Bisphosphonates (Fosamax, Boniva) Podcast
Dr. Ramzi Matar (Winter Park Dentistry): Hello everybody, thanks and welcome to this episode of our podcast. Today’s topic is going to be about oral bisphosphonates, or in general bisphosphonate drugs. It’s kind of an interesting topic, a hot topic in dentistry, and today’s guest is none other than Dr. Andonis Terezides, he is an oral maxillofacial surgeon. I’m going to brag on you a little bit. You are an oral surgeon, you started school, your track to become an oral surgeon, because I’ve known you so many years, was extensive, I don’t think I know anybody who has more desire and push to become an oral surgeon. You started off in Baltimore, you started off I think in Indiana, then you had to leave for some medical family issues, you left, you came back here to Orlando, started practicing as a general dentist, and clearly, being an oral surgeon was in your blood because you just couldn’t do it, you went back, you had to do a year in Miami, basically as a slave, they call that an internship here, didn’t even count for oral surgery, then four years of oral surgery in, I understand, the toughest or one of the most rigorous oral surgery programs in the world. So I don’t think anybody that I know spent 10 years becoming an oral surgeon. So bravo for you, your training’s extensive.
So, one more add to that, the reason why I wanted you for this topic and no other, is as you know, and nobody else watching this may know, but the director of your program in Miami is Dr. Marx. He is pretty much the guy who invented or discovered everything there is to know about bisphosphonate drugs, and how they affect dentistry. So you trained under him, so other than having him on here, I can’t imagine you’re pretty much going to be a shadow here, I know you know the stuff like backwards and forwards. So let’s get right into it. What are bisphosphonate drugs, what is it I’m talking about, what do people need to know that are watching this, or learning about this?
Dr. Andonis Terezides: Bisphosphonates are the classic medications that are used for multiple medical indications. There’s an oral form, which is commonly used for something like osteoporosis, and there are IV and injection forms, which are common for things like metastatic cancer or treating some electrolyte and metabolic disturbances that are related to cancer treatment, something called hypercalcemia malignancy. They’ve come into play, the medications, because more and more people are on them, over the years, over the last close to 20 years, the bisphosphonates have come into the market, and with them, over time, not necessarily in its initial stages, we started to see problems, and as you alluded to, Dr. Marx from Miami in 2003 wrote some of the initial publications, actually the first documented cases, of bisphosphonate induced osteonecrosis of the jaws.
Dr. Ramzi Matar (Winter Park Dentistry): Okay, what is that? In lamest terms.
Dr. Andonis Terezides: Well, that means jaw bone death, in other words. Dead jaw bone. It doesn’t heal, it just dies after some sort of trauma or injury, which can be something as simple as certain dental procedures.
Dr. Ramzi Matar (Winter Park Dentistry): Where I’ve seen that the most, I’ve seen these lawyer ads, during the day, “have you been taking these bisphosphonates”, the big one being Fosamax, they say “call our law line” and they’re obviously having some big lawsuits over it. What’s the segment of the population, male, female, what age category, who are mostly taking these medications? You said cancers, but who are the bulk of people that use these medications, and what are the major label names of these medications?
Dr. Andonis Terezides: Well the bulk of medications being taken is by post-menopausal females, who are suffering from osteoporosis. There are also patients that have pre-osteoporosis or osteopenia, also being treated by using these medications. That’s the biggest subset, and those are the oral form pills, which come in a medicine Fosamax, which we said, which is also called alendronate, the generic form. And more commonly, we’re starting to see more patients on a medication called Boniva, which is ibandronate, that’s one that’s on a lot of the commercials during the evening news. There’s one form of IV bisphosphonate, also for osteoporosis, called Reclast, that’s zoledronic acid, that’s a very powerful medication. So that’s the one category, it’s mostly post-menopausal females.
Dr. Ramzi Matar (Winter Park Dentistry): So middle aged women. So people watching this, that know somebody, middle aged women, what you see day in and day out, women in their 40s, 50s, 60s, whatever the case may be, those are the major label drugs… So what do you do? You’re obviously treating these patients, you don’t want to have these jaw deaths clearly, what do people need to know, if they’re coming to see you, you obviously know all about it so that’s not a big deal, but what do they need to know about it so they’re informed going to their dentist, going to their oral surgeon, what to look out for?
Dr. Andonis Terezides: Probably the most important thing is to know the medications that you’re on. Know the history of medications that you’ve been on in the past. It’s really a pleasant experience when a patient comes prepared for a consultation with the list of medications, and knows their medical history, or at least has contacts with their physicians that we may be able to contact. When we look at a patient’s medical history, we look at the conditions that they may check off on that check box list. Sometimes they show us problems that may be on, and sometimes they don’t check off that they may have something because they think they’re treated for because they’re taking a medication. “I don’t have high blood pressure because I take blood pressure medication.” The same thing with this medicine.
When we see any sort of history that made lead us off into the direction that the patient may have been exposed to bisphosphonates, either for osteoporosis or for metastatic cancer, or if they’ve checked off other powerful medications such as long term steroids, methotrexate or chemotherapy, then as surgeons, we kind of automatically go down the path to rule out this history of having been on bisphosphonates at some point, whether now presently or in the past. And from there we really want to find out how long they’ve been on it, because there’s correlation on how many medications you’ve been on and for how long, to avoid the risk of certain complications.
Dr. Ramzi Matar (Winter Park Dentistry): Okay so I’m a patient coming to you, I’m a 60 year old post-menopausal woman, I’ve been on this medication for two years, let’s say two or four, let’s give those two examples, what do you do… Let’s say it’s the pill form, what are you doing, how are you treating me differently… I need a tooth taken out obviously, and that’s where this whole thing starts for some sort of surgery, how do you manage that?
Dr. Andonis Terezides: Well, if you’ve been on it for two years, I’ll enquire if you’ve been on other brands or formulations of the medicine in the past. And at the two year mark, we’ve seen in the research, two years of that medication without certain other medical conditions, we’re okay to proceed with surgery as we normally would, but if you’ve been on that medication for two years and you’ve also been on steroids or methotrexate or had chemotherapy for an unrelated condition, then we start to worry that you might show signs of poor wound healing so we want to do is take a step back, if possible, if we have the luxury of it not being an urgent treatment, to gather a little bit more information, and that usually come in the form of doing a lab test.
In our practice, that laboratory test, it’s called a CTX, which is a C-terminal telopeptide, and what we do is we give you a prescription, and we have you take that same prescription to your physician, and have them re-copy what we write for you. And we send you to a lab, and you give one or two vials of blood in the morning, between 8 and 10 in the morning, you’ve give a fasten blood withdrawal, and they send that lab test off to a lab, usually in Tampa or California, and it comes back with a value.
Based on that value, if you’re above a certain number, we can correlate a risk whether or not we should proceed with surgery or if we should delay surgery. Sometimes we don’t have that luxury as surgeons because we have patients who are in pain, they have infections, they have things that sometimes need to be treated. Other times we can see that we really do need to wait, as the risk or complications that can come from having an extraction can be pretty serious. So then we go down with talking to a root canal doctor or somebody to try at least temporarily hold the tooth off while we can talk with the patient’s physician, about maybe stopping the medications or putting them on what we call a drug holiday.
Dr. Ramzi Matar (Winter Park Dentistry): What is that? You said if you have some luxury of time, so let’s say the test comes back, it’s too high, it’s too risky, what’s a drug holiday? Tell me a little bit about that.
Dr. Andonis Terezides: Sure. Usually the test would come back as too low, we look for a number, 150 picograms per mL or higher to be safe, so if it’s below 150, we like to have what we call a drug holiday, where we’ll coordinate with your physician, and ask the physician to have you stop taking that medication for a period of time, usually in the range from 6 to 9 months, because this would allow for it to start to heal and grow these cells that are used for bone healing. To allow them to repopulate where they’ve been depleted because of the medications. And in doing so we have a better chance of healing, following the procedure.
Dr. Ramzi Matar (Winter Park Dentistry): In essence, you take the patient off the drug, you check with the physician… They come off it for 6 months, I take it you re-take that CTX test, now it’s over 150, it’s 300, and now that’s low risk, and now you can proceed with the extraction, that’s the ideal way…
Dr. Andonis Terezides: We can proceed with confidence, usually knowing that, and I can tell you from my experience in Miami, I never saw a patient develop osteoporosis or osteonecrosis or dead jaw bone if their CTX were 150 or higher at the time of the extraction. It’s a positive musing that goes back to the works of Dr. Marx.
Dr. Ramzi Matar (Winter Park Dentistry): Yeah, I said it at the beginning, Dr. Marx invented all this stuff, I think it’s called the Marx Protocol, it’s all over the place. Clearly I know that you know this stuff inside and out, and I appreciate you trying to simplify it for somebody like me to understand it. Some of the messages I’m getting, these medications called bisphosphonates, Fosamax, Boniva, Reclast, it’s obviously very important for patients watching this or you know somebody doing oral surgery that’s in this age, make sure you know what medications you’re on, tell the surgeon who’s doing the surgery what you’re on, from there you can manage what’s the best way to take them off the drug, do a test to see if they’re safe… So, one other question. What are the major procedures you have to be careful with? What if you’re having dental implants done, can you do the implants? Is there anything that basically involves bleeding? Can you do cleanings if you’re on this medications? What are the things that a patient should say “okay I have to make sure somebody knows what’s going on here”?
Dr. Andonis Terezides: Sure. Well we would usually tell patients, and we’ll tell their referring dentists to us is that patients can have routine general dental work. This means fillings, routing cleanings, crown and bridge work, restorative treatment, dentures as well, all the sort of cosmetic work you’d do… We’d like sometimes for people to hold off on special deep cleanings that involve surgical manipulation like surgical periodontal, as well as denture implants and bone grafting, those are the ones that can get patients into trouble. Surgical procedures.
Dr. Ramzi Matar (Winter Park Dentistry): Things involving the bone, the jaw, obviously, it’s called jaw death. Well, listen, I really appreciate it, I think anybody watching this enjoyed it, learnt something, I know I did. Please, add some comments to the YouTube video, if you have any questions, me myself or you, Dr. Terezides can try to answer them. I really appreciate your time, looking forward to our next podcast episode.