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Dental and Oral Health Center

Fosamax and Tooth Extraction

09/28/2010

Question:

My mother is 89 years old. She has taken Fosamax as an osteoporosis preventive for well over 10, maybe close to 20 years. We stopped her use in January/February of this year as part of a process where we discontinued one medication at a time to see why she was regurgitating after every meal. This was along with a round of consults with a gastroenterologist. Upshot on the regurgitation seems to be a hiatal hernia that comes and goes. Best control of the regurgitation seems to be small, frequent meals spaced at least 2 hours apart and avoiding coffee and some other foods.

My mother has a lifetime of dental woes. At this point my mother has 7 natural teeth left in the front arch of her lower jaw, a full upper denture and a partial lower one that has wings extending out from the 7 remaining natural front teeth. She had some gum pain last October and wasn’t wearing one of the dentures (I forget which one) and we took her to a dentist who removed some material from one of the dentures and made it comfortable for her again. He wanted to remake the dentures – estimate was close to $3500 - $4000 for both.

We stared with a new dentist in February who says the dentures are still serviceable and that preservation of the 7 teeth and the nubs of 3 former teeth that have been left to help anchor/locate the dentures is of greater importance than new dentures. She agrees that the regurgitation and possible acidic content of it may be contributing to the weakening of these remaining teeth. She started on a program of prescription strength fluoride toothpaste; fluoride based mouthwash, and cleaning and cavity repair of the 7 teeth.

In the meantime, the top of tooth # broke off in two separate incidents between March and May 2010. This dentist wants to pull what’s left of the tooth. She said a root canal and cap could be done – about $1800 to $2000 but it wouldn’t last, as what’s left of the tooth is fairly weak.

My sister-in-law said she has been told that people on Fosamax are a great risk for jawbone necrosis when teeth are pulled. I checked the Internet and that seems to be the case, but most references are sources about 4, 5 or more years ago. What is the latest thinking on this? We have put off the tooth pulling 2x times – dentist has become a little put off and has referred my mother to a tooth extraction specialist instead.

One internet resource I checked said a CTX test is important – I mentioned this to my mother’s internal medicine doctor at her July 2010 checkup she had a NX test done instead she said that’s the Cleveland Clinic equivalent.

Question: can the tooth extraction dentist use this NX result? How risky is the tooth extraction for my mother?

Answer:

This topic is of intense interest to the millions of Americans who use oral bisphosphonate medications to control osteoporosis. Unfortunately, there is still no clear answer to the question: can serum CTX levels be used to determine a patient's risk for developing the complication of jaw osteonecrosis following tooth extraction? Studies and opinion for both sides of this issue have been published, but no consensus has been reached.

The latest, published this month in the Journal of Oral and Maxillofacial Surgery, showed that patients using bisphosphonates (both intravenous forms for the control of bone cancer and oral forms for osteoporosis) with pre-surgical CTX levels less than 150 picogram/milliter of serum were statistically more likely to develop osteonecrosis of the jaw (ONJ) than patients with levels greater than 150 picogram/ml. Most patients who developed ONJ, however, were cancer patients, a result that confirms previous studies that have shown their risk for ONJ is much higher than for osteoporosis patients. The authors of this most recent study wisely stated, however, that CTX serum level is not (at least not yet) a definitive predictor for the development of ONJ.

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Response by:

John R Kalmar, DMD, PhD John R Kalmar, DMD, PhD
Clinical Professor of Pathology
Associate Dean of Dentistry Administration
College of Dentistry
The Ohio State University