Puzzled

[Clarrisa]

My Internist as of late seemed fit to be tied with me for not starting a course of anabolic bone building medications ("50% of people die after breaking a hip ..."). I have delayed due to two gum procedures, one of which the Endodontist wants to see me back in June to see if it was successful. I may be in need of a tooth extraction. I am told by both Endocrinology and my Internist that it is OK to go ahead and take these type of medications now, but that is not the impression I received from my primary dentist. Another doctor, who does my annual breast exam suggested I wait. Has anyone navigated this situation? I am going to step out for a walk!

[HappyGranny55]

yep! Endocrinologist says Tymlos, then Reclast or Prolia or this or that and then this or that……orthopedic surgeon who runs a bone clinic says the same. I need two dental extractions /implants for resorption issues and my dentist says to stay away from all the bone drugs. It’s exasperating, I know. Then my endocrinologist left the practice, so now I’m starting over, I am in a holding pattern because I am not ready to start medications, call it paralysis by analysis!

[Clarrisa in reply to HappyGranny55]

Thank you so much for replying. I asked my Internist if I have to follow up later with Reclast why not just take that(?). He replied it is expensive & insurance won’t cover it. Nice to know who is doing the doctoring … My endocrinologist has only seen me by telemedicine since COVID, I am wondering if your parting doctor would see you that way, if they are still practicing(?). A new doctor may provide a second opinion though. Thank you again for your input.

[FrogLeg]

Please forgive me, but I don’t quite follow what you mean by “seemed fit to be tied with me.” Just to be clear, is your internist for or against you starting the anabolic?

In your reply to HappyGranny55, you mention that you had asked your internist why not just skip the anabolic and take the bisphosphonate. The reason is that the anabolic will build bone more significantly (thus the term “anabolic”) than the bisphosphonate. There are studies showing that a person who takes a bisphosphonate and later realizes that they aren’t gaining bone mass significantly and so they want to switch to an anabolic (to accelerate bone growth), for these people, the growth they get from the anabolic will be less than if they had just started fresh with the anabolic. Taking the bisphosphonate first tempers things.

This is all to say that there are various protocols one can follow. That is a key area of interest and research in osteoporosis treatment now. There is actually some research I saw recently saying that taking both an anabolic and a bisphosphonate simultaneously from the beginning may improve bone growth even more. It is a complex system. But if your internist is unaware of these differences in treatment protocols, or doesn’t share them with you, that would raise a red flag for me. The endocrinologist should be aware and prescribe accordingly. Did you pose the same question to him/her?

With regard to dental work, you should specifically ask what the statistical risks are associated with a given drug and specific types of dental work. It is hard to work with just a basic yes or no recommendation. It doesn’t shed light on their experience and knowledge related to the question at hand. Moreover, the same risk might make one person hesitant and another completely comfortable. If they can’t quantify it at all, even coarsely, then you have no way to know how YOU would tolerate the same risk.

It is also important to distinguish between the risk you would incur while taking a bisphosphonate versus while taking an anabolic. My sense is that the anabolic poses little or much lower risk as it doesn’t retard bone healing in the way a bisphosphonate does. Some studies suggest that teriparatide, for example, may even improve bone healing after dental procedures like tooth extraction or implant placement. If anyone you question cannot speak to these distinctions, I would weigh their opinion differently. An endocrinologist would be my preference for a resource.

Finally, to be clear, the thing we are most concerned about dentally is osteonecrosis of the jaw. There is an abundance of literature on this subject. It might reassure you.

[Clarrisa in reply to FrogLeg]

Thank you, thank you FrogLeg for so kindly taking your time to help the lost! My Internist is actually a Fellow (who plans on becoming a Cardiologist). He will of course not deviate from endocrinology recommendations to take Tymlos, Forteo or Evenity anabolic therapy (as first choice recommendations). Reclast and Prolia were at one point offered as alternatives however. Nor will the Fellow's Attending ever deviate either.

No, I did not pose the question of taking Reclast first to my endocrinologist. I went for a endocrinology second opinion however. They provided more specific recommendations: "Overall my first choice would be romosozumab (Evenity) or abaloparatide (Tymlos), followed by IV zoledronate (Reclast). But any therapy would be great! I actually had prior been on Raloxifene for a spell but unfortunately did not tolerate it. My second opinion mentioned to "Keep up the calcium intake as that seems to have fixed your PTH elevation (which is great for the bones)." She too was unable to explain why my CTX is higher than it should be.

Regarding the dental work and above medications my reluctance to move forward stems from longstanding oxalate issues. I have actually had a kidney stone or two. That is why my inclination has leaned towards the less aggressive approach, but now that I think about it if I get laid up with a broken hip, that won't help either. Especially with the high oxalate, salty meals I would surely get served.

I did by the way earlier on data entry all requested labs etc. on the Norman Parathyroid Center CalciumPro App. It registered my "likely" having hyperparathroidism. After reading some of their online articles on that site I self paid for a series of Calcium, Ionized, PTH, Intact and Calcium levels which all came back within normal limits. I spoke by phone with their staff and did not pass criteria for a more formal telephone consultation (which if you are out of state is very pricey).

I will pursue the dental angle more closely, starting with my upcoming primary dentist whom I see soon. Thank you again for your invaluable insights.

[GoldPhoenix in reply to Clarrisa]

Check out Dr. Deva Boone's website. She is a doctor in Phoenix, Arizona who specializes in Parathyroid disease. Her website has a free parathyroid disease analysis tool where you plug in certain bloodwork values (calcium, PTH) and your age and it will pump out a brief statement about your status and some things to consider. Very useful. If there are parathyroid issues, these must be addressed first. No medication given (osteo meds) will stop bone loss occurring with this underlying condition. I didn't know this until recently and this could make a difference in your osteoporosis journey. Best of luck!

[Clarrisa in reply to GoldPhoenix]

Thank you GoldPhoenix, I will look into Dr. Boone’s website right now. I wondered if the Raloxifene I had taken had led to a parathyroid level elevation but my doctors say no. I’d like to learn more, so thank you very much.

[GoldPhoenix in reply to Clarrisa]

You bet. good luck!

[Met00]

It shocks me how so often doctors abuse statistics in this way! 50% of people fracturing their hips do NOT die! The risk is to very frail people who are no longer living independently, probably because their lack of mobility and co-morbidities often leads to complications. See, for example, ncbi.nlm.nih.gov/pmc/articl....

[Clarrisa in reply to Met00]

It is said to never schedule these type of (medical) appointments on a Monday or a Friday. I saw this doctor on a Monday. He is a Fellow, perhaps had been "on call" and seemed to be coming off the weekend quite poorly. I printed your mentioned study, thanks, I will hand it to him on my upcoming "Wellness" visit if he still is in a semi unglued state.

[yogalibrarian]

I would follow the endocrinologists advice. Your dentist might be lumping all osteoporosis medications together, when it is only a few that might cause osteonecrosis of the jaw.

Doing a quick scan of the scientific literature, I found several articles that discussed the efficacy of treating ONJ with anabolics (PTH).

You might ask the Endo for some clear guidance for your dentist.

[Clarrisa]

Thank you yogalibrarian for responding, great idea! I see my dentist soon and they are very cool so I am more confident now (Thanks to everyones helpful input here) I can get to the heart of this matter, and if not involve Endo as you suggested. I was originally on Raloxifene and had to stop it due to side effects which heighten my fear factor on moving forward once again.

[Southerngirl2787]

Tymlos is the only one my dentist is okay with thus far. My neurosurgeon recommended it, I started it, and he says do not any of the other types of OP meds, they inhibit healing fractures and fusions. Both I have, 10+ fractures and 6 discs bone on bone. I had to stop taking a biologic for AS as it slowed healing as well, did great to control joint pain and bowel issues, but I had a cut on my toe that would not heal. Went off Rinvoq, and it healed up in 10 days. Neurosurgeon says to not take any biologic before surgery, and in post op either. We have no idea how long healing fractures takes, for me, I'm slow, testing showed edema for months afterwards.

[Clarrisa]

Thank you Southerngirl, This medicine puzzle is coming together with everyone’s help here. Your tip is excellent. My friend had one fracture and he was in such pain. I hope that you are far more comfortable than he was. I wish you good luck with your medical plans. My neuro problems (dyslexia & whatnot) were from birth so I haven’t experienced otherwise. To be sure it is harder to adapt to adult onset conditions when older. I especially appreciate your thoughtfulness, take care.

[uncountable3]

There is no issue with dental work while on anabolic as they actually enhance bone healing. Forteo has even been used off-label to coax difficult fractures to heal. The trouble is with anti-resorptive agents like bisphosphonates which slow bone healing.

[Clarrisa in reply to uncountable3]

I have read of two categories of dental work: One includes fillings and root canals and another is more major like tooth extractions. I am wondering if because of the lawsuit culture of the states some in our dental profession skirt the issue altogether by requesting drug holidays before they will work on you(?).

I meant to thank you for your input, Thanks! It is in agreement with my doctors. I just need to get my dental team onboard!

[Di04]

I think you can wait for extraction. I had one extraction after my second Prolia shot. It went fine, in spite of my concerns. Now I need another extraction because of a cracked tooth. They tell me it will likely become infected at some point. I have been on Prolia 3 years now. Oral Surgeon acknowledges risk but believes it is low. I am between a rock and a hard place so I am going for the extraction, but I am not happy. I suggest you do as much dental work as recommended before starting the drugs.

[Clarrisa]

Thank you DiO4 for your firsthand experience, very appreciated. Good to hear it sounds like the Prolia has been going along acceptably for you. It does feel that way, being between a rock and a hard place. I wish you success with your second extraction.