Extraction and implants in patient taking oral bisphosphonate: thoughts?

I had planned extraction and implants for 3 teeth for a 61 year old female patient, who had no medical issues other than osteoporosis. Extraction of two root stumps – left mandibular second premolar and second molar due to a failed bridge, and replacement with 3 implants including the first molar site was planned earlier. Now , the patient says she has taken 2 weekly doses of oral bisphosphonate alendronate 70mg/once a week, for the last 2 weeks, as recommended by the orthopaediacian for osteoporosis. Everything appears favourable for implants except this.

I have read about osteonecrosis of the jaw following extraction in patients taking bisphosphonates and implant failures too. I have seen in one conference, the speaker showing failure of multiple implants in patient who started on bisphosphonates many years after implants. I understand that the problem is more with IV bisphosphonates. But, in my case, the patient is on oral alendronate, that too , only for last 2 weeks. But she may need to take it later for osteoporosis. I cant ask her not to take it forever. Should I proceed with extraction and implants, at least in a phased manner, or should I avoid implants? Please share your views and experience regarding this. Thanks , in advance.

9 Comments on Extraction and implants in patient taking oral bisphosphonate: thoughts?

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CRS

8/5/2015

Drug holiday you are under the three year window. Now look at the rest of her mouth and restore everything before she goes back on the Bis phosh.. People go on holidays all the time the critical part is the osteoclastic remodeling after extraction and osteointegration. Document well and warn her. Marx and AAOMS has a good protocol, look it up and read it. If you are not comfortable with the sequela then refer to someone who is, the responsibility is yours not what someone may post. It is interesting that the pills have little bones on them, remind me of dog biscuits!

Natarajan G

8/6/2015

Thank you

Dime Sapundziev

8/11/2015

Hello, yes you are right! Sometimes people really take them like biscuits and they even don't consider that they are on medications. In our department we started couple of years ago after having few incidents of osteonecrosis after extraction to explicitly ask in anamnesis if they take same medications for osteoporosis once a week or once a mount or any other anti-resorbtive medications. In this particular case patient just started with bisphosphonates orally and since their accumulation rate is low and is outside of 3 years window I would consider this patient as having a low or no risk for development of osteonecrosis if proper treatment is undertaken. I suggest to make a simple plan with proper loading and prosthetic design to enable good cleaning and motivate patient for good oral hygiene with regular check ups and close follow up. Best regards. Dime Sapundziev

M Montana

8/11/2015

CTx.

Masuod Adeli

8/11/2015

The best way for evaluating the risk of ONG in a bisphosphonate patient is measuring serum CTX. Send her to lab. If her CTX is more than 150 pg/ ml or ideally more than 200, there will be no risk of developing ONG after extraction or implant surgery.

Dime Sapundziev

8/12/2015

No changes of CTX at the begging of the treatment. The patient has just started orally administrated BP. Their mechanism of action are different to venously administrated BP The significance of CTX in also questionable for predicting the chance for ONJ. No need for CTX at this moment.

Natarajan G

8/12/2015

Thanks for the suggestions . I went through Marx and ADA recommendations. In the meanwhile, patient came for review. Her orthopaediacian had agreed to stop the bisphosphonates for some time.................she had taken just 2 doses. I am planning to proceed in staged manner, extractions now and implants 4 months later , and loading 4 more months after that. Her bone density in the hip region appears to be poor and fracture chances appear to be high. So, she might need to start the bisphosphonate again, may be in the near future. I am planning to take the opinion of the orthopaedician before implants. I have heard that already osseo-integrated implants can also fail due to bisphosphonate therapy, later in life. Please share your opinions and experiences in this regard.

Dime Sapundziev

8/26/2015

No need to stop. Now you put the patient at risk for hip fracture which is hard treatung condition with high mortality rate. At this moment there is no need to stop with BP. As far as the osteonecrosis and alredy inserted implants are concerned that happends in patients on venously BP. What is in the background of that eather bone changes due to BP, periimplantitis or secondary inflamation of bone cracks due to improper loading is not cleared. How will I proced: extract the teeth, without stoping BP treatment. Wait for the wounds to heal. If thay heal properly I woud place the implants and closelly folow the patient. Good luck!

Natarajan G

8/26/2015

Thanks for your suggestions. The patient has stopped the BP after orthopaedician's consultation. She will consult the orthopaedician, once the extraction wound heals, to ask if the BPs are required again. Im planning to wait for 4 months for the bone to fill the socket space before implants. Thank you.

Extraction and implants in patient taking oral bisphosphonate: thoughts?

9 Comments on Extraction and implants in patient taking oral bisphosphonate: thoughts?

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