Bisphosphonates are prescribed by geriatricians, and other primary and secondary care doctors for the treatment of osteoporosis, Paget’s disease, and malignancies. Bisphosphonate-related side effects have become newsworthy of late including bisphosphonate-related osteonecrosis of the jaw (BRONJ).

From our own observations, and feedback from colleagues, we have found that the dental health of patients before commencement of bisphosphonates is largely not assessed even in fragility fracture patients.

Mavrokokki T et al1 proposed that the patients should be declared fit from a dental health point of view before the commencement of bisphosphonates for bone diseases and the Scottish Dental Clinical Effectiveness Programme (SDCEP)2 has produced guidance, which can help both medical and dental healthcare staff to modify their practice as appropriate. 

One study3 found that in those who developed osteonecrosis of the jaw, one of the commonest characteristics was previous invasive dental treatment. It was concluded that there was a strong association of osteonecrosis of the jaw with both IV and oral bisphosphonates, and that the independent risk factors for osteonecrosis of the jaw were dental extractions and treatment with bisphosphonates for more than two years.4,5

In light of the evidence available, we appreciate that the risk of BRONJ especially with dental procedures be born in mind when prescribing bisphosphonates, and the patients should be informed of the risk. We are in favour of an informed and documented consent of patients when commencing bisphosphonates. It can serve as a useful tool for patient information, communication between primary and secondary care, and any associated medico-legal aspects and we propose that this practice be encouraged. We also support the guidance produced by the relevant professional organisations eg. SDCEP2, that the dental health of patients be assessed before commencing bisphosphonates. 

To do that, however, good communication and a close working relationship between medical and dental care ought to be encouraged irrespective of certain potential barriers eg. cost effectiveness etc. 

One way of doing this would be through patient information leaflets on bisphosphonates, providing full advice as a standard practice at the time of commencing bisphosphonates. Regional audits on the practice of commencing bisphosphonates yielding a much bigger data for performance comparisons among the organisations should be considered and encouraged. 

In those patients who lack mental capacity and are on bisphosphonates, it is vital to educate their caregivers to seek immediate help for the patients in the event of them developing any dental problems. 

References 

Mavrokokki T, Cheng A, Stein B, Goss A. Nature and frequency of bisphosphonate-associated osteonecrosis of the jaws in Australia. Journal of Oral and Maxillofacial Surgery 2007, Mar; 65(3):415-23.

Scottish Dental Clinical Effectiveness Programme (SDCEP). Oral Health Management of Patients Prescribed Bisphosphonates (April 2011). http://www.sdcep.org.uk. (Accessed on 28/06/2013)

Pazianas M, Miller P, Blumentals WA, Bernal M, Kothawala P. A review of the literature on osteonecrosis of the jaw in patients with osteoporosis treated with oral bisphosphonates: prevalence, risk factors, and clinical characteristics. Clinical Therapeutics 2007 Aug; 29(8):1548-58.

Barasch A, Cunha-Cruz J, Curro FA et al. Risk Factors for Osteonecrosis of the Jaws a Case-Control Study from the CONDOR Dental PBRN. Journal of Dental Research. 2011 April; 90 (4): 439-444

Malden N, Beltes C, Lopes V. Dental extractions and bisphosphonates: the assessment, consent and management, a proposed algorithm. British Dental Journal. 2009 Jan 24; 206 (2): 93-8.