Dear Doctors Column for October 30, 2006

Jaw Decay and Osteoporosis  Drugs

Question:

I’m going through menopause and am considering a prescription bone-building drug for osteoporosis, but I’ve heard they can cause jaw disease. Who’s at risk for this complication?

Answer:

Bisphosphonates, a family of drugs widely prescribed for osteoporosis and other conditions, have recently been linked to a serious and painful condition called osteonecrosis of the jaw. Osteonecrosis, which means dead bone, can cause abscesses, loose teeth, severe pain, and degeneration of the jawbones.

The link between the popular drugs and the painful and potentially disfiguring condition has been widely publicized and is now the subject of several lawsuits. Osteonecrosis of the jaw, however, is a rare complication for people taking oral bisphosphonates for osteoporosis.

In 2003, oral and maxillofacial surgeons began reporting cases of nonhealing, exposed bone in the jaws of patients receiving intravenous (IV) bisphosphonates, which are typically given to people with advanced cancers to help reduce bone pain and other complications. These IV drugs are far more powerful than oral formulations prescribed for prevention or treatment of osteoporosis. Since then, a small number of otherwise healthy individuals taking oral bisphosphonates have been diagnosed with osteonecrosis of the jaw.

How bisphosphonates affect the jaw and cause bone death is not clear. Healthy bone is constantly rebuilding itself. Cells called osteoclasts break down old bone, and their bone-building counterparts, called osteoblasts, form new bone. When this process becomes unbalanced, with bone breakdown outstripping bone formation, conditions such as osteoporosis can result.

Bisphosphonates inhibit osteoclasts, slowing down the resorption of bone and helping maintain bone density. The drugs increase bone density in the short term, but scientists think long-term use may impair the formation of new bone and reduce the jaws’ ability to heal after traumas such as invasive dental procedures.

More than 90% of cases of osteonecrosis of the jaw have occurred in cancer patients taking powerful IV bisphosphonates. As noted, oral bisphosphonate users are at much lower risk. If you’re considering taking these drugs, you can lower your risk for the condition even further by optimizing your dental health before you start.

Achieving and maintaining good oral hygiene is key to preventing osteonecrosis of the jaw. Most cases of osteonecrosis of the jaw occur after dental surgeries, such as tooth removal. You should have a thorough dental exam and explain to your dentist you are considering bisphosphonate therapy. Any needed invasive dental work should be completed several months before you begin the drugs to give your jaws time to heal.

Once you begin taking bisphosphonates, be alert to the signs and symptoms of osteonecrosis: infection in the mouth, loose teeth, and pain and swelling around the site of dental procedures. 

Once you begin bisphosphonate therapy, the drugs will remain active in your bones for years even if you stop taking them. If you are taking the drugs now, or have ever taken them, you need to let your dentist know so he can manage your oral health accordingly.

Used correctly, oral bisphosphonates can help prevent osteoporotic fractures and other painful, debilitating conditions. But not everyone needs the drugs. Since you haven’t started therapy yet, you might want to discuss all your options with your physician, who also can explain your risks for osteoporosis and determine your current bone density.

If your bone density is adequate and you are not at high risk for osteoporosis, you can help maintain bone health by getting 2 to 3 servings of low fat dairy foods each day or taking a calcium supplement (1200-1500 mg a day). A vitamin D supplement (400-800 IU per day) or 15 to 20 minutes of sun exposure 2 to 3 times a week provides sufficient vitamin D for bone health. Getting regular exercise also will help your bones stay strong. And smoking cigarettes decreases bone density, so if you smoke, try to quit.