Bisphosphonates and the Dentist
Osteoclasts are normal cells found in bones and are responsible for bone resorption. Our bones are a dynamic tissue that is constantly being absorbed and rebuilt. Osteoblasts are the cells that build bone. Bisphosphonates are administered to oncology patients with bone metastases. In addition to their inhibitory effect on osteoclasts, recent studies show their action against several types of cancer cells, such as multiple myeloma, breast cancer, prostate cancer, and pancreatic cancer.
These drugs reduce bone morbidity, that is, the complications of bone metastases such as pain, fractures, and hypercalcemia observed in these conditions. Besides oncology patients, bisphosphonates are also administered for the prevention and treatment of postmenopausal osteoporosis. They are also given to protect against the long-term use of corticosteroids. As with all drugs, the attending physician weighs their beneficial effects against the side effects.
A rare but significant side effect of the drug is osteonecrosis of the jaws. As mentioned earlier, bisphosphonates inhibit the action of osteoclasts but also have an anti-angiogenic effect, preventing the formation of new blood vessels and thus disrupting blood circulation. These mechanisms explain osteonecrosis of the jaws. Therefore, patients about to start treatment with bisphosphonates should undergo a complete dental check-up.
Before starting treatment, patients should have completed dental procedures such as:
- Tooth fillings
- Endodontic treatments
- Treatment of gingivitis and periodontitis
- Extraction of roots or damaged teeth
- Apicoectomies, surgical removal of cysts, jaw tumors, and benign gum tumors
If dental surgery is required during bisphosphonate treatment, the dentist must necessarily communicate with the attending physician and be aware of the drug’s side effects in the mouth and how to prevent and manage them. Briefly, the allowed dental procedures are:
- Treatment of gingivitis
- Treatment of periodontitis without deep scaling
- Fillings and endodontic treatments
- Prosthetic work and biopsies of soft tissues
Conversely, the following should be avoided:
- Deep periodontal scaling
- Tooth extractions
- Implants, biopsies of the jaw mucosa
- Surgical procedures on the jaws (bone regenerations, implants)
Bisphosphonates should not be discontinued by the dentist. This decision should be made by the physician who prescribed them, in consultation with the dentist, who must describe the type of required procedure and the associated risks. Generally, discontinuation is recommended 3 months before and 3 months after the surgery. However, there is no conclusive evidence that discontinuation of bisphosphonate therapy can prevent complications in the jaws.
