Question:

I submitted a question about my mother’s Fosamax use and tooth extraction in an un-edited form at 10:59 A.M. today to get it in before the 1 hour deadline imposed by the WCPN Sound of Ideas radio show but it needed a lot of editing and a little data from mother’s recent physical exam to make it complete.

Hope you can still take, at this point, the edited question: my mother is 89 years old. She has taken Fosamax as an osteoporosis preventive for well over 10, maybe close to 20 years. We stopped her use in January/February of this year as part of a process where we discontinued one medication at a time to see why she was regurgitating after every meal. This was along with a round of consults with a gastroenterologist. Upshot on the regurgitation seems to be a hiatal hernia that comes and goes. Best control of the regurgitation seems to be small, frequent meals spaced at least 2 hours apart and avoiding coffee and some other foods. This provides partial, but not complete control.

My mother has had a lifetime of dental woes. At this point she has 7 natural teeth left in the front arch of her lower jaw, a full upper denture and a partial lower one that has wings extending out from the 7 remaining natural front teeth. She had some gum pain last October and wasn’t wearing one of the dentures (I forget which one) and we took her to a dentist who removed some material from one of the dentures and made it comfortable for her again. He wanted to remake the dentures – estimate was close to $3500 – $4000 for both and had nothing else to say about her dental condition.

We started with a new dentist in February who says the dentures are still serviceable and that preservation of the 7 teeth and the nubs of 3 former teeth that have been left to help anchor/locate the dentures are of greater importance than new dentures. She (the new dentist) agrees that the regurgitation and possible acidic content of it may be contributing to the weakening of these remaining teeth.

She started on a program of prescription strength fluoride toothpaste, fluoride-based mouthwash, and cleaning and cavity repair of the 7 teeth. In the meantime, the top of tooth #23 broke off in two separate incidents between March and May 2010. The dentist said it was one of the weaker teeth she had observed. This dentist wants to pull what’s left of the tooth and replace it with a tooth added to the lower denture. She said a root canal and cap could be done – about $1800 to $2000 but it wouldn’t last, as what is left of the tooth is fairly weak.

My sister-in-law said she has been told that people on Fosamax are at a great risk for jawbone necrosis (ONJ) when teeth are pulled. I checked the Internet and that seems to be the case, but most references are sources that are about 3, 4 or more years old. We have put off the tooth pulling 2 times to get this better researched – dentist has become a little put off and has referred my mother to a tooth extraction specialist and told us to get back to her once the extraction is done.

Questions: 1. What is the latest thinking on tooth extraction risk for a Fosamax patient? 2. One Internet resource I checked said a CTX test is important in determining a Fosamax patient’s risk for ONJ. I mentioned this to my mother’s internal medicine doctor at my mother’s July 2010 check up and the doctor had an NTX test done along with the normal blood work done a that check-up. This doctor said the NTX is the Cleveland Clinic equivalent of the CTX test. This is the result of that test: NTX, Serum 14.6 nM BCE. The normal range is supposedly 6.2 to 19.0 per the Cleveland Clinic MyChart.

Question: Can the tooth extraction dentist use this NTX result? 3. How risky is the tooth extraction for my mother? Are there any other alternatives? Does the dental implant alternative involve even more disturbance to the jawbone and would it be even more risky and even more expensive? How expensive is it?

Answer:

1. The risk for ONJ in patients taking oral bisphosphonates (like Fosamax) for osteoporosis has been estimated by several authors with significant variation from study to study. It is universally agreed that the risk is MUCH less than that in cancer patients who take intravenous forms of bisphosphonates to keep the cancer from spreading to their bones. But a precise estimate has been elusive, ranging from 1 in 10,000 patients to as high as 1 in 2,000 patients being treated for osteoporosis. It is also agreed that while ONJ can occur spontaneously, the risk increases following dental extractions, up to as high as 1 in approximately 300. This is still not a daunting number, but one to be aware of and one to balance against the risk of keeping a questionable tooth (with risk of jaw infection) in the mouth.

2. This topic is of intense interest to the millions of Americans who use oral bisphosphonate medications to control osteoporosis. Unfortunately, there is still no clear answer to the question: Can serum CTX levels be used to determine a patient’s risk for developing the complication of jaw osteonecrosis following tooth extraction? Studies and opinion for both sides of this issue have been published, but no consensus has been reached. The latest, published this month in the Journal of Oral and Maxillofacial Surgery, showed that patients using bisphosphonates (both intravenous forms for the control of bone cancer and oral forms for osteoporosis) with pre-surgical CTX levels less than 150 picogram/milliter of serum were statistically more likely to develop osteonecrosis of the jaw (ONJ) than patients with levels greater than 150 picogram/ml. Most patients who developed ONJ, however, were cancer patients, a result that confirms previous studies that have shown their risk for ONJ is much higher than for osteoporosis patients. The authors of this most recent study wisely stated, however, that CTX serum level is not (at least not yet) a definitive predictor for the development of ONJ.
NTX and CTX levels usually correlate quite well. Although the concept of predictive value for these markers of collagen turnover has not been rigorously proven, the NTX value for your mother would suggest that her bone turnover (and by extension, her ability to heal an extraction socket) should be reasonably close to normal. In my opinion, even in the absence of CTX/NTX information, extraction of the remnants of #23 would not be contraindicated in the setting you describe with your mother. The NTX number only reinforces that opinion of low risk for ONJ.

3. A worthwhile alternative to extraction is removal of all of the remaining crown portion (decoronation) with endodontic treatment to keep infection from passing through the root of the tooth into the bone. A cap is not absolutely necessary. Depending upon your mom’s esthetic concerns, a plastic denture-like device can be used to hold a tooth in this position or a bridging connector could be bonded into place between the two adjacent teeth. These choices, however, will be more expensive than tooth extraction alone. An implant is also not contraindicated, but would likely be the most expensive option.

There is much to think about and no simple answers.

Hope this helps.

For more information:

Go to the Dental and Oral Health Center health topic.