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Spring Survey Results 2012

Bisphosphonates & Necrosis of the Jaw

Program: Getting Help to Fight Osteoporosis
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Andrew Schorr:

Now, there's one situation that's come up where some people who were taking the medicines stopped or do stop, and that is when they're going to have dental work. And there's been this concern in dentistry and in oncology as well related to people taking at least one group of medicines, the bisphosphonates, and if they have dental work they could have basically I think you call it necrosis of the jaw and it just won't heal. Dr. Bauer, talk about that for a minute. Is that a big, prevalent problem? Should, in your view, stop taking their osteoporosis medicine?

Dr. Bauer:

Well, fortunately this is not a common side effect, but when it happens it's really terrible. The good news is that the vast majority of individuals who have developed this unfortunate complication, which is called osteonecrosis of the jaw, which is really a condition where patients develop exposed bone in their jaw. So the gum actually breaks down and there's actually exposed bone. This has now been reported in a number of patients. All the evidence suggests that this is an extremely unusual side effect or complication of taking bisphosphonates, and the vast majority of them, over 95 percent of the individuals that have developed this unfortunate side effect, have been taking very high doses of bisphosphonates not for osteoporosis but because they have some sort of malignancy, and typically and it's a malignancy that might cause fractures.

So this is a very important thing to know about, but fortunately it's extremely rare. In the 30 or 40,000 patients that have been studied in large clinical trials for patients with osteoporosis there wasn't a single reported case of this osteonecrosis of the jaw. But of course there are millions and millions of individuals taking these medications now, so this is something that clinicians and patients need to be aware of, if they develop a painful sore in the mouth, that they need to notify their dentist and their doctor right away.

What to do about this has also been problematic. This is a condition where there's no good treatments. There's no specific medication or surgical procedure for these unfortunate problems with the jaw. Our best evidence now is that we should stop the bisphosphonate and the patient should be followed by a good oral surgeon who is familiar with this type of problem.

The more troublesome issue is what to do about patients that need to have dental work or a tooth extracted while they're taking this medication because many of these episodes of osteonecrosis of the jaw have been apparently precipitated by dental work. There are some experts, particularly dental experts that feel that it might be a good idea to stop bisphosphonates for a number of weeks or months prior to having any dental work. The medical community is a little bit less certain about the wisdom of this because we know that these medications, the bisphosphonates, are retained in your bone for many, many years if not decades, so simply stopping them for a short period of time before you have dental work may not be particularly useful. But it is something you should probably discuss with both your dentist and the doctor that gave you the prescription for the bisphosphonate.

Andrew Schorr:

So, Dr. Kohlmeier, it seems like for the vast majority of people though, if you need medicine is keep taking it, have an active dialogue, and maybe the best thing that they can do is seek out a provider, such as yourself, such as Dr. Bauer, where they can have an ongoing relationship for the management of this condition.

Dr. Kohlmeier:

Yes. And I think another one other important point that has to do with how long do you take a medication and do I want to take a medication that stays in my bone for decades comes up every day, several times a day. And a few other comments about the osteonecrosis of the jaw that I like to tell my patients is there is a big difference between, one of our dentists called it chemotherapeutic bisphosphonate doses, three to 20 the dose intravenously every month for cancer patients versus the osteoporosis doses. So that's the first difference, I think.

And where that applies is when my patients say, I've heard if you take this medicine for so many years then this and this happens, in the cancer patients there was a dose response, meaning the longer patients were on this chemotherapeutic bisphosphonate doses for cancer the closer they became to having a .6 to 2 percent risk, something that's really tangible, of ONJ, but that doesn't apply to people on long dose osteoporosis bisphosphonates. And I think that difference even in the medical and dental community needs to be looked at. Now, there are very smart and brilliant investigators that are looking into this and that are concerned, and we're thankful for that because, as Dr. Bauer said, there are millions of people who are being treated with bisphosphonates.

The one other message to my patients is that, I'd love Dr. Bauer's opinion, that the marker of bone turnover, which we haven't even talked about because it really isn't a common test for our osteoporotic patients though it is for studies, does not help in any way predict the risk of osteonecrosis of the jaw. So when patients say my dentist ordered a CTX or an NTX, I really think that that has not been shown to have any indicator of ONJ. Would you agree, Dr. Bauer?

Dr. Bauer:

I would absolutely agree with you. Everything you said.

Andrew Schorr:

Okay. We're going to move on. I've got some questions from our audience. So Mary from Wenatchee, Washington, I think we've covered this but I just want to give her a good answer. She said, "My great grandmother and my grandmother both had osteoporosis. I know that there's not much I can do completely to prevent osteoporosis, but will exercise lower my risk of fracture?"

It sounds like, Dr. Kohlmeier, it's yes, it's to the good.

Dr. Kohlmeier:

Doing all of the things that we have been talking about as soon as you start focusing on your skeleton, knowing your family history is fantastic and also to reflect that on her children and her relatives. One study that Christine Snow and her colleagues did is they took children in elementary school and several hundred of them went through jumping exercises and the other group stretched, and they did this for months, and those children had a different peak bone density depending on the load of their skeleton. So any bit that we can do improves our bone density.

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