Dr. Tom Viola does an excellent job of explaining osteoporosis and osteonecrosis. We have so many patients, friends, family members, and maybe even one of us that will have issues with bone density and the medications we need. Tom breaks down some concerns with medications and what to look for with certain meds.
With over 30 years’ experience as a pharmacist, educator, speaker and author, Tom Viola, R.Ph., C.C.P. has earned his reputation as the go-to specialist for delivering quality continuing education content through his informative engaging presentations. Tom’s sellout programs provide an overview of the most prevalent oral and systemic diseases and the most frequently prescribed drugs used in their treatment. Special emphasis is given to dental considerations and strategies for effective patient care planning.
Tom’s homepage – http://www.tomviola.com/
Pharmacology Declassified – http://www.tomviola.com/welcome-to-the-pharmacology-declassified-blog/
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This TIPisode has been transcribed for your viewing pleasure:
Tom Viola: Hello, everyone. This is Tom Viola with Pharmacology Declassified and tomviola.com. Today, our TIPisode involves osteoporosis and osteonecrosis of the jaw.
Well, estrogen as a hormone may just be one of the most important hormones we have. The best thing about estrogen, in my opinion, is its ability to build bone density in women to an extent that men may not be able to achieve. Men get greater bone density by getting larger muscles. The larger the muscle, the stronger the muscle, the stronger the attachment point for that muscle needs to be, and therefore those bones need to be denser.
But women can accomplish that same bone density with smaller muscles. This might give them the competitive advantage if they’re competing against men in certain sports because they get greater bone density without all that bulky muscle and therefore weigh less and potentially are more fleet-footed or are more likely to be more speedy than men. So, in that respect, estrogen does great wonders for women, provided you have estrogen. A downside of estrogen is that when it weans later in life towards menopause, well, now the estrogen’s not there to develop that great bone density, and bone density suffers as a result.
Of course, if I stopped there, you’d get the idea pretty quickly that, well, the best way to stave off osteoporosis, or thin bones, is to simply do weight-bearing exercises and get those muscles nice and large to, again, form stronger attachment points. True. But large bulky muscles aren’t necessarily every woman’s cup of tea. We of course rely on things like calcium and vitamin D to help build bone density. Some of the recommendations for calcium I’ve seen go as high as 1500 milligrams per day, and vitamin D up to 800 international units a day. But there’s really no guarantee that any of that works.
Weight-bearing exercises we have evidence for, and calcium. But vitamin D has gone back and forth lately because no one really seems to know, again, if it works or how much is the right amount. And it may very well vary from woman to woman. Well, you say, “Okay, Viola. You’re the drug expert here. Tell us about medications that are used to treatment osteoporosis.”
Well, we got quite a few. But the problem, I think, is every one of the medications we have to treatment osteoporosis causes some nasty side effects. Take, for example, the most obvious one: estrogen. Okay. You’re going through menopause, and therefore your estrogen is weaning, and therefore your bone density is declining. Makes sense, then, that if you want to build that bone density back up, give that woman estrogen. That makes sense except using estrogen long-term increases a woman’s risk of cancers, uterine cancer, breast cancer. So, as a result, estrogen may not be the way to go, not long-term anyway.
Okay. Well, what about some other drugs out there? What about the drug Miacalcin? Well, Miacalcin was a drug that involved the hormone calcitonin. “Oh, I’ve heard of that,” you say. “Calcitonin would be great for building bone density.” Yeah. Problem is that the FDA says that it doesn’t work. And, for the most part, calcitonin is gone as a drug now.
Well, what about a drug that works like estrogen but really isn’t estrogen and therefore may not cause cancer? Well, then you’d be talking about the drug Evista. And does Evista live up to its promise? Well, it does build bone density, and cancers, while they happen, are pretty rare, but Evista may cause patients to be more likely to develop blood clots. And especially since we’re talking about women in advanced years, blood clots may already be a problem for them.
Well, maybe we got to step back here and take a look at some other hormones we can use. How about parathyroid hormone? Well, parathyroid hormone would be a great candidate considering that it would help build bone density from a different perspective. Does it work? Well, we did come up with a drug. Its name is Forteo. Forteo. Wow. That sounds like a great drug. And? Well, the problem is it may work too well and actually end up causing bone cancer.
Okay. We need to start over again. How does this bone density thing work? Osteoclasts and osteoblasts? Well, that makes it easy. We’ll just come up with a drug that suppresses osteoclastic function. If the osteoclasts can’t break down the bone, then the osteoblasts can’t put back thinner and thinner bone, which is what we believe is the cause of osteoporosis long-term. So just shut off the osteoclasts, and we’ll be fine. And so the drug’s name is Prolia. Does it work? Yeah. A lot of people have great success with Prolia. “Well, we found it, Viola. What’s the problem?” Prolia causes osteonecrosis of the jawbones and atypical femur fractures.
Well, you nice folks right now are listening to this and saying, “Um, didn’t you miss a whole class of drugs called a bisphosphonates?” Yes. What about the bisphosphonates like Fosamax and Actonel and Boniva? Well, I kind of put them together in the same class, if you will, of Prolia based on their adverse effects. Again, we’re talking about what? Osteonecrosis of the jawbones and atypical femur fractures.
Now, you might be saying, “What the heck does my femur have to do with this?” Well, let’s go back and talk about bone physiology just a little bit. What do those three bones have in common? The maxilla, the mandible, and your femurs? Well, they get the most abuse day to day, don’t they? I mean, if you’re walking, running, you’re putting some pressure and some force on your femurs, and you’re chewing, and you’re chewing, and you’re putting force on your mandible and your maxilla, right?
Well, then, since they get the most abuse every day, they are sort of preprogrammed to get the most turnover, meaning the most osteoclastic and the most osteoblastic activity to repair them, right? Because otherwise that bone will get just more and more microfractured and more and more damaged. And so they’re in need of greater repair. And they do get greater repair than other bones. They also interestingly have more blood flow than other bones. Well, that’s due to capillaries that are in — as part of the bone structure.
“Sounds good to me. What’s the problem? As long as my body’s turning over that bone on a regular basis and removing those microfractures, the bone should be healthy.” Correct. But the problem is, of course, that when you take a drug like Prolia or the bisphosphonates, you are shutting off that osteoclastic function. And, as a result, those bones that require it the most — mandible, maxilla, and femurs — don’t get it.
Well, what does that mean? Well, those bone suffer more and more damage and more and more microfracture, which are not repaired, and as that happens, those bones start to compress. And eventually they compress so much that the bone literally collapses in upon itself, the structural architecture is compromised, and the blood vessels running through those bones become so compressed, blood stops flowing, and the bone itself dies. Osteonecrosis.
“Well, I get that with the jawbones. But femurs? That’s a bit of a stretch, Viola.” Nope. Happens with them too. And the problem is we call these “atypical femur fractures” in that they don’t happen midshaft like many femur fractures do but more towards the top by the hip, and they’re harder to repair. Bit of irony, if you will, because we tell women to take these medications so they don’t get hip fractures because we can have a lot of evidence that suggests that hip fractures can be deadly long-term for women based on the rehabilitation and what happens during that rehabilitation. And, yet, we’re giving them a drug that doesn’t cause — that prevents hip fractures but ends up causing a femur fracture a few inches away.
So, my friends, this is the conundrum we’re in when it comes to treating osteoporosis. Again, I don’t think any one drug is necessarily bad or good. I think as long as they’re FDA approved, we have a chance to come up with a good regimen for women to treat osteoporosis. But let’s not forget the opportunity here for us. If anyone’s going to be the first to identify a potential patient who has osteonecrosis, it would be you. If your patient has osteonecrosis, they’re going to make you aware of it. Sort of like “Hey, I’ve got this thing here. I feel like a new tooth is coming in.” “Nope. That’s probably exposed alveolar bone,” you say, “because as the bone dies, the tissue above it recedes, and the jawbone becomes visible.”
Well, osteonecrosis can go from stage I, which is basically asymptomatic, all the way to stage III, which involves pain and infection and some nasty things like fistulas. So — and it’s important for us to be able to recognize that patients on these medications — Prolia and the bisphosphonates — may develop ONJ, and that you, of course, are the person most likely to be able to see those effects. And remember that these folks rely on you for treatment planning.
It’s important for us to follow the FDA guidelines when it comes to these medications, especially since the FDA says if you’re on a bisphosphonate, you should stop the bisphosphonate 90 days prior to any dental procedure that might involve traumatizing the bone. And that, in a way, is what the FDA’s best advice can be.
But remember the problem is that bisphosphonates are retained in the bone for years. Some estimates say as long as 10 to 15 years. So does stopping the bisphosphonate 90 days prior to the procedure really reduce that patient’s risk? Hard to say. The good news is that osteonecrosis of the jaw is still exceedingly rare. Based on the number of women who take bisphosphonates — and men who take bisphosphonates — the statistical incidence of ONJ in patients taking these medications: pretty small.
But, again, this is just one more instance of where the dental hygienist can take the lead role in protecting patients from adverse effects of medications and also taking steps to make sure that these patients have the best life they can.
Well, I want to thank you, my friends, for listening to me one more time on these TIPisodes. Again, thanks, thanks, thanks to Michelle and Andrew for allowing me the opportunity. I look forward to speaking to you again on a future TIPisode. I look forward to seeing you again at one of my live lectures or online during one of my live webinars.
Again, this is Tom Viola from Pharmacology Declassified and tomviola.com. Thanks so much.
Michelle Strange: We hope you enjoyed this week’s TIPisode. Be sure to reach out to our guest experts and let them know how helpful their tips were. Follow A Tale of Two Hygienists on Facebook, Instagram, and head over to ataleoftwohygienists.com and subscribe to our newsletter. You can also email us at ataleoftwohygienists@gmail.com, and keep listening for more awesome content from your unofficial dental hygiene podcast.
