Patients on Bisphosphonates: Current Thoughts on Implant Treatment?
Dr. T asks:
There is universal agreement that high dose intravenous bisphosphonates for e.g. myeloma or disseminated carcinoma, are an absolute contraindication to dental implants, whereas most US implantologists do not seem overly worried about treating clients on low dose oral bisphosphonates, such as Fosamax 70mg weekly.
However, I am seeing more and more patients who are on monthly, 3-monthly or annual regimes and I would be interested in your views on the wisdom of treating these people with dental implants. None of the various position papers on oral surgery and bisphosphonates seem to tackle these “in between” cases. Any comments?
9 Comments on Patients on Bisphosphonates: Current Thoughts on Implant Treatment?
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Dr. C
6/16/2011
Interesting topic. I am general dentist and have placed numerous implants in patients on oral bisphosphonate therapy. My protocol is to get a CTX marker test/risk assessment. Although some would argue it is pointless, its the only test I know of. I am also very clear and blunt with my consent with these patients. There doesnt seem to be alot of clear cut literature on protocol and I tell them they are taking a higher than nomral risk of failure and complications-including ORN. I have not had an implant fail in a patient with a CTX marker test in the "minimal risk" category. Although, that doesnt mean it cant and wont happen. This will be a very interesting topic and string of posts!
Tyler
6/19/2011
Dr. C
Just a point of clarification for you.... These patients are not at higher risk for ORN, rather they are at risk for BIONJ. Although these may seem similar, they are in fact actually different.
Dr C
6/19/2011
You are correct, I did not mean osteoradionecrosis, but osteonecrosis.
Dr. Wolanski
6/21/2011
In our office we do not do Tx on anyone who has had IV Bisphos. If they have had oral Bishphos we will Do treatment if they have takent them for 3 years or less. We go over a special informed consent with these patients and lengthen the normal time/load protocols (they do heal slower). This was the concensus of a number of oral surgeons a few yers ago. Interesting to note the bone has a much more yellow color in these patients. I am not so much concerned about an implant failing as I am concerned about the potential damage done to the patient.
Dr. B
6/23/2011
According to the American Association of Oral and Maxillofacial Surgeons consensus report led by Dr. Marx if the patient has been on oral bisphosphonates for three years or more, he or she needs to stop meds for three months prior to elective surgery. That being said, the risk for necrosis is very low in comparison with IV bisphosphonates. Nevertheless, patients need to be informed of the risk, no matter how small.
Dr. Wolanski
6/27/2011
Another collegue asked if their is a quantification of the risk they can show to their patients. According to Fang,Fazio and Menhall the risks for ONJ as of 2010 are:
IV BP's -risk is high - incidence of 0.8-12%
Oral BP's 3 yrs - risk is elevated to modest and protocol should be adapted
The drug holiday was contoversial as to its real effects. Could Dr. B say if the OMS protocol for the drug holiday now has supporting data?
Thanks
Dr. Wolanski
6/27/2011
My comment failed to show the risks numbers for Oral Bp's which are Low with and incidence of 0.04 - 0.3%
There should be a "greater than sign" in front of 3 (Oral BP’s >3 yrs ):-)
Dr.B
6/27/2011
Dr Wolanski, I am not aware of any supporting data. Thanks for sharing your thoughts.
Dr. Godinho
2/22/2012
There is a very good review of implant placement and bisphosphonates therapy by Dr. Carlos Madrid.
Regarding to the CTX test, is the only way available to determine the risk of ONJ that we have. Normally patients who develop ONJ present low values of CTX. So if we have the bone turnover rate values of the patient we can have a perception of how much this rate is suppressed and therefore the risk for developing ONJ.
The drug holidays can increase this CTX values. Dr. Marx showed that for each month of drug holiday we can have a raise of 25,4-26,4 pg/ml in this values.
