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Osteonecrosis of the jaw (or ONJ) is a potential side effect of dental surgery while taking osteoporosis medications such as bisphosphonates or denusomab (Prolia).
The objective of this blog post is to give you the information you need about osteonecrosis of the jaw and osteoporosis medications so that you can have an informed discussion with your physician and dentist.
In order to understand the causes, symptoms, and how you can protect yourself against osteonecrosis of the jaw, I approached one of the best oral surgeons in Ottawa, Dr. Hassan Moghadam.
Dr. Hassan Moghadam
Dr. Hassan Moghadam is an oral maxillofacial surgeon. He graduated from McGill University in Montreal and the University of Toronto.
While doing his studies, Dr. Moghadam conducted research on bone regeneration. In addition to his formal training in oral surgery, Dr. Moghdam has a Master’s degree in bone engineering. He spent a lot of time growing bone, understanding how stem cells create bone, and how the body works with bone.
His day practice is dedicated to regenerating bone for dental implants.
Osteonecrosis of the Jaw and Osteoporosis: Key Points
This post (and the video interview) covers a lot of ground. I encourage everyone to read the article and listen to the interview with Dr. Moghadam in their entirety.
However, I recognize that some readers are pressed for time. For those readers, here is a summary of the key points made by Dr. Moghadam.
- Osteonecrosis of the jaw (ONJ) means that a region of the jaw bone is dead.
- ONJ is not caused by osteoporosis medicine. The ONJ can be brought on after the surgeon has done surgery and the jaw bone has difficulty healing because osteoporosis medications slow the removal of old bone and affect the bone remodelling process.
- Get a clean bill of dental health before starting an osteoporosis medication.
- Assuming you are on a bisphosphonate or Prolia, the risk of developing ONJ after surgery is very low.
- Your risk of developing ONJ when you are on Prolia or a bisphosphonate increases when you have co-morbidities such as diabetes, or you are on an oral steroid (such as Prednisone).
- Do not assume that your dentist understands osteoporosis and the subtleties of osteoporosis medications or that your physician understands the implications of dental surgery procedures.
- Biomarkers cannot determine the risk of developing ONJ.
- Standard dental procedures such as teeth cleaning, fillings, etc are safe to do when you are on a bisphosphonate or Prolia.
- If you are on Prolia and are otherwise in good health, you can have a dental surgery provided the surgeon does what is called an atraumatic surgery, where they are extra cautious about traumatizing or heating the bone.
- If you are on Prolia but have the co-morbidities listed in point 5 above, you may need to pause Prolia while you get the dental surgery. Your surgeon will need to co-ordinate the treatment protocol with the your physician. In another article I wrote (this time on Prolia), Dr. Rick Adachi suggested delaying the dental surgery until the last month of your Prolia treatment cycle. This may give your dental surgeon enough time to perform the procedure and allow the wound to heal.
Osteonecrosis of the Jaw: Definition and Causes
The American Association of Endodontists, defines osteonecrosis of the jaw (or ONJ) as “a progressive bone destruction in the maxillofacial region”. (1) According to Dr. Moghadam, osteonecrosis of the jaw refers to the death of the bone in jaw region.
There are several ways you can develop osteonecrosis of the jaw. You can get osteonecrosis of the jaw from radiation. This is called radiation-induced osteonecrosis of the jaw.
Another cause of osteonecrosis of the jaw is bacterial infection.
Lastly, you can develop osteonecrosis of the jaw from a dental surgical procedure (i.e., a tooth extraction or a cut of the jaw bone) while on osteoporosis medications. We discuss this in detail below.
Bisphosphonate (or Denusomab) Induced Osteonecrosis of the Jaw
Bisphosphonate related osteonecrosis of the jaw (BRON jaw) was first identified in 2004. During 2005, several research journals published cases of patients who developed osteonecrosis of the jaw while being treated with Alendronate (Fosamax) and other early bisphosphonates for osteoporosis. (2)
In my interview, Dr. Moghdam explained how bisphosphonates affect the bone remodelling process which, in turn, can cause osteonecrosis of the jaw.
Bone Remodelling in the Jaw
During the bone remodelling process, osteoclasts eat holes through the bone (to remove old bone). After that, osteoblasts lay down new bone to replace the old bone. This continuous regeneration process is called bone remodelling.
The family of osteoporosis drugs, including denusomab (Prolia) and bisphosphonate, inhibit osteoclast activity. That is, they stop the removal of old bone. As a result, there are no more holes being made that need to be filled.
This is not a problem if everything stays static and no surgical intervention is required to address dental problems that may arise.
However, imagine you need dental surgery and the oral surgeon has to cut your jaw bone. If a bisphosphonate is active, then the bone remodelling process is hampered and bone repair is impeded.
[The video below is an interview I did with endocrinologist Dr. Janet Rubin. In it, she describes bone remodelling.]
Osteoporosis in the Jaw Bone
Dr. Moghadam explained that he has had patients who have osteoporosis and are concerned that their jaws are weaker (because of the osteoporosis). They believe that they are at risk of a fracture in the jaw if they have a dental surgery, such as dental implants.
Dr. Moghadam stated that this is absolutely not true. The last place your osteoporosis is going to affect is your jaw. This is because your jaw is constantly in motion and your teeth are continually stimulating the bone.
However, if you take all your teeth out, the bone in the jaw bone shrinks significantly because the bone is not being stimulated.
If you have bridges and partial dentures, the jaw bone shrinks. When you take a tooth out, anything under a bridge or under a partial denture will shrink with time. In fact, the bone density is less in an area where there’s no tooth.
A dental implant, on the other hand, is different. When an implant is put in place, the implant provides stimulus to the bone in much the same manner as the original tooth.
Risk of Osteonecrosis of the Jaw
The risk of osteonecrosis of the jaw is elevated when the oral surgeon performs a procedure.
Dr. Moghdam stated in our interview: “Patients come to me and say that they are at risk of osteonecrosis of the jaw because they are on Prolia [or a bisphosphonate]. In my opinion, you’re more at risk if I go and do a procedure on you and I take a tooth out or I cut into your jaw bone.”
For comparison purposes, the risk of spontaneous osteonecrosis of the jaw (that is, a healthy person not taking osteoporosis medications) is very low. Dr. Moghdam estimates the risk at one in 10,000 (or 0.01%).
He estimates the risk of a person developing osteonecrosis of the jaw when someone takes a bisphosphonate and has dental surgery procedure as one in a thousand, or 0.1%. The risk is quite low.
However, the risk of developing osteonecrosis of the jaw increases under the following conditions.
Three Years on a Bisphosphonate or Prolia
During the first three years on a bisphosphonate or Prolia, your risk of having bone necrosis as a result of a surgeon doing a procedure, either a surgery or an extraction, is small. After you have been on the pharmaceutical for three years, the risk increases and it stays elevated.
Diabetes and Steroid Use
People who are diabetic and individuals who use an oral steroid such as Prednisone have an elevated risk. The risk does not apply to nasal spray steroids.
Cancer Treatment
The drug, Zometa (Zoledronic acid), is used as a support medication to treat symptoms of cancer such as hypercalcemia (high blood calcium levels) or to decrease complications (such as fractures or pain) produced by bone metastasis (spread of cancer to the bone). (3)
Zometa is far more potent than the bisphosphonates used in osteoporosis. If the patient is being treated with Zometa, you cannot do any oral surgery procedure unless they stop the drug, according to Dr. Moghadam.
There is almost a 90% chance of having significant necrosis of the jaw if oral surgery is performed while you’re on zoledronic acid IV for cancer.
You have to go off of Zometa for three months before you can have the oral surgery. Even then, there’s still a high risk of necrosis.
After that drug holiday, the surgery can be performed and sometime is needed for the wound to heal. Unfortunately, the metastatic disease is allowed to spread for three months.
Dr. Moghadam recommends that these patients receive a proper dental exam before the application of the Zometa treatment in order to avoid future dental problems.
Oral and IV Bisphosphonates and Osteonecrosis of the Jaw
I asked Dr. Moghadam if he has seen any difference related to osteonecrosis of the jaw between oral bisphosphonates and IV bisphosphonate.
He has found that the IV bisphosphonate is more potent than the oral form of the drug.
Causes of Osteonecrosis of the Jaw
In our interview, Dr. Moghadam stated that we do not know the true cause of osteonecrosis. He told the story of early watchmakers in England painting phosphate onto the dials of the watches only to develop osteonecrosis in their finger tips (they would fall off).
As a result, some scientists believe that phosphate potentially causes the issue for osteonecrosis of the jaw. However, this has not been confirmed.
Exercise Recommendations for Osteoporosis
Exercise is an essential ingredient to bone health. If you have osteoporosis, therapeutic exercise needs to be part of your osteoporosis treatment program.
But what exercises should you do and which ones should you avoid? What exercises build bone and which ones reduce your chance of a fracture? Is Yoga good for your bones? Who should you trust when it comes to exercises for osteoporosis?
A great resource on exercise and osteoporosis is my free, seven day email course called Exercise Recommendations for Osteoporosis. After you provide your email address, you will receive seven consecutive online educational videos on bone health — one lesson each day. You can look at the videos at anytime and as often as you like.
I cover important topics related to osteoporosis exercise including:
- Can exercise reverse osteoporosis?
- Stop the stoop — how to avoid kyphosis and rounded shoulders.
- Key components of an osteoporosis exercise program.
- Key principles of bone building.
- Exercises you should avoid if you have osteoporosis.
- Yoga and osteoporosis — should you practice yoga if you have osteoporosis?
- Core strength and osteoporosis — why is core strength important if you have osteoporosis?
Enter your email address and I will start you on this free course. I do not SPAM or share your email address (or any information) with third parties. You can unsubscribe from my mail list at any time.
Denusomab (Prolia) and Osteonecrosis of the Jaw
Dr. Moghdam stated that Prolia (also known as denosumab) can lead to osteonecrosis of the jaw. He pointed out that when Prolia first came out, he and his colleagues we told by the manufacturer, Amgen, that Prolia (a monoclonal antibody and different from a bisphosphonate) will not cause osteonecrosis of the jaw.
The reality is that Dr. Moghadam said that he is seeing more patients from Prolia than patients treated with bisphosphonates for osteoporosis.
However, the risk of developing osteonecrosis of the jaw using either Prolia or a bisphosphonate is still quite low.
Dr. Moghadam states: “If you come to me and you’re on one of those drugs and you are [otherwise] healthy, you don’t smoke, you’re not a diabetic, you don’t drink alcohol, and you are physically active, the chance of developing osteonecrosis of the jaw is extremely rare.”
On the other hand, if you have been on an osteoporosis medication for over three years, you are diabetic and you have been taking an oral steroid, the risk of developing osteonecrosis of the jaw is elevated.
Dental Surgery While on Prolia
If Dr. Moghadam has a patient who requires an extraction, is a diabetic, on Prednisone and Prolia, he will likely ask the physician to pause the Prolia injection for a three month period. This will allow him to perform the surgery and give the wound adequate time to heal.
However, if you are a normal healthy patient who needs an extraction and you’re on Prolia, a drug holiday is not required. He would go ahead and do the surgery.
Regardless of your situation, he suggests an atraumatic dental surgery. This means that your surgeon will take extra precautions during surgery, be careful, minimize exposure of the bone, and limit the drilling and heating of the bone.
An atraumatic surgical procedure is less traumatic and inflammatory to the bone, and less likely to cause osteonecrosis of the jaw.
Biomarkers and Osteonecrosis of the Jaw
Several years ago, Dr. Robert Marx, a dental surgeon in Florida, used the C-terminal telopeptide (CTX) test to detect osteonecrosis of the jaw. (4)
Researchers were able to find a correlation but no one’s been able to properly prove in double blind controlled trials that the biomarker is an indication for people who are going to have problems. As a result, Dr. Moghadam does not use biomarkers to diagnose or determine the risk of developing osteonecrosis of the jaw.
Drug Holidays and Osteonecrosis of the Jaw
Dr. Moghadam used to require a drug holiday (from the bisphosphonate) before a procedure. He would ask that you to pause the drug for three months if you were on the bisphosphonate for greater than three years and you’re a diabetic or you’re on prednisone.
After the three month holiday, they would do your surgery, let it heal, and then have the patient go back on the medication.
However, research has not shown a statistical difference and Dr. Moghadam has stopped following this protocol. One reason is that the bisphosphonate can bind to the bone for as long as 10 years. As a result, a drug holiday is not going to affect the outcome of the surgery.
Osteonecrosis of the Jaw Symptoms
Initially there’s no pain or symptoms if you have osteonecrosis of the jaw. Medical professionals don’t see much clinically when osteonecrosis of the jaw is in its early stages.
The first sign is either exposed bone or an ulcer. The patient might say that they have a sharp piece of bone that they rub their tongue against.
They often do not experience pain. Eventually the ulcer grows bigger and bigger, and it starts taking over more space. An x-ray will show the necrosis or dead bone.
As it spreads and the bigger it is, the harder it is to treat.
Osteonecrosis of the jaw usually occurs in areas where there’s no teeth.
If you get a dental infection and you’re on Prolia, then your bone isn’t re-vascularizing and cleaning itself. That could spread into and becomes an osteomyelitis — a bone infection that can have significant implications.
Bacteria and Osteonecrosis of the Jaw
Osteonecrosis of the jaw starts off with an ulcer and exposed bone, and then the bone gets seeded with bacteria. There are theories that osteonecrosis of the jaw is bacterially related.
Researchers found out that if you culture these areas they have actinomycosis — a type of bacteria. Clinicians thought that six to eight weeks of penicillin was one of the best treatments for it.
Dr. Moghadam uses amoxicillin and clavulanic acid or penicillin-based antibiotic rather than a clindamycin because it has clinical gut issues.
Areas of the Mouth at Risk of Osteonecrosis of the Jaw
Certain areas of the mouth are more prone to developing osteonecrosis of the jaw. The back of the jaw is where it’s most likely to occur because of the anatomy and the blood supply. The blood supply is less in the lower jaw.
It’s very rare in the upper jaw because the blood supply is completely different. High blood supply in the upper jaw, very small blood supply to the lower jaw.
Upper job procedures almost never have an issue. The lower jaw is a riskier location and specifically, the posterior mandible is the highest risk region in the mouth.
Can You Eat and Drink When You Have Osteonecrosis of the Jaw?
Osteonecrosis of the jaw starts off with an ulcer and, perhaps, a little bit of discomfort. Then if it continues to spread and the patient isn’t treated, this becomes so extensive that it involves a large area.
It will spread into the muscle and they get trismus. This means that the patient can’t open their mouth and can’t eat normally.
The patient can have severe pain and it can become very debilitating. Over time, the infection continues to spread and destroys the bone.
How to Prevent Osteonecrosis of the Jaw
If a patient is able to see a dentist every six months, the dentist picks up on the presence of osteonecrosis of the jaw very early. The dentist will send the patient to an oral surgeon, and they treat it.
However, if we have a patient is not able to see a dentist and the osteonecrosis of the jaw spreads, the patient can end up in the hospital. If an infection develops and it’s not treated, then it will lead to a massive procedure.
When caught early, osteonecrosis of the jaw is very treatable. Caught late, it is very difficult to treat.
Forteo and Osteonecrosis of the Jaw
Dr. Moghadam has never seen an osteonecrosis of the jaw with someone treated with Forteo.
Screening for Osteonecrosis of the Jaw
Dr. Moghadam thinks every physician should encourage their patient to go to their dentist for a screening before starting the osteoporosis medication.
For example, let’s say that during an examination your dentist sees a tooth that’s questionable. There might be an abscess that only shows on x-ray but, otherwise, there are no symptoms. You are either going to have a root canal or pull the tooth out.
If you go on a bisphosphonate or Prolia and the abscess becomes problematic, it’s way harder to heal and to fix.
The best thing for anybody who’s going to go on these drugs is to get a thorough dental screening. Tell your dentist that you are going on an osteoporosis medication and they will look at things differently.
Your dentist can see if there is something that’s going to blow up in the next six months to a year. They can tell if there’s a big, deep cavity that might end up in a root canal and might develop an abscess.
Once you get that cleaned up and you’ve had your root canals, your dental health is stable.
Gum disease, on the other hand, is an ongoing, progressive issue. It’s not an acute concern. That is something you can deal with as it surfaces.
Once your dentist clears you and takes care of any of the acute things, then you’re able to go ahead with the osteoporosis medication treatment.
Dental Procedures While on a Bisphosphonate or Prolia
I asked Dr. Moghadam what dental procedures can safely be performed by your dentist while you are on a bisphosphonate or Prolia. He stated that the following procedures are safe but that you should let your dentist know your medication usage and history before any dental intervention or treatment.
- Any dental procedure that doesn’t involve surgery.
- Fillings.
- Cleanings.
- Root canal.
- Veneers.
- Bleaching your teeth.
- Crowns.
Avoid any procedure that involves a gum flap, lifting the gums off of the bone, or trauma to the bone by doing an extraction.
Advice and Recommendations
I asked Dr. Moghadam for any final advice for the readers.
“If you’re going to go on one of those drugs, make sure you get the clearance from your dentist. Get a clean bill of health. Have them look at everything and make sure there are no ticking time bombs in that region.”
The factors that change the risk profile for osteonecrosis of the jaw, above and beyond using a bisphosphonate or Prolia, also need to be considered. The risk factors are:
- Are you a diabetic?
- Do you use steroids?
- Is your bisphosphonate an oral or infusion?Are you being treated for cancer with Zometa
Exercise Recommendations for Osteoporosis
Exercise is an essential ingredient to bone health. If you have osteoporosis, therapeutic exercise needs to be part of your osteoporosis treatment program.
But what exercises should you do and which ones should you avoid? What exercises build bone and which ones reduce your chance of a fracture? Is Yoga good for your bones? Who should you trust when it comes to exercises for osteoporosis?
A great resource on exercise and osteoporosis is my free, seven day email course called Exercise Recommendations for Osteoporosis. After you provide your email address, you will receive seven consecutive online educational videos on bone health — one lesson each day. You can look at the videos at anytime and as often as you like.
I cover important topics related to osteoporosis exercise including:
- Can exercise reverse osteoporosis?
- Stop the stoop — how to avoid kyphosis and rounded shoulders.
- Key components of an osteoporosis exercise program.
- Key principles of bone building.
- Exercises you should avoid if you have osteoporosis.
- Yoga and osteoporosis — should you practice yoga if you have osteoporosis?
- Core strength and osteoporosis — why is core strength important if you have osteoporosis?
Enter your email address and I will start you on this free course. I do not SPAM or share your email address (or any information) with third parties. You can unsubscribe from my mail list at any time.
Summary and Conclusion
This post covers the relationship between osteonecrosis of the jaw and osteoporosis medications, such as Prolia, bisphosphonates and Forteo.
Dr. Moghadam provided an excellent overview of osteonecrosis of the jaw for people using osteoporosis medications. He covered the risk factors, how to manage the issues, and provided sound advice on how to avoid the development of osteonecrosis of the jaw.
The presence of the following potentially increase the risk of osteonecrosis of the jaw after dental surgery:
- Three years of usage of an osteoporosis medication such as a bisphosphonate.
- Use of an oral steroid.
- Presence of diabetes.
- Alcohol use.
- Poor overall health.
You can decrease the risk of osteonecrosis of the jaw by:
- Regular dental checkups.
- Receiving a clean bill of oral health from your dentist before starting an osteoporosis medication.
Dental surgery is safe if you are on an osteoporosis medication and in, otherwise, good health. There is no need for a drug holiday. However, the surgeon should be careful and perform an atraumatic surgery.
If you are on an osteoporosis medication (specifically Prolia) and also have the additional risks (listed above), then your dental surgeon may ask your physician to implement a drug holiday to allow time for the dental surgery and the healing of the wound.
About Dr. Hassan Moghadam
Dr. Moghadam joined Argyle Associates in 2002 and is the Chief of Dentistry/Oral and Maxillofacial Surgery at the Montfort Hospital. He holds degrees in Dentistry, OMFS, and a Masters degree in Science in Bone Engineering. Dr. Moghadam published the first-ever stem cell regeneration in human jaw bone using BMP and is internationally recognized for his special interest in dental implants and bone reiteration.
He is currently on faculty at McGill, lectures at the University of Ottawa, and is an active staff surgeon at The Ottawa Hospital, The Montfort Hospital, and University of Ottawa’s Faculty of Medicine.
References
- American Association of Endodontists. https://www.aae.org/specialty/communique/guidelines-for-medication-related-osteonecrosis-jaw-an-update/
- Sarathy, A et al. Bisphosphonate-Associated Osteonecrosis of the Jaws and Endodontic Treatment: Two Case Reports. Jiournal of Endodontics. P759-763, OCTOBER 01, 2005.
- chemocare.com website: https://chemocare.com/chemotherapy/drug-info/zometa.aspx
- Marx, Robert et al. Oral bisphosphonate-induced osteonecrosis: risk factors, prediction of risk using serum CTX testing, prevention, and treatment. Journal of Oral Maxillofacial Surgery. 2007 Dec;65(12):2397-410. doi: 10.1016/j.joms.2007.08.003.
Comments
October 12, 2021 at 11:33am
Sue
I often read your articles with great interest, and I have stopped taking my alendronic acid because I had an eye stroke. At first the medical profession would not admit it could have been my medication, but I researched it, and persevered. They now say it is a possibility, although they can’t advise me whether to stop taking my medication, and have left it up to me to decide. I feel I don’t want an eye stroke in my other eye, so I am taking natural medication, in particular bone smart. I also do some of your exercises and have started Pilates classes.
I wondered whether you had heard of the connection between alendronic acid and eye problems before?
October 12, 2021 at 3:41pm
Richard Martin replies
We have not.
October 12, 2021 at 1:02pm
Peggy kong
Very helpful information. Thanks Margaret for having the interview on blog.
October 12, 2021 at 3:36pm
Richard Martin replies
You are welcome.
October 12, 2021 at 2:05pm
Josephine
What about the infusion, Reclast? How safe is this? Is Prolia better?
October 12, 2021 at 3:42pm
Richard Martin replies
You should discuss drug choice with your physician. Margaret covers Prolia in detail in this post: http://melioguide.com/osteoporosis-treatment/how-long-can-you-take-prolia/
October 12, 2021 at 2:59pm
Lml
Hi Margaret. I am concerned with stopping Prolia for high risk fracture patients. This video indicated stopping it prior to extraction (is the oral surgeon also stopping the diabetic medications and steroid) but there are presently no other options to replace it for high risk pts. What exactly is the message?
October 12, 2021 at 3:40pm
Richard Martin replies
Dr. Moghadam indicated that if you are otherwise healthy and on Prolia, he would likely do the surgery without stopping the Prolia. However, he would use atraumatic surgery to minimize the impact. This is explained in the post and the video.
If you have a mixture of conditions that elevate your risk of ONJ (oral steroids, diabetes, etc), the surgeon will have to work with your physician on how to manage the situation. There is no easy answer here. Again this is explained in the post.
October 12, 2021 at 3:44pm
S. Suzuki
I was on alendronate and had to have a dental implant. My oncologist took me off alendronate and later put me on raloxifene (evista). It is promotes bone health and blocks estrogen. My dental implant took well over a year, so I was glad to have something for my osteoporosis.
October 12, 2021 at 6:36pm
Richard Martin replies
Thank you for sharing.
October 12, 2021 at 7:13pm
nalaxu
I wish my doctor had me visit my dentist and get my dental surgery done before getting the prolia injection. In fact he told me I could proceed with all dental work. I was in the midst of bone grafts. When I saw the oral surgeon after the bone graft healed and he found out I was on prolia he preferred not to do the surgery because of the high risk of jaw necrosis.
October 13, 2021 at 11:01pm
Dorothy Brett
Because I am on Prolia , My dentist insists on me taking four antibiotic tabs one hour prior to treatment. (Even just cleaning). I don’t know anybody else whose dentist recommends this.
October 14, 2021 at 7:32am
Richard Martin replies
You might ask him why.
October 14, 2021 at 11:02am
Trish Worgan
Very informative discussion. Thank you!
October 14, 2021 at 11:03am
Richard Martin replies
Thank you.
November 3, 2021 at 7:45pm
Fran clark
I am the RN with metastatic breast cancer that had spontaneous ONJ due to xgeva from 07-2016 to 11-2017. I went through 7 dental professionals. I did not learn what had happened until 2 days after the dead bone came off.
Why is there no one studying those of us that got through this? I never smoked. Do not have diabetes. I did have undiagnosed blood clots. They diagnosed those 11-2019. I was given a lot of steroids.
I did start the FB group.....living with Osteonecrosis of Jaw. Everyone shares what they did....
There needs to be more out there for people like me.
Why us?
Thanks
Frances clark