Patients on bisphosphonates may be unaware of BON risk

2010 06 02 16 21 01 409 Confused Patient 70

Performing invasive dental procedures on patients who have been on bisphosphonate therapy can be tricky enough. But what if the patient is completely unaware of the possible -- and potentially devastating -- side effects?

Bisphosphonate drugs are a popular and effective choice for battling conditions such as osteoporosis, but they have also been linked to the rare but serious condition of osteonecrosis. Bisphosphonate-associated osteonecrosis (BON) is a relatively new condition triggered mainly by the increased use of bisphosphonate drugs.

And despite much media attention regarding the potential risks of developing osteonecrosis from bisphosphonates, a study conducted at the University of Tennessee Health Science Center (UTHSC) found that patients who take bisphosphonates may not be aware that BON can develop after they undergo invasive dental care (Journal of the American Dental Association, May 2010, Vol. 141:5, pp. 562-566).

“The patient needs to take responsibility for their health/oral health, once they are properly informed.”
— Peter L. Jacobsen, D.D.S.

While treating a new patient who has been on bisphosphonate medication, it is necessary to discuss the possibility of jaw osteonecrosis after an invasive procedure, lead author Cesar Migliorati, D.D.S., a professor of oral medicine at the UTHSC College of Dentistry, told

"We observed that the vast majority of these patients would be surprised by this information and would very often comment that they had not been told by the prescribing providers about this possibility," he added. "They also would tell us that they did not know they had to inform the dentist about the bisphosphonate treatment."

Observational study

Dr. Migliorati and his colleagues conducted a single-center observational study of 73 patients on an oral or intravenous bisphosphonate drug who were seeking routine care from June 2008 through April 2009 at Nova Southeastern University's College of Dental Medicine, where he was working at the time the study was done.

One of the study authors interviewed the participants regarding the interaction that took place between them and the provider who prescribed the bisphosphonates. The questions focused on the bisphosphonate being taken, the specific medical condition being treated by the medication, the expected duration of the bisphosphonate therapy, and knowledge of potential adverse effects.

Among the study findings:

  • 84% of the participants said they recalled being informed about why they were receiving bisphosphonate therapy.
  • 80% of the participants said they did not know or were uncertain about the duration of the treatment.
  • 82% said that they had not been told about the possible side effects. Participants reported having no knowledge of BON and reported that their physicians had not told them that they needed to inform their dentists they were taking bisphosphonates.
  • Most participants requested a consultation with the oral medicine specialist to discuss the risk of developing BON based on the type of dental treatment plan they would be undergoing.

"The results of our small study show that patients who take bisphosphonates may not be aware that BON can develop after they undergo invasive dental care," the authors concluded. "We believe that a more effective communication process between prescribing physicians, dentists, and patients using bisphosphonates is needed."

Improving communication

The subject of communication between provider and patient communication is not well explored by researchers, Dr. Migliorati said. Patients taking many medications to treat a number of medical diseases may be "lost in translation" regarding side effects, even if they are informed by the prescribing provider.

"We must consider this fact when prescribing medications to our patients," he said.

Peter L. Jacobsen, D.D.S., an adjunct professor at the University of the Pacific Arthur A. Dugoni School of Dentistry and a member of a panel that compiled a report on the management of patients who have been on oral bisphosphonate therapy (Journal of the American Dental Association, December 2008, Vol. 139:12, pp. 1674-1677), feels that better communication is needed among physician, patient, and pharmacist but not necessarily between physician and dentist.

"The patient needs to take responsibility for their health/oral health once they are properly informed," he said. The study results were not surprising, he added.

"Physicians are very busy, and all medicines have side effects," Dr. Jacobsen said. "The FDA requires side effects with an incidence of greater than 3% be put on package inserts of medicines, but the risk of osteonecrosis in patients taking oral bisphosphonates is much less than 1%."

However, the risk of getting osteonecrosis in patients taking IV bisphosphonates is 3% to 6%, which is "very significant and should be presented to the patient for sure," he added.

Treatment precautions

Patients must be educated about the risk of oral complications after invasive dental treatment, and treatment plans should consider what is best for that particular individual based on the overall health status, oral health status, and risk for complications, Dr. Migliorati noted.

While this is a complex question that is still in the process of being answered, Dr. Jacobsen said his best advice to general dentists relative to doing extractions would be to refer the patient to an oral surgeon. "Not because they can't do an excellent job on the dental extraction, but they are not as well-trained, relative to management, if the patient gets osteonecrosis," he said.

Both doctors agreed that it is especially important for patients who are about to be treated with IV bisphosphonates to have a complete oral checkup to minimize the risk of problems related to the oral cavity.

Physicians are less likely to talk to patients about BON because the risk of developing it is still considered quite small and the condition is still not that well-known, Dr. Jacobsen noted.

"It is a newly discovered side effect that is still being researched as to the incidence, causes, precautions, and treatments," he said. "It is very much in the unknown stage at this point, and it will take about one to three years to clearly delineate and understand the problem."

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