Dental work and alendronate

[Pawscat11]

I need a tooth extraction after a tooth has completely collapsed and became infected. The dentist has tried root canal treatment with the hope of adding a crown but it is still infected in the gum and he says it must come out due to a sepsis risk. He sent me to my consultant for permission as I have been taking alendronate every week for 2 years. The rheumatologist doesn't really see a problem and says dentists panic. She told me to stop the alendronate for 4 weeks which I have done but also said it stays in the body for years so it wont make much difference. I am now booked in for next week for the extraction. Has anyone else had any experience with this at all as I am very apprehensive to say the least.

[DorsetLady PMRGCAuk volunteer]

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[PMRpro Ambassador]

I think the consultant is probably correct - they certainly are extremely risk-averse in the UK and rather less apprehensive here in northern Italy! However - it IS a risk factor and shouldn't be totally disregarded. It is most significant in the case of cancer patients where i.v. high doses are used. Oral doses in rheumatology are associated with far less risk.

I know I saw an article recently that outlined best practice for a patient who cannot avoid an extraction after bisphosphonate treatment but if course I can't find it!

This is the NHS guidance

england.nhs.uk/mids-east/wp...

So things you can influence include stopping smoking and improving oral hygiene prior to the extraction. The dentist should use an atraumatic extraction technique and monitor closely after the procedure. If healing isn't occurring in 4 to 6 weeks the max-fax specialists in the hospital should be consulted.

and this

onlinelibrary.wiley.com/doi...

is a detailed protocol which says

Routine treatment of patients receiving bisphosphonates

The following are recommended in the routine dental management of patients

receiving bisphosphonates:

Maintenance of oral hygiene.

Routine restorative dentistry should avoid soft tissue injury.

Perform routine scalings but avoid soft tissue injury.

Inspect and adjust removable prostheses for potential soft tissue injury.

Treat dental infections aggressively but avoid surgery, if possible.

Endodontics is preferable to extraction. Coronectomy with root canal therapy may be an option.

Only grossly mobile teeth should be considered for extraction. An atraumatic technique is essential. Primary closure of wounds may be helpful. The use of prophylactic and post-operative antibiotics (preferably amoxicillin or clindamycin) should be used. Patients should be followed-up till healing is complete.

One suggestion is that local anaesthetic without vasoconstrictors (adrenaline) should be used. LA with adrenaline is used to reduce bleeding after the extraction and that seems to have a negative effect on the blood flow to the socket.

[Pawscat11 in reply to PMRpro]

Thank you. I am in Spain so with consultant say so he is happy to do the extraction. I have already had 2 weeks of amoxicillin and antibiotics into the root.

[PMRpro Ambassador in reply to Pawscat11]

Good luck.

[Gimme]

I had a tooth extraction last week. When I commented to the dentist that I was glad that I hadn't started on the alendronic acid with all the remedial work that I need doing, he seemed very relaxed about it. He is also the guy who did all my implants, so he is doing that kind of work all the time. He said that he would be a lot more cautious if the patient is having the infusions, but if you are taking the tablets, it is much less of a risk.

[PMRpro Ambassador in reply to Gimme]

If you had been put on AA they should have told you to get checks first in case remedial work would be likely to be required in the future AND have any work completed before starting the drug. I know from personal experience - it is hardly ever mentioned.

[Gimme in reply to PMRpro]

No, wasn't mentioned to me either. But I'm not sure that advice is helpful, in any case. Of course, any outstanding work could be fixed before you started AA, but you can't possibly foresee what dental work that you will need in the future and as we get older, the likelihood of dental emergencies is going to increase anyway. I am 11 months in on pred and a couple of months ago, my teeth started to fall apart, so now I need a lot of work. The only way sure way of knowing that you wouldn't need dental work is to have the lot pulled out before you start AA and have dentures, which would seems a little extreme.

For me, it is a bit academic, I only took the horrible stuff for 3 weeks, but I got fed up of spending one day a week sitting on the toilet . Ugh! No more! 🙄🤔

[PMRpro Ambassador in reply to Gimme]

No, exactly. And that was the thought I had as I wrote my reply in fact. Prof Mackie is very concerned about patients not wanting to take bisphosphonates and I have been discussing it with her recently. But I don't think they realise just how difficult it becomes to have dental treatment once you have started on AA. I wonder if they are still under the impression anyone over 60 has dentures? Come to that - I wonder how many of us are proud we still have our own teeth? I have had 2 out in the last few years - one was a broken root having bitten on a very hard seed, the other a wayward wisdom tooth! Not the end of the world either of them - they have actually allowed the orthodontic effect from 50 years ago to improve even further! My front teeth are straighter than they have ever been!

I took it for 4 weeks but never with a quiet conscience. By then I had done my homework and discussed it with a different GP who agreed with me about the information that was just emerging and that I could wait until I got my dexascan result. It was good enough for us to decide we'd delay my taking it - and I still haven't taken any more 14 years later.

[Gimme in reply to PMRpro]

Ha, yes! The Dexa scan! That's another thing. I haven't been able to have one of those. I consider it unethical to put people on AA without one. Not only do you not know if you need AA in the first place, but you then have no way of knowing if it is helping.

I wasn't keen on it in the first place, as I dimly remembered from my professional life that there were issues. I dumped it when the GI symptoms developed and then joined this group soon after and felt vindicated when I started reading the posts about it. I was relieved then that I hadn't continued.

[PMRpro Ambassador in reply to Gimme]

Prof Mackie is really concerned about patients not taking the stuff - but she is only seeing one side of it ...

And in the UK at present - you can't get a dexa, a dentist or anything else you might need in this situation as far as I can see!!!!!

[Gimme in reply to PMRpro]

Well, that just underlines my belief that when there is an issue with patient compliance, then it is usually because the healthcare professional is not listening to their patient.

All medication is a balance of risk versus benefit and that is precisely the reason years back for the regulatory initiative to makes sure that patients have information about their medicines and treatments offered and their health conditions. Some people are happy to do as their doctor says without question, but the only person who can truly decide whether the risk is worth taking is the patient themself. If there is concern that patients do not want to take AA, then the issue of both short and long term side effects needs to be addressed.

If AA were compulsory when taking pred, then I would forego the pred. AA made me feel a lot worse than the PMR did. I lost a day a week of my life for those 3 weeks. I was either in bed or in the bathroom all day and that is just not acceptable Plus, I am not prepared to risk my teeth and/or jaw and to deny people essential dental treatment when they are in pain, it is positively inhumane.

I'm waiting for a similar conversation when someone decides that I need statins. I've got quite sufficient in the way of aches and pains without adding to them. I bet doctors hate patients like me.

[PMRpro Ambassador in reply to Gimme]

Done the statins bit - refused for years until the Actemra sent it even higher but because I was "good" and had agreed to try again after the first statin made me ill and the rheumy saw the result of the second statin, I have had no more arguments and been given ezetimibe which is fine. I think the trouble is that the rheumies take the view mentioned above - because I don't think it IS as bad as dentists make out - they see no reason why you shouldn't take them. BUT aren't aware of the fight patients have later to get dental care when it is too late, you can't go back. Most of our problems actually arise because different groups of HCPs don't talk to each other. Then, when someone reports THEIR experience on the forums, other patients become more aware of the potential problems and ask more questions.

[Missus835 in reply to Gimme]

Pretty sure you're not alone. I couldn't take AA either due to stomach issues. Developed osteoporosis over the last year or so. Ended up getting a ZA infusion a couple of months ago with no education from my Rheumy about it. No dental checkup prior. I haven't taken my statins yet for the same reasoning as you. Will talk with my GP about it this week (I've not had a GP for two years). I had the infusion because my vertebrae are fracturing at will. Have 8 fractures last count.

My bite guard needs to be refitted so I will tell dentist I've had the infusion. Damned if you do and damned if you don't. All the best.

[Janstr]

I have been on alendondrate for several years, & when I needed to have an extraction was sent to specialist because of the alendondrate

[YogaJM]

I'm in the same position, and trying to decide how to manage my wisdom tooth extraction. I think i will stop the Risedronate for ? 6 weeks and get it done under antibiotic cover, with the chlorhexidine mouth wash. Best wishes!

[Pawscat11 in reply to YogaJM]

Thank you and to you too

[Miserypants]

I have to have a tooth out. Have yearly infusions. Dentist wouldn't do it so found an oral surgeon who said I needed to have it done in hospital. However he spoke to the hospital Consultant and he has permission to do it following the Max Fax Protocol. So antibiotics starting an hour before op and 5 days post op. Two follow up appts one a week later and then eight weeks.

[Pawscat11 in reply to Miserypants]

I have already had 2 weeks of antibiotics as I had an infection then the dentist tried root canal to then crown afterwards to avoid extraction. I have broken the tooth so much he had to say it needs to come out. The infection has moved out sideways sadly. I have a temp filling on top of the root canal antibiotic's jammed inside for a week and he will remove the tooth on Wednesday.

[Miserypants in reply to Pawscat11]

Good luck woth it all.

[Exflex]

I’ve mentioned my experience in response to an earlier, but similar post to this. I was on Risedronate for 3 years up until 12 months age when I stopped taking the drug. I’ve had recent root canal restoration by a dentist specialising in the procedure, but was informed implant would be out of the question if the current procedure fails. Apparently the effect of bisphosphonates stay in your bones for 10 years or more.

[ladygigger]

I was prescribed Alendronic acid when I first saw the rheumatologist, in January this year but was told not to start taking it until I'd seen a dentist. I hadn't been to a dentist since before covid so was doubtful that I'd be able to get an appointment and initially I was told no. I argued that I hadn't been in because they hadn't been able to fit me in for my last emergency appointment, just before covid.

Last week had (hopefully) my last extraction - 4 this year, and I now have a denture. I had a telephone appointment with the rheumy in October and he said that I should start taking it 3 months after the final extraction, providing the hole had healed. Going be previous extractions this year, it'll be at least 2 to 3 months before the hole has healed sufficiently!

[PMRpro Ambassador in reply to ladygigger]

And THAT is without having taken the AA!!!!!

[Alchemy8]

A close friend was on Zolendronic acid as part of her breast cancer ongoing treatment post recovery. She had an abscess but was not allowed to have it dealt with except by a dental surgeon. Of course on the NHS she had to wait months to the point she could hardly open her mouth. Luckily it was all sorted but not without a lot of discomfort.