Osteoporosis, Bisphosphonates and your Mouth

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Osteoporosis and low bone density affect 54 million Americans. Women are at greater risk than men, and the odds of being afflicted with it vastly increase with age. Shockingly 50% of women and 25% of men over the age of fifty will suffer from a broken bone due to osteoporosis. (1) Since the teeth are supported by bone, osteoporosis increases the likelihood of dental problems.(2) To further complicate matters, the class of drugs most commonly prescribed to treat low bone density called bisphosphonates can cause severe post dental surgical problems.

What is it and how is it diagnosed?

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The term osteoporosis literally means porous bone because under a microscope the honeycomb-like structures of normal bone appear much larger. It is diagnosed by healthcare practitioners using a bone density scan (DXA scan). The machine is not enclosed like an MRI and the procedure is easy. The results are called T-scores. Normal T-scores should be above -1. A score below -1 and above -2.5 is considered low. Low bone density that has not turned into osteoporosis is sometimes called osteopenia. Scores below -2.5 are considered as osteoporosis.

What causes it?

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There are many causes of Osteoperosis, but the most common are low vitamin D status, low calcium intake and low estrogen in women, especially post-menopausal women. Vitamin D helps regulate how we use calcium which is the building block of bone. I do not recommend taking supplements of either as a first resort. If you are curious why, read these posts here and here. The best food sources of calcium are dairy, canned salmon and sardines, nuts, seeds and green leafy vegetables. The best food sources of vitamin D are fatty fish like salmon, liver, cheese and egg yolks.

How to prevent it

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I have already mentioned that a diet rich in vitamin D and calcium is critical. One survey found the prevalence of vitamin D and calcium deficiency in women to be 40%. (3) This makes perfect sense because low vitamin D will result in low calcium. In other words, you can’t have one without the other. Weight bearing exercises like hiking, jogging and dancing cause stresses on the skeletal system which result in the bones to become denser. Resistance training also causes bones to strengthen, but to a lesser extent. (4) I suggest walking every day for at least 30 minutes and resistance training at least three times each week.

How does it affect the mouth?

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Since the teeth are supported by bone, osteoporosis can affect the mouth. Oral manifestations can include gum recession, gum disease, loose teeth, tooth loss, implant failure and I’ll fitting dentures. In my practice, I consider all the factors leading to oral disease, and osteoporosis (being so prevalent) is one of them. It is critical to identify the possibility that a patient may have the condition and be unaware. Preventative dental practices are always Important, but it becomes more so in patients with low bone density. When recommending dental treatment, I must be careful to inform my patients with osteoporosis that a lesser prognosis may be expected. (5,6)

How is it treated?

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The class of drugs most often used are called bisphosphonates. Some common drug names are Fosamax (Alendronate), Actonel (Risedronate), Boniva (Ibandronate) and Reclast (Zoledronic acid). These drugs have a proven record of success. (7) As with most medications though, the number of people who truly benefit is typically smaller than expected. For more specifics on bisphosphonates, click here and here. Estrogen replacement therapy is also indicated as a treatment. The preventive measures discussed previously in this post should be adhered to when on any drug therapies unless contraindicated by the prescribing doctor.

Bisphosphonates and osteonecrosis

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A small percentage of patients taking bisphosphonates experience a condition known a bisphosphonate-related osteonecrosis of the jaw or BRONJ. Osteonecrosis is a fancy way of saying jaw-death. This is a serious problem where parts of the jaw can die. It is rare and usually only occurs in patients receiving high doses of bisphosphonates intravenously for bone cancers. It is occasionally spontaneous, but most often occurs after surgeries like tooth extraction.  For those who present with painful exposed bone, effective control to a pain free state without resolution of the exposed bone is 90.1% using a regimen of antibiotics along with 0.12% chlorohexidine antiseptic mouth. (8,9)

bisphosphonate action plan

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If bisphosphonates are being considered as a treatment option, I strongly urge all dental treatment should be completed as far in advance as possible prior to the commencement of regimen, especially if it involves high doses. When there is a non-surgical option, it is wise to choose it. Two of these options are choosing to replace a missing tooth with a fixed bridge rather than an implant or having root canal therapy to save a tooth rather than extracting it. Since osteoporosis is so common as we age, if you are reading this post and have been neglecting your teeth, I highly recommend calling your dentist for a cleaning and check-up. If you maintain a healthy mouth, you will have little to worry about if you get diagnosed with osteoporosis.