Bone health

Bisphosphonate holiday not needed for tooth extraction to prevent ONJ

Patients taking bisphosphonates for osteoporosis prevention do not need to have a ‘drug holiday’ before tooth extraction to avoid osteonecrosis of the jaw, a prospective study suggests.

Japanese dental researchers found no cases of osteonecrosis of the jaw among 132 patients receiving oral bisphosphonates who continued treatment while undergoing tooth extraction.

Patients who had been using bisphosphonate therapy for more than five years showed delayed healing of the tooth extraction socket but there were no cases of osteonecrosis of the jaw during three months of follow-up in any patient, regardless of duration of bisphosphonate use.

There was a dose-response relationship between the duration of bisphosphonate use and duration of extraction socket healing, with healing taking around three weeks for patients who had been using bisphosphonates for less than two years and six weeks for those using bisphosphonates for more than five years.

The results, reported in Osteoporosis International, relate to extractions of 274 teeth in  a patient cohort who were using bisphosphonates such as alendronate and risedronate, but not denosumab. The patients had tooth extraction done according to a low trauma protocol that also included strict infection control and antibiotic prophylaxis.

The study investigators said current guidelines on bisphosphonate use were based on case reports and observational studies of osteonecrosis of the jaw, and many advise a drug holiday for patients who need tooth extraction.

But bisphosphonate use was just one factor in the development of osteonecrosis of the jaw, which may also be promoted by infection and inflammation from untreated dental problems, they noted.

“Our treatment strategy is based on a protocol that allows tooth extraction without hesitation even by dentists who do not specialise in oral surgery, and is highly versatile. The present results suggest that our method is not inferior to the treatment strategy that includes a pre-extraction drug holiday from BP and is a viable treatment option,” they said.

However a drug holiday may still be considered to avoid the delayed healing seen with long term bisphosphonate users, they suggested.

“Although it is uncertain how effective a short-term bisphosphonate drug holiday would be considering bone physiology and the pharmacokinetics of BP, it maybe valuable to consider a drug holiday in high-risk patients, such as those who have taken oral bisphosphonates for more than five years.”

The researchers said their findings did not apply to denosumab use and they are now conducting a prospective study of tooth extraction and osteonecrosis of the jaw among denosumab users.

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