Re: Bisphosphonates


Sue wrote:
The Webby wrote:
In article <1165942887.637400.202300@xxxxxxxxxxxxxxxxxxxxxxxxxxx>,
"Sue" <chrlie699@xxxxxxxxx> wrote:

The Webby wrote:
I brought the subject to smd on March 22, 2005. The thread is available
for review on Google groups for anyone interested. I am reposting my
old post.

From: The Webby - view profile
Date: Tues, Mar 22 2005 4:00 pm
Email: The Webby <nospamattmjiatroepidemicnos...@xxxxxxxxxx>
Groups: sci.med.dentistry, alt.support.jaw-disorders
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http://www.niams.nih.gov/hi/topics/avascular_necrosis/

In my case, it was (later) determined that I suffered bilateral
avascular necrosis of the temporomandibular joints as a result of
surgical complications from surgical error (orthognathic surgery). The
joints were destroyed and thus began the saga of my chronic and
permanent TMJ disability and disease.

If you search Google Groups for "osteonecrosis jaw" you'll discover
posts that you may not have paid attention to in the past -- or maybe it
was even *you* who put the posts up! Either way, it's an interesting
review.

The subjects of TMJ avascular necrosis and osteonecrosis of the
maxillofacial area (jaw/jawbone) are or should be matters of interest to
dental related newsgroups.

II'm just tossing these topics out to see if there's any interest in
getting a discussion going. Turn on your television and count how many
times you see an advertisement for Fosamax (alendronate) in one evening.
I watch relatively little television but I sure see a lot of Fosamax
pushing.

Webby
_______________

In article <1165915286.868384.48860@xxxxxxxxxxxxxxxxxxxxxxxxxxxx>,
"Alexander Vasserman DDS" <purple543210@xxxxxxxx> wrote:

Another problem is there are still many dentists and md's in practice
who are not even aware of the risks of doing surgical procedures on
patients who are taking bisphosphonates.
The FDA or state boards have not even made an effort to contact health
care professionals.
I found out about this problem through word of mouth then had to do my
own research.
Later we saw articles on this from the dental associations however
solutions as to how to proceed weren't clear until very recently.


us wrote:
In article <OIWdnZt9Y5DdN_XYnZ2dnUVZ_vKdnZ2d@xxxxxxxxxxx>,
fritzfield@xxxxxxxxxxx says...
Anyone have any horror stories about the ubiquitous oral
bisphosphonates
(Boniva, Fosamax)causing osteonecrosis of the jaw as a result of
perio
surg, implants, or extraction?


I have been researching this on the web and have found plenty of
reassuring statistics such as "Less than 1 chance in 100000", etc.

However, that does not seem to be the correct question and answer.

What I think needs to be identified is, for a given population of
Fosamax users who have tooth extractions, implants, or other invasive
dental procedures, what percentage experiences ONJ?

So:

1. Among those of you who are on therapy now, who among you have had
extractions, implants, etc?

2. For those of you are dentists and oral health professionals, have
you
performedthese operations on patients who are on oral fosamax therapy,
and what sorts of results have you seen?

Thanks for any replies.

Just me

I think the risks should be clearly stated on the prescription and
warnings should be made clear to the patient by the physicians that
prescribe Fosamax (or other biphosphonates) and by the pharmacists that
dispense these.

However even young patients (under age 60) can be confined to
wheelchair because their spines have literally collapsed due to
osteoporosis! So as always, one must weigh the risk versus benefit.

There is rarely if ever any perfect medication or medical procedure
that comes entirely without risk. Medicine is not a perfect science,
by any means.

jmho
-Sue

An elderly relative of mine was put on Fosamax in early 2005. She has
had ongoing dental issues for years; she's one of those people who just
wants to hold onto every tooth she can (for life) no matter how much
dentistry is involved and no matter how much trouble the dentistry
causes her. But at 90 years of age, it seems that putting such a person
on Fosamax, given what is and isn't known about potential complications
related to ONJ, is tipping the scale a bit. After some family
discussions, she told her doctor she didn't want to take "the bone
medicine". She didn't really know why but she deferred to family advice.

Some might say that she should have taken her doctor's advice over that
of the family. For all the dentistry she has had done since then, we
sleep better knowing that the Fosamax isn't going to add misery to
misery.

Webby

From what I understand, the majority of ONJ cases (with biphosphonates)
occur in cancer patients that are receiving large doses IV. The risk
for those taking oral Fosamax is considered low, but is admittedly
UNKNOWN. Another risk factor for ONJ is tooth extraction. If patients
are on biphosphonates for any reason, they should avoid tooth
extraction and should receive RCT instead (according to what I have
read).

I have read summaries of the large clinical study that led to its
approval (Fosamax) and the larger trial did not include anyone over 79.
In addition I think I read elsewhere (re: a separate study) that there
was no benefit found in the very elderly as far as hip fracture
goes.... so in the case of your relative you may have gave her some
very good advice (imho).

IMPORTANT DISCLAIMER: Do not quote me on this information. I read this
a long time ago and am going on memory which is often faulty. I will
look for the references and post them for others to view and interpret.
Also I apologize if I am repeating anything that has already been said
on this thread, I have not read the entire thread.


*Corrections: I went back and checked the clinical trial references.

I wrote:

"I have read summaries of the large clinical study that led to its
approval (Fosamax) and the larger trial did not include anyone over 79.
"


Correction: The safety and efficacy trials for Fosamax (Alendronate)
were called FIT (Fracture Intervention Trial) and FOSIT (Fosamax
International Trial). FIT included 6459 postmenopausal women age
55-81, with prior vertebral fracture and reduced femural neck bone
density score (<2.0). FOSIT included 1908 women (from 34 different
countries), mean age 63 years.

I wrote:

"In addition I think I read elsewhere (re: a separate study) that there

was no benefit found in the very elderly as far as hip fracture
goes...."

Correction: I was mistakenly thinking about Risedronate (a different
biphosphonate sold as Actonel), not Alendronate (which is Fosamax).

The safety and efficacy trials for Actonel included: VERT-MN (vertebral
efficacy with risedronate therapy, Multi-National) and VERT-US
(vertebral efficacy with risedronate therapy, United States). Unlike
the Fosamax trials, these trials inlcuded postmenopausal women with OR
without signs or symptoms of osteoporasis.

**These were then followed up by an additional trial called HIP, the
study that I was thinking about. The HIP trial studied Risedronate and
its effect on hip fracture, and compared women ages(>70-79 yrs) versus
women (>=80 yrs). I must clarify the results. The results showed a
decrease in hip fracture for both groups on Risedronate but in the
women over 80 yrs, only women that had osteoporosis showed a reduction
in hip fractures.

Bottomline:There are few data on osteoporosis treatment in women older
than 85.

I hope this makes sense.

-Sue
Here are some references for anyone intersested They are all mixed up.
I did not have time to put these all together in order):

http://content.nejm.org/cgi/content/abstract/344/5/333

http://content.nejm.org/cgi/content/abstract/344/5/333

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?

cmd=retrieve&db=pubmed&list_uids=8950879&dopt=medline

http://www.medscape.com/viewarticle/410801_2

http://www.ahrq.gov/clinic/3rduspstf/osteoporosis/osteorr.htm

http://www.medscape.com/viewarticle/410801_2

http://www.medscape.com/viewarticle/522830_44

http://japan.medscape.com/viewarticle/547486_1

.

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    (sci.med.dentistry)
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