Dental work and AA

[LMali]

I am having a tooth implant done this week, on Wednesday. The surgeon knows I take Alendronic Acid and has advised to not take it on the morning of the procedure. He also said it was okay to take (should take?) a 3 month holiday from Alendronic Acid. Have you heard of that? The procedure involves drilling into the jaw bone and inserting a plug for the crown which will be done next February. It is just done with local anaesthetic and I am ok to drive afterwards. As I was when the offending tooth was extracted. I am okay on 5 mg pred at the moment. Would the sick day rules suggest that I should increase pred around this time? Even if the procedure goes smoothly?

[DorsetLady PMRGCAuk volunteer]

For completeness have copied my reply to question as in other thread..

As the AA is in your system, and most advice is that it stays there for some time, months if not years -don’t see the point in not taking it for one week -and having a rest may or may not make that much difference to healing which is what he’s probably thinking about.

Think you might need to do a bit more investigation on the subject.

I was on AA for 4 years, but never had any major dental work done. during that time -or since.

[Sillydogsmum]

I presume your surgeon knows you are steroids and has discussed any downside of the procedure?Call me chicken but out of an abundance of caution I'm not sure I would want to put a foreign body in my jaw with the risk of poor healing and infection due to immunosuppression. Its an issue I have been considering myself, madam gap tooth! Experience of others on this would be good to hear.

[LMali in reply to Sillydogsmum]

Yes, I am slightly trepidatious. However, the surgeon has inspired me with confidence! He understands that I have PMR, take steroids and AA. In fact, he explained what AA actually does (which I had never really understood before!). He described the procedure in great detail, pointing things out on my scan and X-ray on a screen on the wall. It is a hi-tech dental surgery! This detailed description included a description of things which could go wrong. He has prescribed a course of anti-biotics, starting the day before the procedure to deal with the risk of infection. He examined the gap and said that I had healed well from the tooth extraction, so that was good. The extraction had been done in two stages: mainly by an NHS dentist who took out most of the tooth, but because of AA did not want to wrestle with the bits of root. The roots were removed by a specialist in this surgeon's practice. I was so impressed by the whole practice that I decided I would go with them for the implant. I am sure I could manage without an implant, but it is a fairly large gap and there is a lonely little tooth on its own behind the gap. It is not supported by other teeth and if anything happens to that, I will have no bite.

[Sillydogsmum]

Take a look at the Royal College of Surgeons implant guidance 2019. Not exactly a ringing endorsement of implants in folks with immunodeficiency or on oral biphoshphonates.

[LMali in reply to Sillydogsmum]

I read that and now I am more trepidatious and concerned so I have emailed the surgeon and will hopefully speak to him tomorrow. From what I can understand, if I can take an AA holiday, it would be better to do that first and then have the implant. The thought of bone necrosis is horrible but the risk seems very low but I cannot quite work out how long. Those medical articles are quite hard to read for non-medics / statisticians! Thank you for the reference anyway, it will help me to make an informed decision!

[PMRpro Ambassador in reply to LMali]

I doubt it will make a difference - once the AA is in the bone, it doesn't go away.

[Sillydogsmum]

Not an easy decision for you at all. As far as I can detect both AA and steroids seem to have have a bone necrosis risk; but the jury is out whether a AA holiday reduces the risk as per DL remark above. I suppose it depends on what the dentist says is the risk of getting it , how keen you are to get your gap filled vs your attitude to risk in general. 🤞😟

[Bridge31]

I had no problems with my implant at all. I was on 5mg at the time and didn’t alter the dose. I don’t take AA though.

[symph]

I also had a dental implant 2 years ago, was on prednisolone 5mg. I also take AA. No problems at all, implant makes a big difference to smile and eating!

[Thelmarina]

My dentist showed me the risk of necrosis of the jaw in relation to an extraction, and I am having a root canal instead, with a much slighter risk. I would be very careful about an implant, especially as your dentist didn’t know that Alendronic acid stays within the system for years and three days non use is meaningless. I wish I could be more positive, this is not a barrel of laughs. However, proper information is vital before taking these decisions. Very best of luck ❤️

[WaltzG]

I have pending tooth extractions and dentist thinks actemra works much like AA in possibility of jaw necrosis. so i am very nervous indeed tho seems risk very low. I do sympathise with you .

[PMRpro Ambassador in reply to WaltzG]

There doesn't appear to be much evidence for that as yet according to this paper

ncbi.nlm.nih.gov/pmc/articl...

It can happen anyway, and patients are often on a range of medications so it is difficult to say what was the cause. They recommend closer monitoring of the patient.

Wouldn't it be nice if these things were simple and straightforward!

[Gimme]

When I asked my dentist about implants with AA, he said that he was not concerned about AA tablets, but he would be more concerned about surgical work if I were receiving the infusion. There was a lot going on at the time and I didn't think to ask what the difference was.

I need root canal work and he is keen to do it ASAP as he is concerned about me getting an abcess whilst being on the pred. They know that I am on pred and have been very keen to reduce any risks of infection in my mouth.

Actually, my teeth were the main reason that I didn't want to go on AA, as initially I thought that I would not be able to have any dental treatment and I considered it inhumane to be denied dental treatment.

[Luciejane]

Hi I'm in the exact same position as you. Had a tooth extracted 3 weeks ago and it seems to be healing well. Also on AA for the last year and taking 5.5 pred. My endocrinologist advised a 6 month holiday from AA but I know the jury is out on this advice. My dentist has advised for me to have a bridge instead of an implant which therefore means no risk of problems with the jaw bones. Maybe discuss this as an option. Good luck

[LMali in reply to Luciejane]

Trouble with a bridge is that you have to ruin the perfectly good teeth either side of the gap . . . I'm speaking to surgeon this morning hoping to be inspired with confidence!

[Luciejane in reply to LMali]

Yes that's correct. I have a crown one side and a filling in the other. It does mean crowning the tooth with the filling but my dentist still feels this is a safer option. Ideally I would prefer an implant too.

[Sillydogsmum]

Very good review article. American Assoc Oral and Maxilofacial Surgeons, Position Paper on medication related osteonecrosis of the jaw 2022. There are lots of interesting/relevant bits all through it. A bit of a turgid read but very balanced, thoughtful and addresses all issues raised above.

[LMali]

So I spoke to the surgeon as planned on Tuesday and decided to go ahead with the procedure yesterday. It was unpleasant (1 hour 20 mins in the chair) but it went well. I took a couple of paracetamol last night and this morning it is, surprisingly, pain free. Which I don't understand, because he was grinding around in there for ages, taking out the remnants of a root and putting the implant in. So far, so good . . .