Risk of jaw bone necrosis with patients on Fosamax or other bisphosphonate drugs

Bisphosphonate-induced osteonecrosis of the jaw adversely affects the quality of life. American association of oral and maxillofacial surgery recently published a position paper on this condition. Majority of patients are on the oral form such as Fosamax, but some are receiving IV therapy which have more serious consequences. It is important that we continue to educate our patients with this condition and its implications, and current knowledge on management strategies. This quick reference guide reviews important facts for every patient on bisphosphonate therapy and their treating dentist.

What is it? Bisphosphonates are used for treatment of osteoporosis, hypercalcemia of malignancy, Pagets disease of bone, multiple myeloma, and metastatic bone disease in a number of cancers

What are the various forms of this drug? Intravenous forms: Zometa and Aredia (for management of cancer related conditions) and more recently, Reclast (for osteoporosis). Oral forms: Fosamax, Actonel, Boniva (for treatment of osteoporosis and osteopenia); Boniva is available in oral & IV

What are the reported effects on jaws? The primary concern is osteonecrosis of the jaws characterized by poor healing of the bone following common oral surgery procedures (i.e. extractions, implants, periodontal surgery, etc.)

How do I know I have osteonecrosis of the jaws? When all the following are present: 1) current or previous treatment with a bisphosphonate, 2) Exposed bone in the oral region for more than 8 weeks, 3) No history of radiation therapy to the jaws

What are the risks for developing bisphosphonate-induced osteonecrosis of the jaws (BIONJ)? Increased risk with use of IV forms, duration of therapy more than 3 years, over areas where there is thin gum tissue, and patients using steroids at the same time. There is 7-fold increase risk in cancer patients exposed to IV form with history of dental disease. It occurs more commonly in the lower jaw.

How can it be prevented? Before treatment with IV bisphosphonate, patients should have complete oral evaluation and treatment to avoid surgical procedures later. In patients on oral form of the drug, if possible, may discontinue oral bisphosphonate for 3-months before and 3-months after elective invasive dental surgery to lower the risk.

What are the treatment strategies?

Asymptomatic patients on IV bisphosphonate: Maintain proper hygiene and dental care, Avoid surgery if possible
Patients on oral bisphosphonate less than 3 years: Elective surgery is safe. There is always a small risk however and informed consent should be discussed for any elective surgery.
Patients on oral bisphosphonate less than 3 years along with steroids: Consider discontinuation of oral bisphosphonate for at least 3 months before surgery; restart drugs once healed.
Patients on oral bisphosphonate more than 3 years: Consider discontinuation of oral bisphosphonate for at least 3 months before surgery; restart drugs once the surgery site has healed.


Dr. H. Ryan Kazemi is a board certified oral and maxillofacial surgeon in Bethesda, Maryland. He is a clinician and lecturer on the topic of dental implants, bone grafting, and other oral surgery procedures. He also produces video podcasts on dental implants and oral surgery to educate dentists and patients for making better and more engaged decisions about their oral health.

To reach Dr. Kazemi for this story and others:

Email: Hkazemi@facialart.com
Tel: (301) 654-7070

web: www.facialart.com

Visit our video podcasts on:
1) iTunes: search word- 'dr. kazemi'
2) Vimeo.com: search 'dr. kazemi's oral surgery channel'
3) YouTube: search 'implantguru'