Bisphosphonates - What the Dentist Needs to Know: Practical Considerations

nBPs are associated with osteonecrosis of the jaws. This includes the intravenous, injectable, and oral formulations of nBPs.2,33,34,38 The increased potency of the nBPs, frequent dosing, and prolonged duration of use, independently or in combination, appear to be associated with an increased risk of BRONJ. The frequency with which this complication develops is difficult to determine. The overall incidence of BRONJ is low, given the frequency with which the medications are prescribed, but of sufficient concern because of the associated morbidity. The difficulty in obtaining accurate incidence data appears to be related to physicians prescribing the medications and, often, dentists and dental specialists diagnosing and managing the condition, often without full knowledge of the patient's medication history, specifically the dosing, duration, and awareness of significant patient comorbidities. BRONJ is a difficult condition to treat. Some patients have resolution with discontinuation of their nBP medications, with sequestration of necrotic bone and healing of the involved site. However, some patients have prolonged painful symptoms that are progressive, despite a variety of medical or surgical interventions. The earliest manifestation of BRONJ can be difficult to recognize clinically and radiographically. Clinical data, in the form of standardized trials, related to the efficacy of using bone marker turnover assays to assess potential risk for BRONJ are currently lacking. At present, therapies or procedures requiring bone remodeling or repair should be avoided and selected treatment alternatives substituted, if clinically in the best interest of the nBP-exposed patient. Routine dental care, including dental prophylaxis, nonoperative periodontal care, restorative procedures, and conventional fixed and removable prosthodontics, is not contraindicated in the nBP patient. Elective oral surgery, apical surgery, periodontal bone recontouring, implants, and, possibly, orthodontic tooth movement should be subjected to an assessment of the risks and potential benefits of the treatment procedure in the context of the patient's unique circumstances. Updates on the bisphosphonate problem issued by the dental and medical societies, specialty groups, and bone biologists should be followed carefully because new data will likely result in improved identification of patients at risk and more efficacious treatment protocols. © 2009 American Association of Oral and Maxillofacial Surgeons.