral & maxillofacial surgeon, and your physician regarding your bisphosphonates and dental treatment needs. There are other drugs out there that you can take instead of bisphosphonates, and they work very well too... but they can be a bit $$$. Simply put Mary, if you were my mother and you were on fosamax for 2-3 years or more, I would be ordering a CTX lab on you before performing any minor or major oral surgery on you. Below is a link to the American Association of Oral & Maxillofacial Surgery's position paper on bisphosphonates. This doesn't mention the CTX, but there will be much much more in the literature on the C-Telopeptide exam in the future. http://www.aaoms.org/docs/position_papers/osteonecrosis.pdf

I don't believe there are any studies that show that the CTX test will reliably determine the risk of osteonecrosis of the jaw (ONJ)nor that a drug holiday is effective. While these two suggestions seem logical, without further studies they may just give the patient and dentist a false sense of security. Since the risk of ONJ with oral bisphosphonates is probably low (less than 1 per 100,000, patients should be fully informed with written and verbal consent of the risk of ONJ. If the patient and dentist feel that the benefits of the surgical procedure outweigh the risk, they should proceed.

i was just at the american college of oral & maxillofacial surgery's national meeting and was very fortunate to attend dr. marx's lecture and saw his research data firsthand. there is no question the ctx is our best tool at the moment. is it fool proof? no. but its the best indicator we have at the moment. there is always going to be a risk but given the circumstances its our best friend. if complications arise we deal with them...

The medical community is finally catching on. JAMA published a multicenter study on the efficacy of alendronate on postmenopausal women that have taken it for more than five years. I was at Dr. Marx's course in So Cal in March, and here is the article he referenced: Effects of Continuing or Stopping Fosamax (Alendronate) After 5 Years of Treatment: The Fracture Intervention Trial Long-term Extension (FLEX): A Randomized Trial Dennis M. Black, PhD; Ann V. Schwartz, PhD; Kristine E. Ensrud, MD, MPH; Jane A. Cauley, DrPH; Silvina Levis, MD; Sara A. Quandt, PhD; Suzanne Satterfield, MD; Robert B. Wallace, MD; Douglas C. Bauer, MD, MPH; Lisa Palermo, MA; Lois E. Wehren, MD; Antonio Lombardi, MD; Arthur C. Santora, MD; Steven R. Cummings, MD; for the FLEX Research Group JAMA. 2006;296:2927-2938. Context: The optimal duration of treatment of women with postmenopausal osteoporosis is uncertain. Objective: To compare the effects of discontinuing Fosamax (alendronate) treatment after 5 years vs continuing for 10 years. Design and Setting Randomized, double-blind trial conducted at 10 US clinical centers that participated in the Fracture Intervention Trial (FIT). Participants One thousand ninety-nine postmenopausal women who had been randomized to alendronate in FIT, with a mean of 5 years of prior alendronate treatment. Intervention Randomization to alendronate, 5 mg/d (n = 329) or 10 mg/d (n = 333), or placebo (n = 437) for 5 years (1998-2003). Main Outcome Measures The primary outcome measure was total hip bone mineral density (BMD); secondary measures were BMD at other sites and biochemical markers of bone remodeling. An exploratory outcome measure was fracture incidence. Results: Compared with continuing alendronate, switching to placebo for 5 years resulted in declines in BMD at the total hip (–2.4%; 95% confidence interval [CI], –2.9% to –1.8%; P

According to australian Data the frequency of Bisphosphonate associated osteonecrosis of the jaws in osteoporotic patients was 0.01-0.04% without extractions and a calculated 0.09-0.34% if extractions were carried out (J Oral Maxillofac Surg. 2007 Mar; 65(3):415-23; Nature and frequency of bisphosphonate-associated osteonecrosis of the jaws in Australia; Authors: Mavrokokki T, Cheng A, Stein B, Goss A) Although the risk is still low it should be remembered that there is only limited knowledge about sideeffects in the long run. Surprisingly the Prescription information/Consumer information for Fosamax in Australia is more cautious compared to the one in the United States.

I've seen 5 or 6 cases of spontaneous necrosis in the maxilla and mandible. All patients were taking Fosamax. The reality of the bisphosphonate controversy is that most of the medical profession is in denial when it comes to bone necrosis and Fosamax. Fosamax commercials prevail on national TV without mention of potential side effects. Tread with caution and definitely use detailed informed consent if and when you place implants in patients on Fosamax. Don't even consider implants or any other surgical procedure if you are not prepared to deal with the potential complications. It is not ethical to operate on these patients and then refer when complications occur.

I only treat facial pain/"tmd" patients. I have close to seventy patients that I suspect have osteonecrosis due to use of a bisphosphonate. ONly three of my patients were cancer patients. I use radiology a lot in my diagnostics and treatment considerations. I use cone beam ct and many times mri. Since I have an unusual patient population and am looking at the TMJs in most of patients I am looking at the ends of the mandible. The majority of my patients have various levels of degenerative changes in the fossae and the condyle. I have patients that have experienced what I believe are compression fractures. The radiologic sings of osteonecrosis are present on the cbct and the mri. Medical radiologists have called the condylar problem osteonecrosis. Is it related to the bisphosphonates? It seems logical that the entire mandible would be affected if the tooth bearing areas have the effect. I have great concern for what is happening to the fossae. The NEJM reported about a case of osteonecrosis of the auditory canal post remeoval of an exostosis. This was in a patient that reportedly had experienced BON in the maxilla. I think that like our medical colleagues that the use of imaging will help greatly with the diagnosis and treatment planning. Hopefully those patients with oral lesions will be able to have imaging done to examine their "joints". As said, these are truly very useful and important medications, but it seems that most all medications have sides in a certain percent of people. We need to find protocols to help determine which patients may be affected.

I have treated many patients who have taken biphosonates and to date have not had any cases of osteonecrosis(I appreciate that the manifestations of thecondition may take several months/years to occur). I treat the patients,when they require unavoidable removal of teeth as though they had received irradiation to the jaw-ie amoxicillin or clindamycin cover for 1 week prior to treatment and 2 weeks post extraction. I endeavour to achieve bprimary soft tissue closure after "atraumatic" removal of the offending teeth. All patients are advised as to the low risk of the condition but informed that there is a real risk of it's occurrence and the difficulties involved in management. As I said, to date over the last few years I have had no problems, but remain aware of the real possibility of occurence of the condition

The substantial difference in the risk for osteonecrosis of the jaw between patients with cancer who receive high doses of intravenous bisphosphonates and patients with nonmalignant skeletal disorders who receive considerably lower doses must be highlighted, but the ADA recommendations for managing the disorder does not reflect the difference. In the past some authors had suggested that all patients starting bisphosphonate therapy should undergo a comprehensive dental examination and panoramic and intraoral radiography followed by surgical treatment for “at-risk” teeth. That idea was later abandoned because of lack of concrete reason. The strategy was based on the recommended evaluation of patients who are about to undergo bone marrow transplantation, hardly a similar situation to starting bisphosphonate treatment for osteoporosis. The incidence of osteonecrosis of the jaw in osteoporotic patients receiving amino-bisphosphonates is uncertain, but no cases were reported in randomized, placebo-controlled trials of alendronate, risedronate, and ibandronate that collectively included more than 20000 patients who were studied over at least two years. Even if the disease had been considerably underreported in patients with osteoporosis, the number of patients needing to undergo the intervention to prevent a case of osteonecrosis of the jaw is likely to be very high. The American Dental Association advises that invasive dental procedures should be avoided in patients taking intravenous zoledronate or pamidronate, but they have not mentioned how to distinguish between patients receiving conventional dose treatment for osteoporosis or Paget disease and those receiving the very high doses for malignant disease. Osteonecrosis of the jaw is overwhelmingly problematic for the second group. The only three cases of osteonecrosis of the jaw reported in patients with Paget disease all occurred after exposure to bisphosphonate doses that exceed those typically used to treat the disease. So, the sloughing of jaw was really because of too aggressive treatment rather than the usual effect of the bisphosphonates themselves. An excessively conservative approach imposes a high risk of malpractice to patients who are already taking bisphosphonates, not getting appropriate dental treatments like implant placement etc., when needed and patients with dental problems not being given proper treatments for osteoporosis and Paget disease.

Last weekend I attended a lecture at the CMF-department of Cologne University, Germany. Prof. Zoeller and his group reported on several cases suffering from bisphosphonate side effects. The serverity of these cases was tremendous; they reported on years of treatments without healing or results and contiuously necessary surgical interventions, even leading to complete resections of jaw bone aeas. With this expierence in mind, Prof. Zoeller expained that, -as a rule -, his group does not place dental implants in patients receiving bisphosphonates or with a recent history of having received bisphosphonates. A postive 99Tn-scan, showing alive bone after therapy is their requirement for accepting those patients. I take this lecture as a warning. There are enough other patients to treat.

After taking Fosamax for about 10 yrs, I now have a failed root canal. Tooth extraction and dental implant is recommended. In attempting to be proactive and prevent any problems, a "drug holiday" has been recommended with no specific length of time indicated. Also, no definitive way to diagnose osteonecrosi is evident. How long should the "drug holiday" be and is the CTX lab test the most desirable diagnostic tool? Thank you Patti

I have missing teeth (upper) and am considering dental implants. I also are taking Fosamax due to osteoporosis. I took the CTX test which is suggested by one dentist. The number came out as 150. I have no idea why their view is conflict. So I asked my family doctor to talk to the dentist. So far there is no results. I really wonder whether this CTX test is scientific. By the way, I had a tooth pulled out in April, everything was OK. I consulted another dentist today, his opinion is stop the Fosamax for a while. What should I do?

As an OMS I have seen 25-30 patients who have received oral and IV bisphosphonates and who seek oral surgical treatment. I have used the AAOMS and ADA guidelines for management including CTX for those taking oral agents longer than three years. With CTX >150 pg/ml I have had no problem with BRONJ. My lone patient with non-healing bone occurred following IV zometa infusion for multiple myeloma. In my opinion for dentistry as in medicine anecdotal references should only serve as a guide until prospective multicenter studies show which therapy is best. My current protocol includes screening with CTX, drug holiday of three months when CTX

Sorry, I made a mistake in my previous email. My CTX number came out as

Yesterday I had my #12 tooth removed and the cow bone prep for an implant. Today my friend asked me if my periodontist knew I was taking Fosamax. Yes, he did. And now I'm finding out that implants may not be recommended for people taking Fosamax. I suppose I will talk to my physician, my periodontist, and my dentist, but what do you think I should do now that we have already begun the procedure?

Vicki I have been placing and restoring implants for over 30 years and this issue of bisphosphonates (Fosamax) has just come up in the last year or so. No one really knows the best answer to your question as we do not have enough data to support either avoiding placement or going forward. In way of an personal experience, I placed 12 implants in a patient 9 months ago with no contrary history. It was only after the surgery, she adivsed me that she had been taking Fosamax but had stopped a month ago. I was very worried, but what had been done was done. Once you have been on the drug, there is no waiting period that can be supported to so the risk is gone. I actually think she (a nurse) knew I would elect not to go forward, had I known about the Fosamax. Today, 9 months later, she is doing very well. All implants have integrated well and there is no evidence of failure. My advice to you is that your implant is in place and for you to not worry about it as long as it is doing well. Most information points to the fact that once the implant has integrated, the risk is very low. Since that experience, I have placed a few implants into patients taking long term bisphosphonates with no problem, as long as everything else medically is good. My personal feeling is that the incidence of osteonecrosis is very low and associated mostly with IV administration for post cancer, etc. treatments. As time goes on, I think we will find the reaction to the osteonecrosis was probably over stated and we will weigh the risks along with other risks and make an informed decision as to wether to go forward or not. I think you should trust the decision of your periodontist and try not to worry. Be concerned, but not worry. WLO, DDS

There is little data on the activity of parenteral bisphosphonates beyond two years of administration. In one report, there was an extremely low incidence of skeletal-related events in a patient population with bone metastasis that was followed for up to 10 years ( A. Bamias et al., Osteonecrosis of the jaw in cancer after treatment with bisphosphonates: incidence and risk factors, J Clin Oncol 23 (2005), pp. 8580–8587). Bone metastases are common in patients with many types of cancer, particularly with breast and prostate cancer. Others include multiple myeloma and lung cancer. This condition is associated with considerable skeletal morbidity, including severe bone pain, pathologic fracture, spinal cord or nerve root compression, and hypercalcemia of malignancy. Among all of these types, breast cancer has the highest incidence of skeletal complications and therefore, zoledronate become the drug of choice in patients with metastatic breast, prostate, lung, renal, and other bone involving cancers. A combination therapy with zoledronate and pamidronate has been successfully used in patients with breast cancer, lung cancer, multiple myeloma, lymphoma, and uterine sarcoma. Different mechanisms have been reported to account for the action of bisphosphonates, including induction of apoptosis and disruption of the cell cycle. They also have anti-invasive, anti-angiogenic, and antimigration effects. The exact molecular targets have not been recognized yet. Osteoclasts have a life span of about 150 days, after which they resorb the mineral matrix of bone and release bone morphogenetic protein (BMP) and insulin-like growth factors, which in turn induce local stem cells to differentiate into osteoblasts and form new bone. If the osteoclast function is too severely impaired, dead and dying osteoclasts are not replaced and the capillary circulation in the bone is not maintained, resulting in bone necrosis. Bone formation is also decreased secondary to diminished resorption. Placement of dental implants in patients receiving the intravenous form of bisphosphonates must strictly be avoided. Any change in surgical planning of the patients who have taken oral bisphosphonates for less than three years and bear no other risk factor, would not be necessary. If a patient is on a combination of oral bisphosphonates and corticosteroids for less than three years, the oral bisphosphonate treatment should be discontinued for three months, and then be resumed after bone healing is completed (AAOMS Position Paper on Bisphosphonate-Related Osteonecrosis of the Jaws. Available at: http://aaoms.org/docs/position_papers/osteonecrosis.pdf)

I have been seeing increasing numbers of patients coming to the office with a history of IV bisphosphonate or oral bisphosphonate use. The vast majority are just here for reassurance, but a few have presented with exposed bone that I am managing according to the AAOMS guidelines and Marx's recommendations in his "bisphosphonate textbook." The problem is real ( no matter how low the incidence) and it will never go away. The consequences can be quit devastating and disfiguring as well. The CTX has enabled us to proceed with treating these patients (mainly the oral bisphosphonate patients) with a relative degree of safety and certainty. As our knowledge and understanding of the problem at hand increases, so too will our level of comfort in treating these patients with implants. But for the moment, I strongly urge extreme caution in any surgical treatment of the bisphosphonate patient (especially implant surgery). Take the time to read the guidelines (the link provided by Dr. Jafari above). I strongly recommend reading Dr. Marx's textbook on Osteonecrosis. It is a very easy and informative read for all dentists. Also take the time to read the following articles: American Association of Oral and Maxillofacial Surgeons Position Paper on Bisphosphonate-Related Osteonecrosis of the Jaws Advisory Task Force on Bisphosphonate-Related Ostenonecrosis of the Jaws Journal of Oral and Maxillofacial Surgery March 2007 (Vol. 65, Issue 3, Pages 369-376) Osteonecrosis of the jaws associated with the use of bisphosphonates: a review of 63 cases Salvatore L Ruggiero, Bhoomi Mehrotra, Tracey J Rosenberg, Stephen L Engroff Journal of Oral and Maxillofacial Surgery May 2004 (Vol. 62, Issue 5, Pages 527-534) Bisphosphonate-Induced Exposed Bone (Osteonecrosis/Osteopetrosis) of the Jaws: Risk Factors, Recognition, Prevention, and Treatment Robert E. Marx, Yoh Sawatari, Michel Fortin, Vishtasb Broumand Journal of Oral and Maxillofacial Surgery November 2005 (Vol. 63, Issue 11, Pages 1567-1575) Pamidronate (Aredia) and zoledronate (Zometa) induced avascular necrosis of the jaws: a growing epidemic Robert E Marx Journal of Oral and Maxillofacial Surgery September 2003 (Vol. 61, Issue 9, Pages 1115-1117)

I have a patient that requires 2 mandibular extractions and is interested in dental implant replacements. She has been taking Actonel for more than 3 years. I ordered serum CTX study which returned with a level of 137. According to Marx, this puts her in the moderate risk category. I currently have started her on a 3 month drug holiday, and am planning to do the extractions soon after that. I'm going to wait to place implants until I assess complete healing of the extraction sites (4-6 months). Does anyone know of any value in retesting the CTX after a drug holiday period? Do you have any thoughts regarding this treatment plan?

Has the drug company alerted anyone? The dentists,doctors,pharmacists and most importantly the taker of Fosamax of the risks involved regarding dental extractions??????. signed a 72year old woman who is about to find out if I have this condition..On Fosamax since 1999 with root surgery feb 04 and has all of the classic symptoms.

My CTX score was 78 pg/mL which was considered to be "In Range". The Out of Range for my age (70) was listed as 87-345. Yet, my dentist told me that I was at "high risk" even though I was "In-Range". In a number of discussions that I found on the website, it was stated that the number should be >150 pg/mL. If 150 pg/mL is considered to be Out of Range, why is it important to have at least this value, if surgery is to be performed?

I suffer 'lichen planus' and I am told I will have it for the rest of my life. I am 70 yrs old in good health except for osteoarthritis in hands and bone thinning in lumbar/spine. I have been taking actonel (bisphosphonate) for 7 years. Should my dentist be informed if I need a tooth extraction?? thx Does this medicatation cause lichen planus???????

I'm a 57 yr old and an 8 yr breast cancer survivor who took Fosamax for 2 1/2 yrs before I quit it 1 year ago due to the jaw necrosis scare. I have only 5 upper teeth that I want extracted and acquire an upper denture. Would you consider extraction a little less invasive than implants? and the 1 year off Fosamax an adequate time span? I had 3 teeth removed at once last May with no problems in healing. -thank you

I am a 59 year old WF, and plan to have lower implants this year on both sides. I have been diagnosed with osteopenia, but have not taken Fosamax or other bone building drugs. Is there any research about the risks to my implants from osteonecrosis of the jaw if I should decide to take oral Fosamax later?

While I cannot give you any direct medical advice, I am no fan of the Fosamax family of drugs. Period. There are safety ranges to adhere to without dental implants being a significant risk procedure. But.. should a person acquire BRON or BON (bisphosphonate related osteonecrosis), they have it and it is a tough almost irreversible situation. I say almost because I know of one case locally that turned around, but it was through aggressive therapy and most likely a lower dose related situation. I think the overall opinion is that if you have taken the equivalent of 70mg/day for greater than 3 years, you need to get a CTX lab result before proceeding with oral surgery. The IV forms of this family of drugs are extremely potent and are a contraindication to implant therapy without satisfactory lab studies to determine that a patient will actually have the capacity to heal. I would strongly recommend your dental health be in excellent shape before any bisphosphonate therapy, keep your hygiene appointments and do your homework prior to implants. Thats just one opinion, there are more and great info on some of the other related threads.

As a civilian -- not a doctor or patient -- I hope the word gets out soon about actual science and bisphosphonates as they relate to osteonecrosis. Two very recent studies absolve products like Fosamax. I am frankly surprised that a dentist has not posted these results from January 2008. Read about it for yourselves at JOMS and JADA. Here are my sources: http://www.joms.org/article/PIIS0278239107018769/abstract http://uk.reuters.com/article/healthNews/idUKLAU37863320080103

Munrry, two articles do not an absolution make. Im sorry but that is not enought for me. Science is science, and necrosis is necrosis. To be totally scientifically analytical, you process all information, not just two articles and say, Ah-HA! I do think the incidence is low for the oral forms of the bisphosphonates, it IS a risk. Whatever the percent, its a risk. Those articles are NOT an absolution for clinicians, just a ray of hope for the future dealings. Hopefully, real science will stumble on a cure for BRON. That will be significant. Until then, its the caution light for me. Bill

Murry, I don't think these studies really add much to what's known about ONJ. The one that was published in JOMS (http://www.joms.org/article/PIIS0278239107018769/abstract) only involved 115 patients. As for the JADA Jan 2008 issue, it seems that the editor of JADA does not think the two studies reported in that issue have added much. There's an interesting commentary at dentalpbrn.org/studyClub/litWatch/default.asp ("January 2008 issue of JADA features 2 articles and editorial regarding bisphosphonate-associated osteonecrosis of the jaws (ONJ)"). The commentary ends with this: "The design of these two studies substantially limit their ability to inform daily clinical practice. An editorial, "Closing in on the Puzzle of ONJ", about these two articles by Michael Glick, JADA’s Editor–in-Chief, notes that “these studies do not help clarify the potential adverse effects of dental treatment in patients taking bisphosphonates.” Jane

Google James Rutkowski DDS on bisphosponates. Excellent researcher and clinician.

My mom had the cTX test done before her oral surgery and the test came back at 55. She had to have the surgery right away because the tooth pain outweighed the risk of not healing as quickly with a higher number. Anyhow, my question is this test measures overall bone density and are her bones going to crumble away and what can she do to increase bone regeneration?

I recently (last week) spoke with Dr. Salvatore Ruggerio, one of the authors of the AAOMS position paper and probably the 2nd most mentioned name behind Dr. Marx, regarding the validity of the CTX scores. He commented that he doesn't put much value in the scores since they measure the overall osteoclastic activity (cleavage of a terminal peptide) and that at present it is not possible to tell exactly where the activity is coming from (hips, legs, back, jaw, etc.). My contact was initiated as I too, was interested in obtaining the CTX values for a patient on Fosamax. I share this not to question those who are so diligently working on answers for all of us wet-handed clinicians, rather to share in this venture for the betterment of treatment for our patients. If you choose to obtain CTX scores then take the time to ask if there is specificity in exactly where the osteoclastic activity is coming from........and share your findings..Respectfully submitted

I am a 68 year old male who has been taking Actonel, 35 mg once a week, for 21 months. I am in excellent health, exercise regularly, and have followed a regular plan of dental treatment (3 cleanings per year) as well crowns, fillings, root canals whenever recommended by my dentist. I recently had an extraction of my # 14 tooth as recommended by my dentist, who inedicated the tooth was failing rapidly. When I informed the dental surgeon that I had been taking Actonel orally for nearly two years, he expressed concern about doing an implant, my second one, due to the fact that I had been taking the Actonel. i really prefer to do an implant rather than a bridge or a partial. Teeth #s 15, 13, & 12 all have crowns, which make a bridge somewhat complicated and very expensive. I had informed my dentist in July of 2007 that I had started taking Actonel and this was reflected on my chart; however, when we started discussing the implant over a year ago, this was never mentioned. I am in somewhat of a quandrary now as I would like to have an implant,but from what I've read online this could put me at risk for osteonecrosis, which appears to be a horrible disease/condition. Some information I've read has indicated that my risk is so low that it should not be a real concern. Other pieces of information have said I should proceed with great caution because there is a certain amount of risk. It appears that there is quite a bit of conflicting information on the relationship of oral bisphosphonates (Acdtonel) and doing implants. I am seeking some guidance/direction as to a reasonable course of action, and in this endeavor I am trying to gain as much input as possible. I plan to talk with my primary care physcian, my dentist and the dental surgeon, who did my recent extraction as well as my first implant in November 2006. Before doing this I woulld like to receive comments/recommendations from your staff. Your comments, hopeully within the next few days, would be very much appreciated. Thank you. Dan Brown Gilford, NH

Dear Dan Brown, This is a gray area. So proceed with caution.

I am planning on having a tooth extracted on April 2, 2009 and am concerned about osteonecrosis of the jaw. I have been receiving Boniva injections, which last for 3 months, for the last 1-1/2 years. I have actually had a total of 4 injections, my last one being January 16, 2009. The doctor, an endocrinologist, who is involved with my boniva injections says to go ahead and have the tooth extracted. I was wondering if I should have the CTX bloodtest or just do what he says.

I have implants on my upper jaw...total...caompleter about a year ago. I have been taking Actoneland now Fosamax for many years. I recently developed an infection on my upper right gum area and the periodontist sent me for an CTX blood test which came to 80. He said I would have to stop the Fosamex for several months before he would operate. Another physician said that the fosamex will never completerly leave my system and that the incidence of osteonecrosis is so small and that it is just a legal protection. I am getting different advice from 2 doctors. Now what??

Marylin, Fosamax has a half life of 7 to 10 years. As per osteonecrosis, I would treat the infection accordingly.

I have seen two periodontist concerning dental implants. I was on Fosamax for about four years and then switched to Forteo injections for a year and a half amd back to Fosamax. One dentist tells me to go ahead and remove some teeth and get dental implants, and the other says to first get a CTX test and get off the Fosamax drugs for about three months. Who do I believe or trust to be right so I wont be at risk of getting osteonecrosis?

Its true that bisphosphonates have a half life of 7-10 years. However, concerning osteonecrosis you have no reason to be worried. The current recommendation of the academy of osseointegration is caution when having a history of more than three years of oral bisphosphonate treatment for implant placement. Sound surgical technique is the safest way to avoid complications, there are recent reports of patients with long term history with this drug having undergone a more extensive autogenous bone graft followed by implant placement with no complications. As far as implants are concerned, there is plenty of evidence (research) out there to support lack of any negative influence of these drugs on implants, if the drug was taken for three years or less. But there's no evidence supporting that more than three years is detrimental for implants. As a matter of fact, only a few of cases of osteonecrosis are reported in the literature that have occurred due to ORAL bisphosphonates. No one reports success or lack of complications so the actual percentage of risk of developing this condition is not known, but is currently though to be negligible. Hope this was helpful. Good Luck.

I have a lower very back molar that needs to be removed. I'm not really sure how long I took fosamax. I know that I first took it in late 1998 and I was not taking it in 2004 but I can't remember when I stopped. Are my risks lower if I haven't taken fosamax in at least six years?

Lucy; You need to have a CTx test performed. Your dentist or physician can order the test from a clinical laboratory.

No one has added any comment on here, nor have I found anything on the internet by someone personally saying they have had osteonecrosis. Having said that, some have had dental issues which they suspect might be related to bisphosphates. But it hasn't been proved. This is very frustrating. I have had conflicting advice from 2 doctors regarding having dental implants. Whoever formulated this medicine, if necrosis really is something to worry about, did not think it through. And, advising people to have any dental work BEFORE going on this med is a bit silly because typically, the age-group of people who are prescribed this are the most likely to need dental age-related restorations and treatments. Are we all just guinea pigs yet again?

Mary: I will weigh in because I feel your frustration. All of us were blindsided with the relationship of the bisphosphonates and osteonecrosis a few years ago. When it was reported initially, the extent and frequency was unknown. With so few examples, it is difficult to identify the etiology. The question is not that we are all guinea pigs but that no one really knew. Today it appears that the possibility that you will develop osteonecrosis using oral medications is extremely small. The majority of cases are with patients receiving the drug through IV administration and that is very small. Personally, I have placed implants into two patients that had been taking them for a long time and denied they had until afterwards and another patient proceeded after signing a waiver. All are now over two since placement and are doing fine. The current thinking is that, yes there is a possibility of developing ostenecrosis, but it is extremely low. You must weigh the tremendous value provided by the implants against the very small chance that the disease will develope. My opinion is that the implants far outweigh the possibility of a negative result.

Wayne: Thanks for the input. We are fortunate to have you opinion due to experience and knowledge.

Nowhere on the net can I find the exact meaning of "half life" What exactly does that mean? Fosamax has a "half life" of 10 years. I understand it means half of the medication leaves our system in 10 years. What about the other half? Does it mean it takes 20 years to totally leave your system? I was on the drug for 3 years (6 years ago). I need an extraction and am worried. Can any doc here explain the "half life" theory? Thanks so much.

I am the same Mary as above, and I just want to say thank you to Dr Wayne O'Roark for his input. It's nearly a year on, and my implant is looking more and more like a necessity due to deep pockets and pain in a root-filled tooth. The start of this thread was way back in 2007, and I just need to know if opinion and evidence relating to Fosamax and implants has moved on. Are more dentists now accepting that necrosis is a low risk now? I have had 2 more opinions the last week on this and one dentist said "low risk", another would not even consider doing it.

It's Mary again. I have just been told by the periodontist that I have to have two upper back molars removed in hospital as the bone loss is too far gone to consider trying to save. The periodontist then said we have to see how I heal before assessing for implant suitability, but my chances of being suitable are not good. I'm almost relieved as the cost would be exhorbitant, but I'm wondering how much more jaw bone mass I will lose without the implant. As a side note, I am going to have gum grafting on lower front incisors and canines. Also a deep scale and root plane on lower back molars right and left. Hindsight: don't smoke - ever - don't drink to excess, floss, eat healthy. The perio said considering my history, I have done well! Will update again after extraction. Gulp.

ps -- forgot to say, I have to have the extractions in hospital because of taking Fosamax, so have to be monitored by a specialist!

Update - confirmed I am to have 2 extractions UR6 & 7. A cross-clip on denture is not an option due to the teeth opposite (one fragile due to having an inlay, and one crowned). Other options are bridges, but as they will have to drill into healthy tooth for that, I am going to try for implants. It is a big ask as a) I've been on Fosamax for 5 years, and b) I have lost a lot of bone and regenerating it is borderline as whether I am a good candidate. I will let you know how I get on but am wondering if this should move over to choosedentalimplants? Anyway, I will relate what happens, and it will be coming directly from a patient rather than someone reporting about a patient. Thank you.

Mary, You do have a delema. There are test that can de done to determine just how much of a risk you would have. It is a CTx test that measures the activity of type 1C telopeptide for type one collagen. I know that is a mouthfull, but the test may be helpful!

Update - Had consultation with Maxillo-facial consultant today. I was told that although they used to recommend patients on oral bisphosies have teeth out in hospital under care of the max-fac surgeon, this is no longer the case, and oral bisphos patients can have extractions done by their general dental practitioner. I decided after discussion with her that I want to be monitored over the next year, as my dental hygiene is good to the point of obsessional. My own dentist and the periodontist did not take into account the fact that I have only recently (last 2 years or so)been having regular hygienist appointments, and due to the fact that the dental office I go to has had so many changes of dentists the last few years. all they saw was the current situation, not taking into account the circumstances. I will probably have them out at some point if monitoring shows I am not doing a good job. Stay of execution. If they become infected again, I will report back. Just wanted to update the advice on bisphosphate risk and extractions as it stands here in the UK ie, no longer considered a high risk.