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The Unintended Oral Benefits of Bisphosphonates in Relation to Osteoporosis.

CLINICAL QUESTION: Do postmenopausal women who have osteoporosis and are using bisphosphonates have less alveolar bone loss than postmenopausal women with osteoporosis not using bisphosphonates?

BACKGROUND

Osteoporosis is a condition in which individuals lose bone density and become more prone to fractures. It can occur due to aging, the body not producing enough bone, or the body reabsorbing too much existing bone. (1)

Multiple factors contribute to an individual's risk for developing osteoporosis. Individuals aged 60 and older are more likely to have osteoporosis than those younger than 60. Females are more prone to have osteoporosis than men are. The races most affected by osteoporosis are the Asian and Caucasian races. (2) Also, individuals with a sedentary lifestyle are more likely to develop this bone disease than those who participate in weight-bearing exercise on a regular basis. If an immediate relative of an individual has osteoporosis, that individual has an increased chance of having osteoporosis, meaning genetics also play a role as a risk factor for the disease. (3) Another main influence on the development of osteoporosis is having a low level of estrogen. (2) Postmenopausal women are commonly affected by osteoporosis due to low estrogen levels.

There is a strong correlation between the increased incidence of tooth loss in postmenopausal women who have low bone mineral densities. (4) Women with osteoporosis may have a higher chance of alveolar bone loss due to low bone mineral density, which could cause destruction to the periodontal tissues leading to the possibility of further bone loss. Bisphosphonate drugs are a common treatment used in individuals with osteoporosis. These drugs alter or inhibit the ability of osteoclasts to reabsorb, which suppress bone turnover by slowing down osteoclastic activity and allowing osteoblasts to produce more bone. (6)

A variety of studies indicate that osteoporosis can affect the periodontium. Research has shown that fibroblasts in the periodontium respond to estrogen levels in osteoblasts, and this affects the overall health of the periodontium.

A study conducted by Scardina and Messina noted a correlation between osteoporosis and alveolar bone loss. The study determined that a decrease in bone mineral density could lead to attachment loss, tooth loss and alveolar bone loss. (7)

A study by Kribbs found that women with advanced stage osteoporosis are three times more likely to experience tooth loss compared to women without osteoporosis. (7) Dodd and Rowe established that postmenopausal women with low bone mineral density had more alveolar bone loss and clinical attachment loss than the control group of women with normal bone density levels. (8) This study also stressed the need for communication between medical and dental professionals. (8) The researchers found that when dental providers communicate the oral findings related to osteoporosis to medical providers, there is a reduction in tooth loss and periodontal disease, and bone improvement occurs. (8)

EFFECTS OF BISPHOSPHONATES

Studies have found that bisphosphonate use benefits the periodontium in postmenopausal women with osteoporosis. One study showed that the mandible is more susceptible to alveolar bone loss and loss of periodontal attachment in postmenopausal osteoporotic women. It also showed that bisphosphonate treatment could have a positive impact on the periodontium. For example, those using bisphosphonates displayed lower probing depths and lesser clinical attachment loss compared with the control group (that did not receive bisphosphonate therapy). Bleeding upon probing was lower and bone height was higher in the bisphosphonate group as well. (9)

There is also evidence that bisphosphonate drugs benefit postmenopausal osteoporotic women who also have periodontal disease. In a study conducted by Bhavsar and Trividi, 22 osteopenic and osteoporotic postmenopausal women with moderate to severe chronic periodontitis were chosen to participate. (10) Probing depths, clinical attachment level, plaque index and gingival index were measured at the beginning of the study. (10) After these measurements were recorded, the patients were given a bisphosphonate prescription before receiving scaling and root planing. (10) The patients were recalled for follow-up at three, six and 12 months. (10) There was no progression in the disease, and it was determined that the use of bisphosphonate drugs in conjunction with scaling and root planing can improve the periodontium by decreasing bone and tooth loss, and increasing clinical attachment level. (10)

In another study conducted by Mostafa, Hamdy and Nasif, 40 postmenopausal, osteoporotic women with chronic periodontitis were divided into two groups. (11) The researchers recorded pocket depths, clinical attachment levels and radiographic bone levels at baseline. (11) Both groups received initial therapy including scaling and root planing, oral hygiene instruction followed by surgical periodontal therapy. (11) Group one received a bisphosphonate drug for six months, whereas group two received a bisphosphonate drug along with calcium and vitamin D supplements. (11) Results showed that both groups had significant gain in clinical attachment level and reduction of pocket depths with the presence of a significant improvement of all the radiographic measurements. (11) Even though both groups improved tremendously, the group taking bisphosphonates, calcium and vitamin D supplements showed a higher percentage of improvement compared to the group taking bisphosphonates alone. (11)

CONCLUSION

Research concludes that postmenopausal osteoporotic women taking bisphosphonate drugs exhibited better and increased bone health compared to those not taking bisphosphonates. Bisphosphonates have proven to benefit bone health in the oral cavity. The use of bisphosphonate drugs has also shown to decrease the amount of alveolar bone loss in women taking bisphosphonates versus women not taking bisphosphonates.

Bisphosphonates have proven beneficial to the oral cavity by stopping the progression of periodontal disease. The combined use of bisphosphonates, calcium and vitamin D showed better improvement in treatment outcomes in both the clinically and radiographically measured parameters, proving that this combination is a valuable treatment modality in management of chronic periodontitis in adjunct to periodontal therapy. It can be concluded that bisphosphonate drugs are a beneficial treatment due to the ability of the drug to decrease the progression of osteoporosis and periodontal disease.

INTEGRATION INTO DENTAL HYGIENE PRACTICE

There are multiple ways in which the knowledge of the benefits of bisphosphonates can be integrated into dental hygiene practice. Dental hygienists should discuss the oral effects of osteoporosis and how bisphosphonates can both help the mouth and reduce osteoporosis. This education can help prevent further bone loss resulting in tooth loss and other irreversible conditions. Radiographs can be taken more frequently to monitor bone levels. Bitewings are recommended every one to two years for individuals with osteoporosis. (10)

Women taking bisphosphonates should be referred by their physician to a dental office before and during treatment to allow for discussion of possible outcomes and the monitoring of bone levels. Collaborative actions toward prevention, evaluation and treatment of oral diseases and osteoporosis in postmenopausal patients could offer benefits, such as reduced tooth loss, a lower incidence of periodontal disease and a decrease in the loss of bone mineral density. These positive outcomes from the use of bisphosphonate drugs lead to a healthier life for postmenopausal osteoporotic women, ultimately reducing comorbidities and oral health care costs. (9)

BY CYNTHIANA M. FURNAS, RDH; BRITTANY N. BENNINGFIELD, RDH; AND MAKENZIE NORRIS, RDH

Cynthiana M. Furnas, RDH, graduated from the University of Southern Indiana and is currently practicing dental hygiene in Saint Clair Shores, Michigan. She can be reached at cynthiana_marie@yahoo.com.

Brittany N. Benningfield, RDH, graduated from the University of Southern Indiana in May of 2018 and is currently practicing dental hygiene in Jasper, Indiana. She can be reached at brittany_benningfield@yahoo.com.

Makenzie Norris, RDH, is a recent graduate from the University of Southern Indiana practicing dental hygiene in Muncie, Indiana. She can be reached at mnnorris1@eagles.usi.edu.

The faculty mentor for this edition of Student Focus is Emily R. Holt, RDH, MHA, CD A, EFDA clinical associate professor, Dental Hygiene/Dental Assisting, University of Southern Indiana.

References

(1.) Osteoporosis, indiana University Health. Available at: http://iuhealth. org/diabetes-endocrinology/ osteoporosis/. Accessed Sep, 30, 2017.

(2.) Davis JM, Wilkerson-Mallory LA. Cancer, women's health and the health of their children. In: Darby, Walsh. Dental Hygiene: Theory and Practice, 4th ed. St. Louis: Elsevier Saunders; 2015: 855,979.

(3.) National Osteoporosis Foundation, Are you at risk? Available at: https://www.nof.org/ preventing-fractures/general-facts/ bone-basics/are-you-awisk/. Accessed March 13, 2018.

(4.) Soyeon J, Young Jin T, Dong Hun H, et al. Low bone mineral density is associated with tooth loss in postmenopausal women: a nationwide representative study in Korea. J Women's Health. 2016;25(11):1159-65

(5.) U.S. National Library of Medicine. Bisphosphonates effects on alveolar bone among osteoporotic women. Available at: https://clinicaltrials.gov/ct2/show/ NCT02115490. Published April 16,2014. Updated September 29, 2015. Accessed Sep. 30,2017.

(6.) Drake M, Clarke B, Kholsa S. Bisphosphonates: mechanism of action and role in clinical practice. Mayo Clinic Proc. 2008:83(9)1032 45.

(7.) Suri V, Suri V. Menopause and oral health. J Midlife Health. 2014;5(3):115-20.

(8.) Dodd DZ, Rowe DJ, The relationship between postmenopausal osteoporosis and periodontal disease. J Dent Hyg. 2013;87(6):336-44.

(9.) Mostafa B, Hamdy E, Nassif N, Combined effect of systemic bisphosphonates, calcium and vitamin d on alveolar bone in osteoporotic postmenopausal females having chronic periodontitis following surgical periodontal therapy. Life Science Journal. 2012:9(3);613-22.

(10.) Palomo L, Clarinda M, Francisco B, et al. Is long-term bisphosphonate therapy associated with benefits to the periodontium in postmenopausal women? J North Am Menopause Soc. 2011: 18(2):164-70.

(11.) Bhasvar N, Trivedi S, Dulani K, et al. Clinical and radiographic evaluation of effect of risedronate 5 mg as an adjunct to treatment of chronic periodontitis in postmenopausal women. J Osteoporosis Int. 2016; 27(8):2611-19.
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Title Annotation:STUDENT FOCUS
Author:Furnas, Cynthiana M.; Benningfield, Brittany N.; Norris, Makenzie N.
Publication:Access
Date:Mar 1, 2019
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