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Do patients with osteoporosis need a thorough dental exam before starting bisphosphonate therapy?
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Dental exam not needed if risk factors are not present
Bisphosphonates carry an FDA warning stating that because ONJ has been rarely reported in osteoporosis patients, “all patients should have a routine oral exam prior to treatment.” The risk of ONJ in patients taking bisphosphonate in the doses for osteoporosis is extremely low, estimated to be an incidence of less than 1 in 100,000 person years of exposure.
A routine oral exam, however, is not the same as a thorough dental exam. An internist can perform the former by examining the patient’s mouth and taking a good history, but a dentist is required for the latter. If a patient is seeing a dentist for routine care this should be noted.
In some parts of the world, such as the United Kingdom, there is a significant wait before individuals can see a dentist. In the United States, a significant percentage of the population does not have dental insurance. We do not want patients to feel that if they can’t see a dentist, they can’t take an osteoporosis medication.
 Stuart L. Silverman |
The routine oral exam recommended by the FDA is sufficient for the majority of osteoporosis patients initiating bisphosphonate therapy, although physicians should also be sure to ask about future dental extractions, gum disease and other issues such as steroid use. If oral surgery such as a dental extraction is planned, the use of a bisphosphonates should be deferred.
If the patient has risk factors, such as a history of cancer, chemotherapy, radiation therapy or steroid use, they should undergo a dental exam. Furthermore, if during the routine oral exam the clinician notes obviously poor dental hygiene – including inflamed or bleeding gums – then the patient should be sent to a dentist.
The bottom line is that the FDA warning is the starting point. Patients without risk factors may not need a thorough dental exam, and the average internist can conduct a routine oral exam and obtain a history.
Stuart L. Silverman, MD, FACP, FACR, is an Attending Physician at Cedars-Sinai Medical Center and Clinical Professor of Medicine and Rheumatology at the David Geffen School of Medicine, UCLA.
Consult a dentist before treating with bisphosphonate
 Lawrence G. Raisz |
Even though ONJ is very rare, it is also very bad when a patient gets it. We ought to be protecting our patients as best we can against this event. If infection and prior dental pathology are common and you are not feeling pressed to give the drug today, you ought to check the patient’s mouth.
I can look in a patient’s mouth, but I don’t know how to evaluate what I see; therefore, a dentist should be consulted. We should try to have a dentist look for any immediate remediable surgical issues in the mouth before we start the patient on bisphosphonate therapy.
For patients who might not have dental insurance or access to a dentist, that would be a judgment call. I would do my best to look in their mouth, and if what I saw looked disastrous to me – such as broken or loose teeth or obvious inflammation – then I would say that the patient should really get looked at by a dentist.
In my belief, we will be giving more and more intravenous bisphosphonates even for osteoporosis. If it is decided to give all patients with fragility fractures an injection of zoledronic acid, I would say go ahead, strike when you have the opportunity.
But patients should be told that they should also have a dentist take a look at their teeth.
Lawrence G. Raisz, MD, is the Associate Director of the New England Muscoloskeletal Institute and Director of the University of Connecticut Center for Osteoporosis.