Information Re: Osteonecrosis of jaw and bisphosphonates, Fosamax etc.
Hi......I am trying to educate a dentist and would like any
imput i can get from people on this board who have found any problems with dental procedures after being on either
IV or oral bisphosphonates as Fosamax, Actonel etc. It seems
like dentists never ask people like myself who have been on
this medication for a long period of time, if they are on it! They ask about heart meds and diabetes but nothing regarding osteoporosis meds. I think it is important if the
person has had chemo and has had IV treatments with a
med and the dentist needs to know befpre he does any big
procedures such as implants or extractions. If anyone has
any imput please feel free to speak up so we can educate
dentists as well as the public regarding the consequences
of jaw bone death and oral or IV osteoporosis meds.
Re: Information Re: Osteonecrosis of jaw and bisphosphonates, Fosamax etc.
Hi Legallyblondied: I recently went through a situation with a dentist, regarding this and I'll post what I was given.
First I took Actonel orally not intravenously for a little over a year and stopped taking it in April 2006. My dentist, primary care, and oral surgeon are treating me like I really need to be careful about ONJ/BON and I'm slightly bewildered by it. I've always believed that the patients at risk for this are those who took this med intravenoulsy, had chemo, rad, and cancer. I haven't had any of these things, yet everyone is treating me with kit gloves. My oral surgeon has had 2 patients with ONJ, but both were the iv bisphos users.
I have 2 teeth that need to be pulled, one already had a root canal and the crown fell off, and the other has calcified nerves so a root canal can't be done. I do not have Osteonecrosis, I only took Actenol for a short time, and my dentist has decided he will not pull either teeth. If I leave the teeth in I risk getting septicemia. One tooth is infected, which I just found out, and the other doesn't hurt, so I need to have a oral surgeon pull them, since the dentist won't. I think my dentist decided not to pull them after he got a fax from my pc that said she wanted me to be followed post extraction for osteonecrosis. I think that statement freaked the dentist out, but who knows???
Anyway, here's a copy of the protocol that needs to be followed on extractions and implants/surgery for patients who have taken bisphosphonates.
Please notice in this link that more than one tooth can't be extracted at once, that medications may be given pre extraction and post extraction, and that a 2 month period of follow up after extraction needs to be completed before attempting another extraction, and oral daily rinses have to be utilized. Also, a special type of primary and seconday surgical closure needs to be done. I guess this means a particular type of stitching, and if the bone is excized, then a bone growth stimulator may be utilized. If this all sounds like a lot, image my surprise when I was informed all this must be done just to pull 2 teeth. Here's the link, Please read the whole article, it is from the ADA (American Dental Assoc). In particular notice the para's on oral bisphosphonate use patients.
Good luck to all I'll let you know what happens next week when or if my tooth is pulled at the oral surgeons. But again, I have to get my pc to release me for surgery, which is really a hassle.
Last edited by DesertBloom; 09-04-2007 at 03:11 PM.
Re: Information Re: Osteonecrosis of jaw and bisphosphonates, Fosamax etc.
Hi again: I forgot to ask you if you are getting ready to have dental work done, and if you took bisphosphonates in the iv form? Also, have you ever had cancer and if so were you treated with chemo or radiation? If you would like to read another paper on this I'll post it. The chances of contracting this disease are still considered slim, but since my recent dilema with the dentist, I'm not sure if the underreporting problem on this disease is a bigger issue than we once recently thought?
Here's another article on this that most dentist/oral surgeons referr to for statistics.
Re: Information Re: Osteonecrosis of jaw and bisphosphonates, Fosamax etc.
Hi thanks for the info.....no i am not awaiting any dental
procedure, but i since i have been
on fosamax for five years now and have done my research, I
was blown away on the slip shod way that dentists have approached the issue. I am more interested that he have
a medical questioner that asks people not only if they havd
had heart valve transplants and hip resurfaces or replacements or have diabetes, but if they had chemo therapy. cortisteriod therapy or medications for osteoporosis
on them and when they sign an informed consent this is
brought up about bisphosphonates whether they be oral or
IV. I think the dentist is a held by law to a standard of
care and if falls below this standard, that he should have
known about this, and did not ,,,,he will be looking a a law
suit down the road.......Thanks and please more posts.Karen
Last edited by moderator2; 09-22-2007 at 01:36 AM.
Reason: peer sharing only - please read the posting rules
Re: Information Re: Osteonecrosis of jaw and bisphosphonates, Fosamax etc.
Hi Legallyblondied: At the ADA they have a consent form that can be used for patients awaiting dental procedures that are on bisphosphonates. I also read an article through the ADA that mentions getting legal advice on this subject for dental practices. It's unfortunate that it seems the legal end of this issue is more important than the medical ramifications.
I know that my dentist really wasn't all that informed on BON until it came up in my case. I'm not sure why that is, because they do check medical histories and medication lists before they will extract a tooth. I have mitral valve prolapse and have to pre medicate prior to any dental work, and my dentist is well aware of this type of problem, but I'm not sure how educated he is on all the other things you mentioned. My oral surgeon is a completely different story, and he seems to be on top of medical conditions that could affect dental surgery.
Did this dentist recieve the "Dear Dr." letter from Novartis that was sent out a couple of years ago? In the letter it explains the precautions with bisphosphonates, and supposedly it was sent to all members of the ADA, but it's hard to say if all those that rec'd it would have read it or paid much attention to it. If your interested in that letter, it's pretty easy to find, and I posted it here about a month ago, I just don't remember the thread it's in.
When my primary care dr signed the med release for extraction and said that the dentist had to follow up on BON/ONJ, the dentists office was really bewildered, because they "expected" the dr (Internist) to "tell" them exactly what to do post operatively in a "step by step" fashion. I explained to the dental nurse that the dr that sent the release couldn't possibly do this, because it's not her field of expertise. I told the dentists office that they are suppose to know what to do, even if that treatment, is in a state of flux since there really is no difinitive treatment for Osteonecrosis of the jaw. Once they realized that they weren't going to be given instructions on what to do, I was dumped so to speak. I also know that this particular dentist continues to do extractions, because he did quite a few on my husband to prepare for partials, so it's not a situation where he just doesn't do them, he does, but not on me, now.
I'm not sure who came up with the advice of going on a 3 month drug holiday from bisphosphonates, for dental surgeries, since anyone with any education in this area knows that the drugs half life is at least 10 years, and I think that is a conservative figure. My oral surgeon said to me that it makes no difference how long you've been off of the med, or whether you took it orally or intravenously as far as he's concerned, because it's still in the bone and the patients he's dealt with had taken it through iv, but he feels oral administration poses the exact same problems. That was the first time I had heard that argument, since all the literature points to the iv users as the patients at greatest risk. I also asked my mineral metabolism dr about this theory, and she agreed. Since she is a bone metabolism dr I was interested in her take on this oral v iv argument on bisphosphonates. Who knows where this will all take us, but I wish everyone was on the same page, and at least informed. Because of this lack of knowledge on this topic, I will no longer rely on a dr or dentist to be fully informed on "anything". If I'm in a situation where I know more than the professional, I'll make sure they know what's going on before they treat me.
Good luck on your endeavor to educate this dentist!!! If you need any direction finding the things I mentioned (Novartis letter, consent form) just let me know. I feel for you having to be the one to educate a dr who should know all this already!! Doesn't he go to any conferences on this topic, since I know there have been quite a few in the last couple of months.
Last edited by DesertBloom; 09-05-2007 at 02:23 PM.
I thought I actually saw a consent form for this that was done in boiler plate fashion, but I can't find it right now. I know I read it at the ADA, so you should be able to find it there.
Thanks for all your work to help the patients/dentists dealing with this or hopefully preventing it. What you are doing is Fantastic, and if I can help in any small way let me know, but I'm sure you've got it covered.
Last edited by DesertBloom; 09-05-2007 at 02:41 PM.
Re: Information Re: Osteonecrosis of jaw and bisphosphonates, Fosamax etc.
thanks so much for the sites you gave me ....i copied and
forwarded the articles to my dentist and he is thrilled with
the info. and will be using all of it. I have also written an
article with him and we hope to run it as a press release in
local papers and maybe later in a larger paper, not for any
advertising purposes, but for consumer information and
awareness. Drug companies and the FDA are a joke at
providing the public or protecting them for that matter!
Any more sites you want to throw my way would be
appreciated.....thanks DesertBloom Karen
Re: Information Re: Osteonecrosis of jaw and bisphosphonates, Fosamax etc.
Thanks Osteo for your concern I really appreciate it, so far everything looks good, but ONJ doesn't rear it's ugly head until 1-4 months after an extraction, so we'll see... Please read the para below and hopefully someone can tell us what the article says.
Legallyblondied: I'm home now, from my extraction which the oral surgeon did, and the novacaine hasn't worn off yet so I have a little bit of time to fill you guys in on something I learned about ONJ. My second tooth won't be done till next month. The oral surgeon pulled the 1st tooth and is going to follow me for ONJ and I have to take antibiotics for 5 days, the interesting thing is that he says there is new research out that says to use PTH (Forteo) for the treatment of ONJ. Since I'm such a skeptic the first thing I did when I came home was to find the research he's talking about, and sure enough I found it, but, it's only available to members of the Maxillofacial Oral Surgeons Journal. If anyone can get into that Journal, I tried and can't, the article is titled: Resolution of Bisphosphonate-Associated Osteonecrosis of the Mandible: Possible Application for Intermittent Low-Dose Parathyroid Hormone [rhPTH(1-34)] I would be forever grateful to find out what it says. I would imagine it will apply to me anyway since I'm on forteo, but I'm curious as to how long you need to take it for ONJ, I hope it's not more than a year, even though "I don't have it".
Legallyblondied if you can access this article it could be invaluable to your research. Good luck and if you find out what the article says could you post back here?
Re: Information Re: Osteonecrosis of jaw and bisphosphonates, Fosamax etc.
DB-I am going to pick up the article from the library. I will let you know as far as possible the import of the article through a summarization that I will post on this thread. Again, hope you are doing ok.
Did you see an abstract or other summary of the article already? Probably the technicals will shoot past me , and perhaps if you have seen a summary you already know as much as I could pass on to you.
It you need the article ,I would suggest contacting a local univ. reference librarian as I did. She had it within about 5 minutes. I was surprised.
Take care.
Last edited by osteoblast; 09-10-2007 at 03:23 PM.
Re: Information Re: Osteonecrosis of jaw and bisphosphonates, Fosamax etc.
Hi Osteo: No there wasn't an abstract available, just the title, date, authors, pages etc. I don't have a Univ library nearby, but there is a community college library, wonder if they would have it. They are closed now so I'll call in the morning. Really the only thing I want to know is
How long do they suggest taking it after an extraction?
Is it the same thing we are already taking-Forteo?
Does it work in the obvious way, through stimulating new bone growth?
And any other fascinating info beyond the above
Thanks for your help, it was frustrating when they don't even give an abstract, and they want $30.00 for it-too steep for me. You can access their older articles if you register, but not the newer ones.
Re: Information Re: Osteonecrosis of jaw and bisphosphonates, Fosamax etc.
DB- You should read the article it is quite interesting. It is a case study with general discussion as well. In the Therapeurtic Regimen Section there are five points:
1.Baseline tests-discussion of panoramic xray, Ct and MRI with and without contrast
and various tests incl. cbc, esr calcium, 25oh, bone markers, bsap, osteocalcin and P1CP/P1NP
2.stop bisphos.
3.start rhPTH1-34 , 20mcg daily for not greater than 2yrs.
4.monitor, treat with local measures chlorhexidine rinse,antibiotics as needed., sequestrectomy w/o debridement
5.followup calcium after 30 days and every 6 mo. from start -I can only assume they mean testing calcium levels
It was stated that the patient showed no sign of resolution of ostenecrosis until treatment had been going on for more than 3 months.
Also stated within 3 months of treatment with rh Pth 1-34 clinical signs of soft tissue healing wer apparent and the xrays showed site healing.
I want to get this off to you asap and will follow with other aspects. The other aspects pertain more to conclusions about pretreatment with bisphos. before forteo and how it delays and diminshes response. I don't see so much other info pertaining directly to your questions that wasn't indicated above.
As they say, I hope this helps!!
Re: Information Re: Osteonecrosis of jaw and bisphosphonates, Fosamax etc.
Thanks Osteo: You are fast. I hope that library is close to you!!! I'm going to still try and read the whole thing, but I won't know until tomorrow if my com college library carries that particular journal.
It's strange I asked the oral surgeon about bone marker tests, making a reference to the C-telopeptide test, and that it should be over 150, and he had NO idea what I was talking about. His brother is my Endo, and all he said was, well he would know more about those test's but the oral surgeon wasn't familiar with it, I even mentioned where we read that and he still look dazed.
He went on to say that it's good I hadn't taken the iv bisphos's, when the last time we spoke, he made the comment that either way oral or iv use is just as bad. He seemed like he wasn't as nervous as he was the last time I saw him, and of course he went on to assure me I wouldn't get ONJ "anyway." Big switch from the last visit.
Since this article is for treatment of ONJ, it's not a real concern of mine, but I was anxious to hear that they were finally saying that at least something was helpling to treat it, when up to this point there was no hope-so to speak; or should I say there is no treatment that actually cures it.
I haven't had a tooth pulled in 30 years and it sure does feel strange.
Thanks again for your speedy help, and hope someone else finds this news interesting. I'm having another NTx soon, and wanted to get the CTx but it's too late now the tooth is out (hooray), just hope it heals right. I asked if he would have to cut the bone and he said just microscopically, so that tooth was out of my mouth in less than 10 minutes, what a surprise (popped out). I'll continue with the oral rinse and antibiotics until the next tooth has to be done and hopefully that will be the last I ever have pulled. I was worried with the infection, and possibly cutting the bone, that the infection could spread to the bone, but he really didn't cut much to get it out. Have you ever had one of those panoramic x-rays where it rotates around your head and takes a picture of your jaw?
Re: Information Re: Osteonecrosis of jaw and bisphosphonates, Fosamax etc.
DB-
My feeling is that you are in a good position because , in effect you have pretreated with forteo for longer than a year. So, given a difficult situation you are really in the best place that you could be for the extractions because you are up and running on forteo and it is for sure working in your system. That is my take. I hope it is yours.
You must get your hands on the article and your oral surgeon should read it as well. Perhaps also the dentist that got spooked.If your local community college can't access the article , call the nearest either state or private colleges and request the reference librarian to check.The reference librarian said she would email the article to me so perhaps a reference librarian will find it and email it to you.. Reference librarians can be amazingly helpful. Just keep trying if you don't find success with the first location.
When you have had a chance to digest the above AND when you feel better , I would like you to consider the following ( which is not so directly related to your present situation- because of your absolutely stunning gains with forteo and that you have now been on forteo for 15 plus months). I don't want to over load you today , but I would like to plant a bee in your bonnet that I hope we can return to when you feel better in the next few days. I hate to say but it is about me and my treatment.And, of course it is relevant to some others who post here as well. I didn't expect to find a gem in the article that I went to get for you but that is what happened. I should preface this to say that I was pretreated with fosamax for 7 weeks, then off 7 weeks then on forteo. No bonemarker elevation of any significance for the first approx 5 months and then whammo out of range as you know at 9 and 10th month.I just didn't have testing beween 5 and 8 months on bone markers. And the really high result wasn't a one off , a second test recently about a month after last showed ntx 200 plus again and bsap up 10 points higher than last month it went from 23 to 33 . So here goes. Please ignore this today if you can't deal with it and check it when you can. This may be big info for others as well ---I hope so. Remember this is from your article.
Anabolic response to stopping bisphos and starting rhPTH will take 6 months to 1 year. Citing an article by J.A. Gasser et al. PTH Interactions with Bisphosphonates. j. Musculoskelet Neuronal Interact 1(2000) p.53.He found the delayed response in rats pretreated with alendronate for 16 weeks. Can you believe 16wks???Also that the pretreated rats did not develop a full anabolic response over the course of the study BUT did not indicate the study time frame in the article.
Then citing an article by Lecart et al.Combination/sequential therapy in osteoporosis , Curr Osteoporos Rep 2 (2004 p.123. It is stated that Lecart noted a 6 month delay in spine and hip bmd increases in patients pre treated with alendronate.
What I am getting at is why should I stop now at one year? . I am now showing significant bone marker increase. If it takes 3 months to show response and if I was delayed perhaps 6 months or longer , then 9 months may be the time where things might start for me ? Maybe I had a delayed response even from the 7 weeks pretreatement with fosamax. If I hadn't read about the delayed reaction in the rats with 16 weeks pretreatment, I would never have thought the 7 weeks could have affected me.
DesertBloom-please do not feel that any response is needed on this until after you feel better.My doc didn't of course mention this could be a possibility and just spoke of the curve. And unfortunately, I know he doesn't want to discuss this with me. He has set the course and that is that.
I like that your article is from 3/2007 and has gathered the most recent up to date info for the docs involved with extractions where people have had bisphos. treatment. There is no shading of the impact of bisphos.- the oral surgeons WANT TO KNOW! You could say they want the best info to protect their patients, also you could say they want the best info, to protect their liability . In any event it helps us that they want to know.You said you were cynical well it is understandable.
Now take good care of yourself.Things are going to get better, I am sure of it. You have been through alot of stress with this, but again, I find the article so encouraging for you.
Last edited by osteoblast; 09-10-2007 at 07:25 PM.
Re: Information Re: Osteonecrosis of jaw and bisphosphonates, Fosamax etc.
DB and others- there is another comment from the article that I wanted to share here
Regarding fosamax , the author quotes from the product insert indicating fosamax has a bone half like of 10.9 years.
Then the author states---
That the extremely slow elimination of bisphosphonates presents a " concern for the possible late onset of osteonecrosis as opposed to the potential early manifestion of osteonecrosis with intravenous bisphosphonate treatment."
Ah-the pieces begin to slip into place, don't they?
DesertBloom- If you have not been able to put your hands on the article , let me know. Perhaps I could give you more information about how the reference librarian proceeded. The more I look at the article , the more fascinating I find it because it really seems to bring together a number of the concerns that we have had here and gives simple answers. As you have previously noted Occam's razor. I do hope that you are doing ok today. Best wishes
Re: Information Re: Osteonecrosis of jaw and bisphosphonates, Fosamax etc.
Hi Osteo: I just wanted to touch base with you to tell you that I've been working on trying to get this article all day. I totally agree with your understanding of effects of bisphos's on bone markers and you could really be on the precipice of a increase if you continued the Forteo, but I realize your dr has a plan, and don't know if he would be amenable to changing his tactics.
I called my local com college and they don't have that journal, and suggested getting it from a Univ with a Dental school. Well anyway Loma Linda was next on my list to call, and they do have it, but they won't email it to me. I would be more than welcome to drive down there and copy it, since I'm a patient there, but the drive is 2+ hours and I'm not planning on making that trip for a while.
I then contacted another State Univ. and am still awaiting an answer from the research librarian. I "really" want to read the whole article before I make a major analysis of it, but from what you've said about it, it seems you are on the right track with your situation and test results.
I'm having trouble with a lot of bleeding and swelling so I don't feel that hot, but will still continue the search. As soon as I get my hands on it I'll make a more comprehensive statement.
Per your last post I agree, because everything I've read about oral bisphos's was that it could take up to 3 years to manifest, where the oral surgeon threw out the figure of 1-4 months, which I totally disagree with. The funny thing is I have 3 drs who aren't going along with the party line on this, that it's overblown, and that's my mineral met (loma linda) PC, and the oral surgeon. Everyone else just pooh pooh's it saying that the incidence of contraction is so fractional it's not worth talking about unless I took the iv med, and even then it's %'s are low. I hate to beat a dead horse, but I don't think I'm in a position to get this, but something somewhere inside is nagging at me, for reasons I'm unaware of, but I do agree that I'm in the best possibly situation to stave it off having been on forteo for the length of time that I have. Maybe my concern is coming from the infection that went untreated way too long, and my periodontal problem.
Just hang on a little longer and know I haven't for one second giving up the search. Thanks for all your continued help. We'll see what happens tomorrow. Sorry for any spelling mistakes, too tired to pre check it.
I just thought of something else and that is to tell you that my oral surgeon did read this article, because he was the one that gave me the lead on it.
Last edited by DesertBloom; 09-11-2007 at 07:58 PM.
Re: Information Re: Osteonecrosis of jaw and bisphosphonates, Fosamax etc.
DesertBloom-Hopefully tomorrow will be a better day for you. Perhaps it will then be time for the swelling to subside.
I know exactly what you mean by something nagging you that you need to follow up on. But, given that you had been on a bisphos., I don't know how you could be in a better position- that is with forteo in your system and up and running.
I have a nagging in my mind that won't stop as well. I want to do whatever I can to help you get the article.
I don't think you should drive for 2 plus hours there and 2 plus back just for the article. There has got to be another way. Maybe we could brainstorm on how to get this into your hands tomorrow or when you feel like it. Maybe you can ask the reference librarian that you talk to tomorrow if she/ he has a great idea. I find reference librarians so helpful. As I said the reference librarian at the state univ. near where I live said she would email but the database that she used wouldn't allow her to do that. She said some databases she could e-mail from.Also she said that there may be other databases than the one she used that she could email from.
Here is an idea- what if the ref. librarian at the local com college requests the state ref. librarian to e-mail or fax the article to her/him at the com college and then you get it from the com college.
I hope you are sound asleep and doing some serious healing.
Last edited by osteoblast; 09-11-2007 at 09:30 PM.
Re: Information Re: Osteonecrosis of jaw and bisphosphonates, Fosamax etc.
DesertBloom, I hope you will remember me as we have talked several times about the dental issues. I have been following these posts, and wanted to add a few things.
First, I hope you are feeling better today, and so glad that it is finally done. After five extractions this summer spanning three months, you have my utmost sympathy and understanding. It is going to take about a week for it to feel totally better. Follow all instructions. You will find that salt water rinses are very soothing and very healing. The swelling will subside and the bleeding will stop and before long the area will feel so much better.
I did talk briefly to my dentist asking him if he was aware of jaw necrosis as relating to these drugs. He said he recieves literature about it all the time. At first he didn't seem too concerned, rather believing the literature about it coming mostly from IV use and being quite rare. When I told him I am following this very closely, why I chose not to take the drugs (a major duh with my mouth!), and that it is being reported more and more with fewer dentists wanting to treat, he took much more interest. This is a great guy - young and using so many new and good techniques with dental work. He did say that he would not do an implant on someone taking these drugs. I do believe that I made him think more about all of this, which is a good thing and he is the type of man who will. It is important, I think, for the consumer to speak up and if we can do this it could help so many people and the doctors/dentists to be more concerned.
It sounds like you are going to be just fine with no problems. How smart you are to be aware and to pay attention to your own health and those of others. I would think you have very little to worry about, so relax today, let that mouth heal, and know I am thinking about you and sympathizing.
Re: Information Re: Osteonecrosis of jaw and bisphosphonates, Fosamax etc.
Hi Glowing: Thanks for your kind words. I definitely remember you and all our discussions. I'm doing fine, just a little frustrated at the state of our library system in CA. Just in case you haven't been following this thread, I'm trying to get a copy of a research article my oral surgeon told me about, and since it's such a new article it's turning out to be difficult.
Thanks again for all you wisdom with the dental procedures, I think about all the work you've gone through, and hope it soon over.
