In life, unexpected dental surgeries such as implants or oral diseases can occur. This may raise questions about age, medication, dietary restrictions, etc. However, addressing all of these concerns in the clinic has its limitations. Therefore, every other Tuesday, Health-K will feature a new column titled 'Dr. Kim Kanghyuk's Dental Health Talk.' Dr. Kim Kanghyuk, who specializes in oral and maxillofacial surgery at Seoul St. Mary's Hospital, Catholic University of Korea, currently serves as the Chief Director of The Prime Dental Clinic. With extensive clinical experience in specialized dental surgeries, including implants, osteoporosis, and cancer treatment, he will provide useful information, from dental surgery insights to oral care tips. We sincerely ask for your continued support and interest in this column. - Editor
Osteoporosis is when bone mass decreases, and strength weakens, leading to a higher risk of fractures. According to the National Health Insurance Service, osteoporosis patients increased annually from 910,000 in 2017 to 1.18 million in 2022, showing an average annual growth rate of 4.8%. It has become a common disease in the aging society. In particular, osteoporosis can result in fractures in various parts of the body, such as the spine and hip joints, significantly reducing the quality of life. Once a fracture occurs, the risk of recurrence is very high, highlighting the importance of consistent drug therapy.
However, osteoporosis patients often feel uneasy when they need dental treatment because it has been noted that caution should be exercised during dental procedures for those who are taking medication for osteoporosis. Many patients wonder whether they can undergo relatively invasive dental surgeries such as tooth extraction or implantation while taking osteoporosis medication, whether they need to stop taking the medication before undergoing treatment, and if so, for how long.
The problematic medications among osteoporosis drugs are those directly related to bone metabolism, such as bisphosphonates or denosumab (RANKL inhibitors). Therefore, if patients are undergoing treatment with these medications, the decision to proceed with dental surgery should consider the type and duration of use. Other medications, such as calcium supplements, vitamin D, estrogen supplements, and selective estrogen receptor modulators (SERMs), have less association with osteonecrosis and thus do not pose a concern for dental surgery.
Bisphosphonates and denosumab act on osteoclasts to inhibit bone resorption, which is beneficial for bone loss and osteoporosis. However, this pharmacological action can interfere with the normal remodeling and healing of the jawbone during dental surgery involving gum incisions, leading to osteonecrosis of the jaw. Therefore, if the medication name ends with '—dronate or—umab', it should be confirmed whether it is a bisphosphonate or denosumab preparation.
If you are taking bisphosphonates, it is essential to determine which type of bisphosphonate you are taking. Injectable forms such as pamidronate and zoledronate have 5-10 times higher potency than oral forms like alendronate, risedronate, and ibandronate. Consequently, the risk of jaw osteonecrosis is significantly higher when administered intravenously than orally.
Denosumab, like the injectable zoledronic acid, indicates a similar risk of osteonecrosis of the jaw. Injectable agents with higher potency are primarily used to treat bone metastasis from cancer and multiple myeloma, conditions unrelated to osteoporosis. Therefore, if denosumab is administered for such malignant tumors, the risk of osteonecrosis of the jaw is even higher.
Next, it's essential to ensure the duration of medication. Typically, if the duration of intake is less than three years, the risk doesn't significantly increase. However, if taken for more than three years, the risk of jaw osteonecrosis escalates rapidly.
Lastly, the risk can vary depending on the surgical site and its severity. Osteonecrosis associated with medication is closely linked to wound inflammation, infection, and vascular formation, so the risk is twice as high in the denser bone of the mandible compared to the maxilla, where blood supply is more abundant. Additionally, procedures with more extensive surgical intervention, such as extraction or implant placement, pose a greater risk than minor procedures with minimal trauma.
Thus, the risk of osteonecrosis varies depending on the type of medication, administration duration, and surgery extent. However, the actual incidence rate is not very high. In 2022, the American Association of Oral and Maxillofacial Surgeons cautioned against overestimating the risk and recommended against discontinuing essential medications. According to various studies, reported rates of osteonecrosis risk range from 0.05% for oral bisphosphonates to 0.02-18% for injectable formulations.
In 2007, it was recommended to discontinue medication for three months before and after dental treatment. By 2014, for those who had been on medication for more than four years, the recommendation shifted to discontinuing medication two months before treatment and three months after. However, in the 2022 update, no specific recommendation for discontinuing medication for a set period exists. Instead, it is suggested to proceed with most dental treatments while coordinating with the dentist to adjust medication dosages and consider switching to different types of medication if necessary. The Korean Association of Oral and Maxillofacial Surgeons and the Korean Society for Bone and Mineral Research recommend discontinuing medication two months before treatment and until wound healing.
In conclusion, while discontinuing medication as needed to mitigate the risk of osteonecrosis of the jaw (ONJ) is recommended, it is not advisable to overly delay necessary dental treatments due to an exaggerated perception of risk. However, if ONJ does occur, it may necessitate prolonged antibiotic therapy and surgical removal of necrotic bone, potentially leading to a lengthy and painful process. Therefore, after dental surgery, it is crucial to pay extra attention to oral hygiene to ensure proper surgical site healing.
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