Some disturbing news has been emerging in the dental world.
It is being reported that there are cases of necrosis (death) of the jaw bones which are unresponsive to treatment.
The common denominator in all these cases is that the patients have been taking bisphosphonate drugs. These are the drugs used to treat osteoporosis, osteopenia, and bone cancer. The brand names of these drugs are Didronel, Aredia, Actonel, Zometa, Boniva and Fosamax.
Originally the earliest cases of dental necrosis reported were only in those who had taken these drugs intravenously for cancer. Now there are cases being reported in people currently taking or who have taken these drugs orally for osteopenia or osteoporosis.
This is a real problem.
The patients are in pain and they have open wounds in their mouths that will not heal, and no traditional means of treatment has successfully worked.
Treatment can help the pain, but not the healing.
The problem will usually manifest after gum surgery, extraction of a tooth, or placement of an implant. Some dentists are refusing to perform these procedures on patients who are on, or have been on these drugs.
More and more patients, especially women, are on these drugs. I decided to look into why so many people are taking these drugs, how that came to be, and whether or not it is a good idea to take them. Essentially, “What’s the story?”
I find many of my female patients telling me they have had bone density testing, and they were told that they have osteopenia. They are worried that it will progress to osteoporosis, and that they will inevitably fracture a hip.
Advertisements on television, and in print, inform women of this potential problem, and assure them that there is a solution. The presumption is that all women entering menopause are in danger and had better have their bone density checked.
When did this epidemic start? I don’t remember this being such a huge problem twenty years ago.
This is what I found.
The disease of osteoporosis has always been around – however it is uncommon, and, under the age of 80, it is pretty rare.
However, in 1982 drug companies started promoting hormone replacement therapy (HRT) as a way to prevent osteoporosis. Through a massive advertising and promotional campaign a fear of this seemingly new disease and hip fracture was created.
In 1988 dual-energy X-ray absorptiometry (DXA) instruments were developed. These machines measured bone mineral density (BMD).
In 1994, the World Health Organization (WHO) sponsored an osteoporosis conference in conjunction with the International Osteoporosis Foundation. The foundation was comprised of representatives of both drug and medical instrument companies.
From this conference came a new WHO definition of osteoporosis. Osteoporosis had always been diagnosed and defined by breakage of bones from low impact, in other words from an injury where one would not expect a fracture.
In 1994 the definition of osteoporosis became defined by bone mineral density (BMD). With “normal” bone density, osteoporosis is not present.
A new disease was created, osteopenia, which is a bone density between normal and osteoporosis
Osteoporosis is a value for BMD 2.5 standard deviations (SD) below the young adult mean. The young adult mean is based on peak bone mass of an approximately thirty-year-old Caucasian woman.
Osteopenia is a value for BMD more than 1 SD below the young adult mean but less than 2.5 SD (which indicates osteoporosis).
Now with the new definition, about half of all women over 50 fall into the osteopenia or osteoporosis category. Because of the fear created, HRT (hormone replacement therapy) drugs were the number one prescription drug in the world in 2000.
In 2002, The Women’s Health Initiative Study found HRT increased the risk of serious disease, like breast and ovarian cancer, heart disease, etc. This opened the door for other drugs to address the “epidemic” of osteopenia and osteoporosis.
The WHO definitions have become the standard even though many independent review groups criticize such a definition.
Four critical questions which must be raised are:
(1) Does low BMD predict future fractures?
(2) Is the normal value of bone density, which is based on an approximately thirty-year-old Caucasian woman, valid for different races and ethnicity groups?
(3) Are the machines being used for BMD standardized? And what are they telling us?
(4) At what point are drugs, with all their potential known and unknown side effects, warranted.
Next month we will look at these questions one by one.
© 2006, Mark A. Breiner, DDS
The information presented is for educational purposes only. You should consult a qualified dentist or health practitioner for diagnosis and treatment.