Whenever a patient, especially a patient in the Department of Rheumatology and Immunology, consults a doctor: “Doctor, I am taking alendronate, can I have my teeth extracted?” The doctor will tell the patient “no” very solemnly. Drugs such as bisphosphonates are commonly used in the treatment of osteoporosis. But why do doctors not allow patients to extract teeth after taking medicine for osteoporosis? Today, let’s talk about the key points of this.
The rare side effect of this drug can cause osteonecrosis of the jaw
Speaking of osteoporosis, I believe everyone is familiar with it, and when it comes to the drug treatment of osteoporosis, bisphosphonates It is a commonly used drug for the treatment of osteoporosis. Currently, the commonly used drugs in clinical practice include alendronate sodium and zoledronate sodium.
Why can’t teeth be extracted while taking bisphosphonates? Tooth extraction increases the risk of osteonecrosis of the jaw in bisphosphonate users. Osteonecrosis of the jaw, avascular necrosis of the jaw, often with pain, swelling, exposed bone, local infection, and pathological fracture of the jaw, is a rare complication of bisphosphonate therapy. When this complication occurs in patients with osteoporosis treated with bisphosphonates, treatment should be discontinued immediately.
The specific mechanism of bisphosphonate-induced osteonecrosis of the jaw is still controversial, and the possible mechanisms mainly include osteoclast dysfunction, local bacterial colonization and inflammation.
Osteoclast dysfunction Under normal circumstances, under the combined action of osteoblasts and osteoclasts, bone tissue is constantly renewed, and sequestrum can be absorbed and regenerated. Bisphosphonates can inhibit osteoclast activity, induce osteoclast apoptosis, and lead to osteoclast energy metabolism disorders. At the same time, bisphosphonates accumulate on the bone surface and inhibit the bone resorption of osteoclasts, leading to a decrease in bone remodeling ability and causing osteonecrosis of the jaw.
Local bacterial colonization and inflammation Bacterial lipopolysaccharides from some oral colonizing bacteria (G-bacteria) can promote local inflammatory response, accelerate bone resorption, increase local oral acidity, inhibit wound healing, and lead to bone necrosis.
In addition, bisphosphonates generate reactive oxygen species during metabolism, leading to local soft tissue destruction.
What does bisphosphonates “do something” about tooth extraction?
Why does tooth extraction increase the risk of osteonecrosis of the jaw in bisphosphonates? Tooth extraction is a invasive procedure and is an aggravating risk factor for osteonecrosis of the jaw. On the one hand, bisphosphonates tend to accumulate in areas with active bone turnover; on the other hand, periodontal disease causes local microvascular damage, bacteria constitute local microenvironmental inflammation, and the wound surface of tooth extraction will affect the process of bone reconstruction.
In addition, diabetes, periodontal disease, use of glucocorticoids, immunodeficiency, and smoking are all high-risk factors for osteonecrosis of the jaw.
Because of this, many patients with rheumatic immune diseases, who need to use glucocorticoids, immunosuppressants or biological agents, belong to high-risk groups.
Patients with rheumatic immune diseases who use bisphosphonates are especially reminded to pay attention to whether they have symptoms such as gum pain, swelling, bone exposure, and local infection during the medication, and they need to go to the stomatology department if necessary. If a tooth is extracted during the medication period, it is necessary to maintain good oral hygiene and pay attention to oral cleaning, which can prevent mandibular osteonecrosis caused by bisphosphonates to a certain extent. If you have symptoms, see a dentist in time.
Reduce the risk of necrosis and look at the people taking the drug.
If you want to prevent and reduce the risk of osteonecrosis of the jaw in people who take bisphosphonates, the following aspects should be paid attention to.
1. Complete necessary oral surgery before anti-osteoporosis treatment, properly use antibiotics after oral surgery, use mouthwash, properly close wounds after tooth extraction, and maintain good oral hygiene.
2. For high-risk patients with osteonecrosis of the jaw, when complex invasive oral surgery (including tooth extraction) is performed, it is recommended to suspend bisphosphonate therapy for 3 to 6 months before implementing oral therapy. After surgery, bisphosphonates can be resumed 3 months after the operation if there is no special oral condition.
3. Keep your mouth clean and pay attention to oral hygiene.
Written by Wei Hui (Peking University Third Hospital)