Osteoporosis and Your Mouth
As we age, bone strength and density tends to decrease. Bone is a living tissue that is constantly
being absorbed and replaced throughout your entire skeletal system – including the bone that
surrounds your teeth. This process tends to slow down as we get older, but sometimes the
creation of new bone is no longer able to keep up with the removal of old bone. As more bone is
absorbed and less bone is being generated to replace it, the entire skeletal system can weaken
and become brittle over time. Osteoporosis (literally
How Does Osteoporosis
“porous bones”) can leave the bones in such a brittle
state that in some cases even bending over or coughing
Oral bisphosphonate therapy is the current
medical standard for the treatment and prevention of osteoporosis. Bisphosphonates work by inhibiting bone
In recent years, there has been a marked rise in the use
resorption – meaning that they slow the body’s removal of older bone structure.
of oral bisphosphonates (drugs such as Fosamax,
Actonel, and Boniva) to combat and prevent the
development of osteoporosis – especially for
increasingly more bone than it can regenerate – osteoporosis and several
menopausal and post-menopausal women. No one
knows if osteoporosis rates are actually increasing, or if
example – bisphosphonate therapy can be an effective treatment in slowing bone loss
the development of bone density testing is simply
over time. But there are side effects, and for
allowing us to see changes that we were not able to see
people who do not actually have a frank bone disorder, these drugs may be doing
In the late 1990s, after Fosamax (the first bisphosphonate) was approved, bone density
screening became more prevalent. Armed with a test and a medication, doctors enthusiastically
prescribed the Fosamax both as a treatment for osteoporosis and as a preventive measure in
cases where bone density screens indicated borderline results. In 2003, The National
Osteoporosis Foundation lowered the recommended treatment threshold as a result.
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But we now know that the progression from osteopenia, or pre-osteoporosis, to actual
osteoporosis is much slower than previously thought – and in many cases (especially in
younger post-menopausal women or seniors who have not already experienced a fracture) the
progression often does not happen at all. Oral Bisphosphonates and Osteonecrosis
Osteonecrosis of the jaw (ONJ) is a rare but well known side-effect associated with
bisphosphonate therapy. It is most commonly seen in cancer patients who receive more
concentrated doses of bisphosphonates intravenously, but in recent years, there has been an
increase of ONJ cases reported in patients who take oral bisphosphonates and undergo certain
Many physicians were initially unaware of these dental risk factors for ONJ. Even dentists and
oral surgeons weren’t aware of the connection between ONJ and bisphosphonate therapy in
the beginning. Today, the actual causal factors between bisphophonate therapy and ONJ are
still unclear, but we do know that the turnover of bone is much faster in the mouth than other
areas of the body and that the mouth is also under a much larger bacterial load.
It is difficult to gauge just how many cases of ONJ are associated with oral bisphosphonate
therapy because most of the large-scale statistical research has been done by analyzing medical
and insurance records. But at the time of this writing (July 2012), there is still no medically-
recognized diagnostic code for ONJ, meaning that we simply do not know exactly how many
cases have been diagnosed, or what the accurate statistical risks are. To view our entire resource library, please visit.
What we do know is that ONJ can be an extremely difficult disease to treat. Osteonecrosis
literally means “bone death.” In the jaw, osteonecrosis is defined as a condition where the
jawbone is exposed (not covered by the gums) for at least 8 weeks and begins to starve because
of a lack of blood. The cells die, small pieces of the jawbone can begin to break away, and
previously healthy teeth can be lost as a result. Stopping bisphosphonate therapy, using
prescription rinses, and in some cases surgery can help stop the progression of ONJ, but not
for everyone. Some cases can persist or recur, even with treatment.
Bisphosphonate-related ONJ is most commonly associated with injuries to the jaw and surgical
dental treatments. Extractions, implants, and other dental procedures where the jawbone may
be exposed seem to pose the greatest risks. Patients who have active gum disease are also at a
greater risk of developing ONJ while taking bisphosphonates. Even patients who wear full
dentures or partials can develop ONJ in areas where these appliances rub against the gums and
To view our entire resource library, please visit.Recommendations
If you are considering bisphosphonate therapy, it is highly recommended that you consult with
a knowledgeable dentist before starting on the medication. Major dental work should be
performed and ongoing infections treated before you begin taking the bisphosphonates for the
best possible results in reducing your risks of ONJ. And if you are already taking medication
for osteoporosis or osteopenia, be sure to let your dentist know as soon as possible so that he or
she can help you make the best possible treatment choices to protect the health of your
jawbone. Here are a few things to keep in mind about dental treatment while undergoing
Tooth extraction is generally not recommended while taking oral or IV bisphosphonates.
If a tooth breaks off at the gumline, a root canal treatment is always preferable to root
Contrary to some dental guidelines, stopping bisphosphonate treatment for several
months in order to undergo more invasive dental treatment may not decrease the risk of
ONJ. All bisphosphonates have a very long half-life in the body, and their effects on
bone resorption can still be seen anywhere from 5 to 10 years after stopping treatment.
Regular dental check-ups and meticulous home care, including brushing and flossing
often and correctly, are essential for anyone on any type of bisphosphonate therapy.
ONJ is not the only concern when considering long-term bisphosphonate therapy. Other rare
but serious side-effects have also been documented. Esophageal cancer and spontaneous
fracture of the femur have both been reported in some patients taking oral bisphosphonates for
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Whether you choose to start bisphosphonate therapy to prevent or treat osteoporosis is up to
you and your doctor. There are certainly situations where the potential benefits to your overall
bone health are worth the risks. However, for as long as you remain on the medication, regular
dental care and good oral hygiene at home will be essential to keeping your mouth as healthy
as you can for the rest of your life. References:
Mayo Clinic: American Academy of Pediatrics: National Institute of Health: Journal of the American Dental Association: The New York Times: Welch, Dr. H. Gilbert, et al; Beacon Press, 2011. To view our entire resource library, please visit.
Corresponding author available concerning management of patients who have Samuel J. Mann, MD New York Presbyterian Hospital-Weill/Cornell Medical School, a pheochromocytoma, fewer than two dozen papers deal 450 East 69th Street, New York, NY 10021, USA. with the 98% who do not. Doctors and researchers simply do not know how to manage these patients. Current Hypertension Reports 2008, 1
T h e n e w e n g l a n d j o u r n a l o f m e d i c i n e This Journal feature begins with a case vignette highlighting a common clinical problem. Evidence supporting various strategies is then presented, followed by a review of formal guidelines, when they exist. The article ends with the author’s clinical recommendations. A 36-year-old woman with a long history of catamenia