Bisphosphonates and Dentistry: Extractions, Risks, What You Should Do, and How We Handle It at Our Clinic
Bisphosphonates are widely used medicines for treating osteoporosis, particularly in postmenopausal women. They are also used in some cancer treatments (bone metastases, multiple myeloma).
And yes: these medicines can have a significant impact on certain dental procedures, particularly tooth extractions.
At Udemax Clinics, we treat patients every month who are taking Fosamax, alendronate, risedronate, ibandronate, zoledronic acid and other bisphosphonates. That is why it is essential that you are aware of the risks and how we manage each case.
What are bisphosphonates and why do they affect the teeth?
Bisphosphonates are a group of medicines used to treat bone conditions such as osteoporosis, osteopenia and Paget’s disease. These medicines work by inhibiting bone resorption through reducing the activity of osteoclasts and slowing down bone turnover, thereby increasing bone density. Furthermore, they are stored within the bone for years, making them effective in the prevention and treatment of bone fractures. However, this mechanism can also negatively affect bone regeneration in the mandible and maxilla, where bone regenerates rapidly. In patients taking bisphosphonates, this healing process is slowed down, which can hinder healing following tooth extractions, implants or other oral surgery.
This adverse effect is particularly relevant in dentistry, as a lack of adequate bone resorption and regeneration can lead to serious complications such as osteonecrosis of the jaws, where the bone is exposed and fails to heal properly. For this reason, at Udemax Clinics we follow strict protocols for patients taking bisphosphonates, including a comprehensive medical assessment, possible temporary suspension of the medication under medical supervision, atraumatic surgical techniques and rigorous follow-up to ensure proper recovery and preserve the patient’s quality of life.
The most feared effect is:
Osteonecrosis of the jaws (ONJ)
The bone ‘does not receive’ sufficient blood supply and part of it may become necrotic (die).
It is uncommon, but it is one of the most serious complications and a serious side effect, with injuries and other maxillofacial conditions that may occur in some cases. This condition is defined as exposed bone that has not healed within 8 weeks.
What types of bisphosphonates are there?
Oral bisphosphonates (the most common treatments for osteoporosis):
- Fosamax® (alendronate)
- Fosavance®
- Actonel® (risedronate)
- Bonviva® (oral ibandronate)
When administered this way, they are usually taken on an empty stomach with water, and calcium levels should be checked before prescribing them. They may cause oesophageal irritation, difficulty swallowing or cramps. Furthermore, the incidence of osteonecrosis is lower than with the intravenous route.
Intravenous bisphosphonates (cancer patients):
Consequently, the risk of osteonecrosis of the jaw is higher and more common in these cases, particularly in cancer patients treated with high doses. The first reports of this complication emerged precisely in this group, suggesting that the risks vary depending on the type of bisphosphonate and the route of administration.
What are the actual risks associated with each type of bisphosphonate?
If you are taking oral bisphosphonates (Fosamax, alendronate, etc.)
The risk of osteonecrosis without surgery is between 0.01 and 0.04 per cent. Following a tooth extraction, this risk rises to between 0.09 and 0.34 per cent. Although the risk is low, it does exist, particularly if you have been taking bisphosphonates for more than three years.
If you are receiving intravenous bisphosphonates (for cancer treatment)
The risk of osteonecrosis is much higher, ranging from 0.8% to 12%. In such cases, we avoid extractions wherever possible.
Can I have a tooth extracted if I’m taking bisphosphonates?
Yes, but with a special protocol. Tooth extraction is the procedure that carries the GREATEST risk for patients taking bisphosphonates.
That is why at Udemax Clinics we follow a safe protocol:
Full medical history
- Which bisphosphonate are you taking?
- Dosage? Duration of use?
- Oral or intravenous?
- Do you have any other risk factors?
Risk assessment
As a precaution and as part of the pre-procedure assessment, there is an increased risk of osteonecrosis if the following conditions are also present:
- diabetes
- corticosteroids
- tobacco
- alcohol
- infection in the area
- periodontal disease
- dentures that rub against the gums
- poor oral hygiene, as it affects health and increases the risk of osteonecrosis
“Drug holiday”: stopping the medication for 2–3 months
Only if your doctor authorises it: discontinuation of oral bisphosphonate treatment prior to the extraction. We cannot stop it on our own, although in some people a therapeutic break from treatment may be considered, always under medical supervision. However, the standard recommendation is to stop taking oral bisphosphonates three months before the procedure, provided the doctor authorises a break in bisphosphonate treatment, and continuing this break afterwards reduces the risk.
Atraumatic technique (minimal damage to the bone)
We use conservative surgery and ensure the wound is tightly sealed; if a tooth extraction is required, it must be as minimally invasive as possible.
Antibiotics and close monitoring
To prevent infection and ensure the area heals properly.
What if I need an implant?
With oral bisphosphonates, it is generally possible to carry out dental procedures following a specific protocol and a careful prior assessment, whereas with intravenous bisphosphonates this is not recommended as the risk of osteonecrosis outweighs the benefits.
Are root canal treatments, orthodontic treatment and dental cleanings safe?
Dental cleanings and orthodontics → No problem
They do not affect the bone in the same way as surgery.
Root canal treatment → This is preferred to extracting a tooth
In high-risk patients, we always try to save the tooth.
What are the side effects of bisphosphonates?
- Bone or muscle pain
- Digestive problems (if taken orally)
- Osteonecrosis (rare, but possible)
- Delayed healing following oral surgery
How do we treat patients with bisphosphonates at Udemax Clinics?
- A comprehensive diagnostic consultation, including a medical and dental history; ideally, this should include a full dental examination before starting treatment with bisphosphonates.
- Direct communication with your doctor/rheumatologist and, in the event of any doubts or complex procedures, assessment by a specialist trained in oral and maxillofacial surgery
- 3D radiological examinations to assess bone condition
- A safe treatment plan that avoids extractions where alternatives are available
- Specific informed consent
- Close monitoring over a period of weeks
Frequently Asked Questions
Can I have a tooth extracted if I’m taking Fosamax?
Yes, but follow the proper procedure and always let your dentist know.
Is it dangerous to take bisphosphonates and have anaesthesia?
Anaesthesia isn’t a problem. The risk lies in the bone surgery.
How long do I need to stop taking bisphosphonates before a tooth extraction?
Usually 2–3 months, if your doctor approves.
Does osteonecrosis cause pain?
It may not hurt at first, but it can later cause pain, expose the bone and increase the risk of infection.
Do you need a check-up if you’re taking bisphosphonates?
At Clínicas Udemax, we assess each case individually to plan the safest course of action for tooth extractions, implants or any other dental treatment you may need; we also offer free check-ups and consultations, so you can book your appointment in Palma by calling 971 767 521.
