Osteoporosis medicines and the jaw bone

What these medicines do to bone

Bone is never finished. Old tissue is broken down and new tissue is laid down in its place, all the time. In osteoporosis the breaking down outpaces the rebuilding and the skeleton grows thinner. Bisphosphonates and denosumab slow the breaking down, so more bone stays where it is and fractures of the hip and spine become less frequent. The same substances are used in cancer care, but at far higher doses, given by drip or injection. Most of what is written about the jaw comes from that setting.

Why the jaw is treated separately

Only a thin layer of gum separates the jaw bone from the bacteria in the mouth. Once a tooth has been taken out, bone lies open for a while, and the socket closes only if the bone renews itself. When renewal is slowed, healing slows with it. Rarely the socket does not close at all: a small patch of bone stays exposed and becomes infected. Dentists call this osteonecrosis of the jaw.

The hip and spine fractures these medicines prevent are common, and their consequences are serious, while the jaw problem is rare. Weighing the two against each other is the job of the doctor who prescribes.

How large the risk really is

In someone treated for osteoporosis, osteonecrosis of the jaw is very uncommon; the great majority never develop it. The picture changes for cancer patients, who receive far higher doses. Putting a single number on it would mislead, because the risk shifts with the substance, the route it is given by, how long it has been taken and what other conditions a person lives with. In osteoporosis, the decision to carry on is usually taken with the fracture risk in view.

• High doses given by drip or injection, as in cancer care
• Years of uninterrupted use
• Procedures that reach bone: tooth removal, implants, gum surgery
• Untreated gum disease or infected tooth roots
• Steroid tablets, poorly controlled diabetes, smoking
• A denture that rubs the gum and leaves sores

A dental check before the first dose

The easiest moment comes before treatment starts. Decay is filled, tartar is cleaned off, diseased gum is treated. Teeth that cannot be saved are taken out then, leaving enough time for the sockets to close before the first dose. If you wear a denture, it is checked for spots that rub. None of this becomes impossible once the medicine has started; the planning simply takes more care.

Dental treatment while you are taking it

It carries on. Fillings, root canal treatment, crowns, scaling and routine check-ups go ahead as normal, because none of them open bone. The group that calls for thought is the one that does reach bone: tooth removal, implants and gum surgery. When one of those is needed, the dentist speaks to the doctor who prescribed the medicine, and the substance, the length of use and your other conditions are looked at together. Sometimes a tooth that would have come out is saved instead. Mention the medicine at every visit.

Do not stop the medicine on your own

Stopping because dental work is due brings the fracture risk back, and it does not change the jaw quickly either. Some substances stay bound in bone for a long time and go on working after the last dose. Whether to pause is decided by the prescribing doctor alone, after a word with the dentist. One more thing: even if you stopped years ago, say so at a dental practice you are new to, because it may not show up in the notes.

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