Would I take Fosamax? Addressing a question about medication-related osteonecrosis of the jaw (MRONJ)

I recently presented a webinar for Colgate entitled Women's Wellness: What a Difference an X Makes. I was asked a question on which I would like to elaborate.

Source: John W. Hellstein, University of Iowa College of Dentistry and Hardin MD, University of Iowa.

The question was on the osteoporosis medication, Fosamax, and any dental/oral concerns in patients that take this drug. I was asked if I, myself, would take this medication, if needed. My answer to that is that if I needed an osteoporosis medication, I would initially try a selective estrogen receptor modulator (SERM). In a three-year study involving 600 postmenopausal women, raloxifene (brand name: Evista) was found to increase bone density and lower LDL cholesterol. (1) However, everyone is different and must check with an endocrinologist or other physician.

If one is taking certain osteoporosis medications and needs any kind of oral surgery, serious problems could occur. We were made aware of bisphosphonate-related osteonecrosis of the jaw (BRONJ), however, bisphosphonates are not the only culprits. An increasing number of osteonecrosis cases involving the maxilla and mandible have been associated with other antiresorptive (e.g., denosumab) and antiangiogenic therapies. (2) Therefore, the American Association of Oral and Maxillofacial Surgeons (AAOMS) feels it is more appropriate to label this condition medication-related osteonecrosis of the jaw (MRONJ). In 2013, a special committee met to evaluate the current literature and revise the 2009 guidelines to reflect current knowledge in this field. The update contains revisions to diagnosis, staging, and management strategies, and highlights current research status. (2)

MRONJ adversely affects the quality of life, causing significant morbidity. Protocols for management of patients with MRONJ, or those at risk for it, were presented in the AAOMS updated Position Paper on Bisphosphonate-Related Osteonecrosis of the Jaw in 2009. (3) The new Position Paper is extremely detailed, and includes background material, risk factors for MRONJ, management strategies for patients treated with antiresorptives or antiangiogenics, treatment goals, and much more. (2)

For more on osteoporosis, these types of drugs, and osteonecrosis, visit the Mayo Clinic, the National Institutes of Health, or MedlinePlus websites. As well, the American Dental Association (ADA) has a paper on Osteoporosis Medications and Oral Health. (4, 5) A new systematic review is also available. (6)

References
1. Selective Estrogen Receptor Modulators (SERMs). WebMD. http://www.webmd.com/osteoporosis/guide/serms. Reviewed on November 01, 2014. Accessed on October 13, 2015.
2. Ruggiero SL, Dodson TB, Fantasia J, et al. Special Committee on Medication-Related Osteonecrosis of the Jaws. Medication-Related Osteonecrosis of the Jaw—2014 Update. J Oral Maxillofac Surg. 2014;72(10):1938-1956. http://www.aaoms.org/images/uploads/pdfs/mronj_position_paper.pdf.
3. Ruggiero SL, Dodson TB, Assael LA, et al: American Association of Oral and Maxillofacial Surgeons position paper on bisphosphonate-related osteonecrosis of the jaws—2009 update. J Oral Maxillofac Surg. 2009;67(12):2698-2699.
4. American Dental Association. Osteoporosis Medications and Oral Health. http://www.ada.org/en/member-center/oral-health-topics/osteoporosis-medications-and-oral-health.
5. Hellstein JW, Adler RA, Edwards B, et al. Managing the care of patients receiving antiresorptive therapy for prevention and treatment of osteoporosis. Executive summary of recommendations from the American Dental Association Council on Scientific Affairs. J Am Dent Assoc. 2015;142(11):1243-1251.
6. Fliefel R, Tröltzsch M, Kühnisch J, Ehrenfeld M, Otto S. Treatment strategies and outcomes of bisphosphonate-related osteonecrosis of the jaw (BRONJ) with characterization of patients: a systematic review. Int J Oral Maxillofac Surg. 2015; 44(5):568-585. doi: 10.1016/j.ijom.2015.01.026.