What do you need to know if you take Bisphosphonates?

By Spec. Dr. Ana Gugushovska , Oral Surgeon 

Dental implants can be problematic if you take Fosamax, Actonel or Boniva. Contrary to popular opinion, this does not mean you cannot have dental implants, sinus lifts or bone grafts just because you take or have ever taken these medications called “bisphosphonates.” They work by preventing bone breakdown and increasing bone density (thickness). This sounds great, but when having a dental implant, bone graft or extraction, you need to have both types of cells that make bone and remove bone to heal normally.

Bisphosphonates are a class of drugs used to treat osteoporosis in a significant proportion of the population. They behave by reducing the rate of breakdown of the mineral part of the skeleton to increase bone density and strength. They are also used in higher doses to treat patients with metabolic disease or cancers that involve bone to reduce the rate of bone breakdown. Bisphosphonate drugs are currently used in the medical management of osteoporosis, osteopenia, multiple myeloma, Paget’s disease, heterotopic ossification, hypercalcaemia of malignancies, breast cancer therapies and prostate cancer androgen deprivation therapy. The IV(intravenous) bisphosphonates are primarily used for multiple myeloma, hypercalcaemia of malignancies, breast cancer therapies and Paget’s disease.

Having been treated previously or currently using bisphosphonate drugs you should know that there is a risk of future complications associated with dental implants, bone grafting or oral surgery treatment. This risk is increased after surgery, especially from tooth extraction; implant placement or other “invasive” procedures that might cause even mild trauma to bone.

The risk is significantly higher in patients who have received the injectable (IV) forms of these drugs. Most severe complication is osteonecrosis.


The risk of osteonecrosis after having an implant is increased if you have been taking it longer than 3-4 years.Fosamax, Actonel and Boniva last in your bone long after you stopped taking it. It may last in your bone for 10-50 years !Unfortunatelymanypatients who take bisphosphonates are unaware of the potential effects that this classof drugs has and the risks associated with oral surgery procedures.

Currently there is no known cure other than extremely good hygiene and application of topical antiseptics.

Guidelines for treatment of dental patients receiving intravenous bisphosphonate treatments should be different than for patients taking the oral formulations of these medications.

In summary,the current ADI(The Association of Dental Implantology UK) guidelinespublished on their website http://www.adi.org.uk are as follows:

  • Patients on IV bisphosphonates are at the highest risk of developing bisphosphonate-associated osteonecrosis (BON), particularly if they have been receiving IV treatment for more than six months. Elective dental implant treatment cannot be recommended for these patients. If treatment is required, this should be undertaken in a hospital environment with intravenous antibiotic therapy and full aseptic technique being considered as appropriate.
  • Patients on IV bisphosphonates for less than six months should be at low risk of developing problems in relation to non-surgical periodontal and restorative care. However, surgical treatment, e.g. extractions, should only be undertaken if absolutely necessary and should be approached cautiously and conservatively. If possible, a single intervention should be undertaken and an interval of two months left to verify acceptable healing before considering further surgical intervention
  • Patients on oral bisphosphonates treatment for three years or less probably have only a slightly increased risk of developing BON and as such, elective dental therapies including extractions and dental implants are not contraindicated. The patient should however be informed of the risk and appropriate consent obtained.
  • Patients on oral bisphosphonates treatment for more than three years are at an increased risk of developing BON and this risk may increase with the duration of bisphosphonates therapy and other co-factors such as smoking. Therefore, surgical treatment, e.g. extractions, should be approached extremely cautiously and conservatively. If possible, a single intervention should be undertaken and an interval of two months left to verify acceptable healing before considering further surgical intervention.
  • All patients on bisphosphonates treatment should rinse for one minute using a chlorhexidine aqueous solution 0.2% prior to dental treatment and to continue rinsing twice daily for 14 days after treatment.
  • All patients on bisphosphonates treatment should be prescribed systemic antibiotics for one to two days prior to any dental procedures, which involve trauma to bone, e.g. extractions, implant placement and periodontal surgery.
  • All patients on bisphosphonates treatment should be encouraged to attend for regular dental assessment and maintenance. The importance of ensuring a high standard of oral hygiene and good diet should be emphasised to reduce the need for possible future dental surgical intervention.
  • Patients who smoke should also be encouraged to cease.

Sufficient evidence exists to suggest that all patients undergoing implant placement should be questioned about bisphosphonate therapy including the drug taken, the dosage, and length of treatment prior to surgery. For patients having a history of oral bisphosphonate treatment exceeding 3 years and those having concomitant treatment with prednisone, additional testing and alternate treatment options should be considered.

Your medical/dental history is very important to the implant dentist.  Let him know if you take or have taken Fosamax, Actonel and Boniva before a sinus lift, bone graft or dental implant. The implant dentist may write you a prescription to have a special blood test to check your risk before he starts. He may consult with your medical doctor to modify your regimen. It is critical to use a very knowledgeable implant dentist when you have taken these types of medications because there are many other factors that can cause problems not listed above

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