Some are stopping Fosamax and other osteoporosis drugs because of the risk of “jaw death”. “While bisphosphonate-related jaw death is still a rare phenomenon since first reported in 2003, researchers have documented more than 1,500 cases, most often triggered by having teeth pulled.

Less invasive dental work, such as the filling of cavities, the placing of crowns and root canals do not spawn the condition.

Why some patients develop problems and others don’t puzzles investigators. Those who develop the condition experience a lack of healing after a procedure. They are left with painful exposed bone, which becomes infected. Once jaw death begins, oral surgeons say there is little that can be done to reverse it.”

This rare complication can occur in those with multiple myeloma and other cancers in conjunction with chemotherapy or radiation therapy. Most of the instances occur in those receiving intravenous bisphosphonates.

As with all alarmist mainstream articles, it is important to weigh the rare risk of this side effect with the proven efficacy of the medication.

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  • Anonymous

    I realize that this side effect is rare and the medicine is effective, but it is one thing if it is taken by people who already have osteoporosis and quite another when it is prescribed to healthy people with osteopenia as it often is. When you are currently healthy even the small potential side effect sounds bad. And the teeth of most of us get worse when we get older.
    This all makes me wonder. Are these new osteoporosis drugs are really so much safer than a low-dose estrogen patch? The HRT has been studied extensively and we are all aware of the risks. None of these new osteoporosis drugs have been studied for as long or as extensively.

    These are completely uninformed thoughts, though. But as a younger woman with premature menopause who already has mild osteopenia and who is currently on HRT, this all makes me wonder what to do when I turn 50 and if my bone loss gets worse. Will I want to stop HRT and go on one of these drugs, will I want to stop HRT and do nothing or will I want to continue on lower dose of HRT… I only hope that more will be discovered in the next few years.

  • Chris Rangel

    I agree. Many patients are started on these expensive medications without clear indications but let me ask you this. What would you do if several years from now (God forbid) you fell and broke a hip and needed surgery and then you had infectious complications from the surgery (because this is a small but definitive risk of any surgery) and you had to have revisions and long hospital stays and significant pain and other complications and big medical bills and lost work and income?

    Would you have a lawyer review your medical records so that he/she could then go screaming to the jury that you had evidence of osteopenia and you were NOT placed on a bisphosphonate by your primary care physician?! Would your lawyer then put some “expert” on the stand who has a medical degree from Kyrgyzstan, holds no US medical license and instead works as an “expert witness” in medical malpractice cases and who will claim that you should have been on combination preventative treatment with a bisphosphonate and HRT even though this is not FDA approved and combination therapy has not been proven to reduce hip fracture rates?

    Will the jury side with your “expert witness” partly because he was handsome, well spoken, and appeared to be very competent as opposed to the expert witness for the defense who was a professor in metabolic bone diseases at a leading medical school but who the jury disliked because he appeared disheveled, stuttered a lot, and was arrogant? Will you then collect four million dollars for your pain and suffering thus causing your physician to lose his malpractice insurance and have to retire early?

    OR! Will your doctor put you on a bisphosphonate in the first place so that after you do fall and break your hip (because such a thing is not 100% preventable) your lawyer will not sue your primary doc because you have much less of a case?

    It’s called defensive medicine. It’s expensive. It’s ugly. It does not result in better medical care. And it happens all the time.

    *awaiting dive bombing attack by CJD*

  • Anonymous

    Chris, no dive bomb for you. You’re no different from the hysterical alarmists who write medical articles. When people pontificate about things they don’t understand, this is typical.

    At least you’re consistent.

    CJD

  • Anonymous

    I am anon from 11:25am. In answer to Chris, no I am not going to sue — a. I know too much to do it and keep my self-respect b. I usually research what I am prescribed extensively myself and then make my own decisions on what to do based on probabilities of worrisome side effects as well as benefits. So it is my responsibility to live with consequences of my decisions. It was my decision to stay on HRT at least until I am 50, so I am the only one responsible if this decision was wrong. c. As I understand it Fosomax doesn’t do a thing for hip fractures – I just checked the link in the article, only for vertebral – but this is beside the point.
    I do realize that most people don’t bother to even read the list of side effects and a small percentage of them might sue. I think the percentage of people who really sue is small but that there are some peole who’d sue even if they sustained a fructure while falling during rock climbing.

    When I posted to this thread I didn’t really think about what individual doctors do or do not do. I was thinking about the guidelines and whether the authors of the guidelines are right in including more and more healthy people in “shall be on this drug” list. Also I am honestly wondering whether all these newer osteoporosis drugs are really that much safer than HRT (at least for women who are under 60 and who do not yet have heart desease) because none of these drugs have been studied as intensively and for as long. But as I said, these are just completely unscientific musings of an ignorant lay person.

  • Chris Rangel

    CJD. No pontification nor rumination here! It’s called sarcasm. Look it up.

    Anon. You did ask why “perfectly healthy” patients with osteopenia are given medications like Fosamax. From a primary care perspective, many relatively healthy patients are placed on preventative medications if they have even the slightest indication and no obvious contraindications because 1.) This is what primary care physicians do these days. 2.) It’s expensive for the patient and but costs the doctor nothing. 3.) Many of our patients EXPECT us to do something when there is an abnormal test. 4.)We try to do everything to reduce the risk of a lawsuit (defensive medicine).

    The evidence for a decreased rate of hip fractures with alendronate is not as strong as for vertebral fractures but it does exist! HRT does show benefit as well but the evidence is not as strong as that for the bisphosphonates and the benefit appears to decrease once HRT is stopped. I think that many more physicians feel that the risks of developing gastric reflux symptoms with bisphosphonate use is more acceptable than the small increased risks of cardiovascular and thromboembolic disease (blood clots) with HRT use. Short answer; Bisphosphonates show greater benefit and have safer side effect profiles than HRT.

    Then again, we know less about the bisphosphonates than we do about HRT. In life there are always risks. Pick your poison.

  • Anonymous

    “4.)We try to do everything to reduce the risk of a lawsuit (defensive medicine).”

    This sentence makes no sense. But it is consistent!

    But I do enjoy your thoughts on the medical issues. You are pretty good at putting them in terms the layman can understand.

    CJD

  • Chris Rangel

    “This sentence makes no sense.”

    Ahh, the ‘ol appeal to ignorance argument. It makes no sense to YOU or does it make no sense in general or to the average reasonable person? Of course it makes sense! Every sentence if it has the proper syntax makes sense!

    Do you seriously believe that physicians DON’T do things to reduce the risk of lawsuits?? Every day I order tests that I KNOW (from training and experience) have an extremely low chance of being positive just because I want to avoid that one in 1,000 patient who does end up with a very unlikely presentation for a serious disease. My partners do the same thing. Dozens upon dozens of other physicians that I have worked with do the exact same thing (often causing me to roll my eyes when I read some of their orders).

    Does it make sense now?

    CAN YOU HEAR ME NOW??????!?!??!??

  • Anonymous

    Actually, it’s an appeal to common sense. Putting aside the fact that there is no objective way to measure “defensive medicine”, it pits two of physicians’ claims against each other.

    1. That there are more lawsuits than ever.

    2. That the only way to combat them is defensive medicine.

    If you’re doing more of #2 to combat #1, but #1 keeps increasing, either you’ve incorrectly diagnosed the disease or you’re applying a remedy that doesn’t help. So which is it? Are you making up the first or wasting time and health insurance dollars doing the second with no tangible result?

    And also, of course, putting aside that what this is really all about are physicians’ insurance premiums, something most all have a terribly lacking understanding of.

    CJD

  • Anonymous

    Yes CJD I am sure you know all about why insurance premiums are being driven up while us idiot MD’s are just the insurance industry’s flakey’s. From what I have seen of the studies the funding source has a lot to say about the result. If the source is the insurance industry then it is the lawsuit’s fault. If the source is connected with your industry in some way then it is the losses in the 2000 stock market meltdown. I suspect the truth like most things lies somewhere in the middle. However, In my state we are LOSING insurers. Period. You tell me why would insurers leave states if they need us to jack up their rates to make money of of their stock market losses. The truth is much more complicated then one of your soundbites CJD.

  • Anonymous

    I think that many more physicians feel that the risks of developing gastric reflux symptoms with bisphosphonate use is more acceptable than the small increased risks of cardiovascular and thromboembolic disease (blood clots) with HRT use. Short answer; Bisphosphonates show greater benefit and have safer side effect profiles than HRT.
    Thanks, Chris. Although this risk of the jaw death although small sounds mighty scary. There are btw, those who say that heart desease risk shown by WHI was due to the fact that most women were so old, some years after menopause, and that many already have heart desease and that for younger healthier women just starting menopause the story is different. Just conjecture at this point, but they have a plausible explanation; I also read a meta-analysis of all HRT studies that showed 38% all-cause-mortality benefit for under-60 women. I am grateful that I still a few years to go before 50 — most specialists believe that HRT makes sense until that age as we are replacing hormones that most women of our age get naturally – and that more will be known (always optimist) in a few years.

    Then again, we know less about the bisphosphonates than we do about HRT. In life there are always risks. Pick your poison.
    Love the “pick your poison” comment…

  • Anonymous

    “However, In my state we are LOSING insurers. Period. You tell me why would insurers leave states if they need us to jack up their rates to make money of of their stock market losses. The truth is much more complicated then one of your soundbites CJD.”

    What state do you live in? I’ll be glad to give you some insight as to why you’ve lost insurers if I can.

    Insurers leave states because they don’t price their product correctly and get their butts kicked, or because they loot their company, or because the insurance commissioner won’t let them jack up rates.

    You’re right though, the truth is more complex, and I am necessarily limited by the space of a comment board. For a good starting point on understanding insurance, I would encourage you to read the February 2004 letter from Warren Buffett to the Berkshire shareholders. You can find it online at http://www.berkshirehathaway.com.

    Berkshire has longtime experience in the insurance industry (they just bought Medical Protective from GE, incidentally) and Buffett lays out how insurance works in very plain terms. The insurance part starts on page 6 of the letter. It truly is a must read.

    CJD

  • Anonymous

    Sunday night, I saw an 80 year old guy with chest pain and shortness of breath in the ER. Normal O2 Sats, unchanged EKG. It was his 5th visit in 5 months for the same thing. The last 4 visits he had CT-PA’s, all negative to rule out PE. 4 Ct-Pa’s in 4 months. What did I do? I ordered a CT-PA. Low yield, but I practice defensive medicine. Nurses and Residents gave me a load of crap for ordering it. Well, I found the needle in the haystack. It was positive. He had multiple PE’s. Reminded me why I practice defensive medicine.

  • Anonymous

    Because you’re very poor at diagnosing cures for problems?

  • Stephanie

    Back to the original issue of the safety of bisphosphonates (before the lawyers clouded the picture!)–remember that “bone quality” is much more than “bone mineral” (it’s proteins, mechanical strength…). And while we’re at it, the whole point of DEXA scans and treating low T-scores is to prevent fragility fractures and disability (agility, proprioception, safety…)

    I’m at a loss how to advise my patients about taking Fosamax, etc…at what age is a T-score of -2 bad? 50 or 90? So your score improved after 2 years on Fosamax–are you going to spend $80/month for the rest of your life? Is there an endpoint to therapy, or do we wait until these people turn to chalk? When would you restart it? Do you get DEXAs q 2 years routinely? What if she breaks her hip anyway 4 years later–stop? Who’s measuring patients’ core strength/proprioception as a means of fracture prevention? What if her dentist tells her to stop?

    I’m asking because my patients are asking me!

  • Anonymous

    Poor old fellow showing up time after time in the ER with chest pain, the docs rolling their eyes at him, telling him he’s a hypochondriac and shipping him off home. Do you KNOW how much nerve it takes to go BACK to the ER after you’ve been treated that way? It’s anxiety producing to say the least. So gramps hauls himself back the fifth time and finally you hypereducated types find the problem, and your reaction?? That you over-tested him and it’s all the lawyers’ fault! You docs with these lousy attitudes really need to get a grip and realize it’s not about you you you. You miss a diagnosis, and it’s still the patients and the lawyers at fault.

  • Anonymous

    I believe my facial bones have been slowly dying for years while multiple uninformed dentists keep doing invasive procedures on me. When my symptoms got much worse, shortly after starting Fosamax, I learned of the connection between these drugs and jaw death, but I also found out that dentists who had previously helped patients with ONJ (osteonecrosis of the jaws) are afraid to touch a patient who is also taking a bisphosphonate. It appears that even some of the leading experts on ONJ have been driven out of business by Aetna insurance company and other nay-sayers who deemed the diagnosis and treatment of ONJ to be fraudulant. As a physician treating others with long term facial pain and headaches that started after dental reconstruction, I fear there will be many more people fated to a lifetime of pain, disfigurement and disability if the alarm is not sounded much more loudly than the drug manufacturers seem willing to do. My advice: If you are undegoing dental work do not go on these medicines. If you are already on these medicines, avoid any dental work that is not absolutely necessary.

  • Anonymous

    So, after reading the comments on this Blog site, what is one supposed to think and do if you are presently on Fosamax? Even though the evidence has yet to surface based on long term use if you do not fall into the category of one with cancer or dental surgery there is definitely a concern of continued use. I guess the basic question is can one continue to take large doses of calcium to fight Osteoporosus and benefit WITHOUT Fosamax? Since ONJ appearance is a function of time why would one logically even take the chance? Comments?

  • Anonymous

    why do not try fortical. It is naturally and has no side effects. see http://www.fortical.com / Safety record of over 30 years with calcitonin / fda approved.

  • Anonymous

    Fortical sounds like the best way to start. I am 53 and just diagnosed with osteopenia. I did some research and learned that Fortical (Calcitonin Salmon) is the most natural, safest way to protect my bones from further detioration. I am fearful about going on Fosamax now because I could be on it for the rest of my life…could be 20- 30+ years…who knows what the long term effects could be. That stuff stays in the bone forever…nothing can get rid of it…It acts like Thompson’s Waterseal coating the bone, can cause hypermineralization…interferes with natural bone remodeling, unlike calcitonin that the body makes…The calcitonin in Fortical is about 40%+ more potent.

  • Anonymous

    Why aren’t Doctors prescribing Fortical. All the woman I know are on either Fosamax, Actonel, or Boniva. I am afraid of the side effects of all three. Does Actonel and Boniva have the same problems with the jaw as well.
    I would like to try Fortical. Does Fortical contain seafood? I used to be allergic to shellfish.
    I have just been diagnosed with Osteoporosis of the spine. minus 2.7. I am 63 years young. I was told by my GYN to take Fosamax and the more research I do, the more I don’t know what to do.
    Please give me some feed back.

  • Anonymous

    The reason you and your doctor may not be aware of Fortical is because it is from a small company, however, it is the same as Miacalcin, which your dr. should be familiar with. It is calcitonin salmon but it is not actually made from salmon, no fish died in the making of this product including shell fish. Talk to your dr about it.

  • Anonymous

    Has anyone given any thought to the fact that if in fact Osteonecrosisof the jaw can be caused by this family of drugs, why not ON in other bones. The physiology of bone is the same regardless of location. Many older patients have ON of the hip and require replacement joint surgery. Many of these same patients have been on these drugs for many years and don’t fit into any high risk group. We have just bcome complacent and accept this malady as a side effect of old age. Why?

  • Anonymous

    The reason there is more Osteonecrosis of the jaw than anywhere else in the body is probably due to the fact that the rate of bone turnover in the jaw is every 2 years vs. every 10 years in the other bones of the body. All bones are not the same!

  • Anonymous

    The rate of turnover may be different but that doesn’t preclude the strong possibility of the drug causing ON elsewhere, especially if the patient has been on it for a long time. The physiology of bone is essentally the same, therefore being open to similar destructive processes. Why exclude the possibility if no other risk factor is present, and especially when the ON is found in more than one site.

  • Elizabeth

    What I’d like to know is whether these doctors who act so nonchalant about the risks of ONJ would prescribe it for their wives or daughters? Would they take it themselves? There is a long history of phosphorus causing jaw necrosis, phosphorus being part of what makes Fosamax, Boniva, and all the other bisphosphonates what they are.

    In the 19th century, workers in match factories who were exposed to phosphorus got something called “phossy jaw” – just like women today are getting it. Rotting jaw. This is not a coincidence and it isn’t just women taking intravenous Fosamax, either. How many women are walking around with ONJ and just don’t know it because they haven’t yet had a tooth extraction?

    We’ll be posting a timeline of bisphosphonates and phossy jaw, starting in the 19th century, over at our bone health blog, Got Bones? It’s a very interesting history, indeed.

    Visit us for the timeline and other news on this issue: Got Bones?

  • Anonymous

    Read “The myth of Osteoperosis”. This whole “disease” has been manufactured in the same labs as the dangerous drug you are all debating. I wouldn’t take ONE of those pills. Our bones are designed to change over time. Our best defense is exercise, Calcium and magnesium and vitamin D.
    We all want a “wonder pill”, but guess what? There isn’t one!!! Wake up people. You are being scammed and big Pharm is getting rich off of the ignorance and pie in the sky wishes of women.
    Just reading how the bone gets “better’ is sickening. Taking old bone matter and sticking back onto the existing bone?!?!?! Hello!! Would you drive around on tires that had worn off pieces of rubber stuck back on? Should we take menses(sp?) material and re-attach to our bodies…no! The process for bones is SUPPOSED to happen.
    How many of you actually KNOW someone who has the hump on their back or who has died of a bone injury?
    WAKE UP!!! You (and your wallets) and being scammed and Dr.s and Big Pharm is reaping the benefits…not anyone taking this dangerous drug!

  • Anonymous

    I am a 60 year old active female who fractured my fibula and tibula on November 5, 2006. After surgery my surgeon informed me that while he was attempting to repair the fracture that the bone disintegrated like glass. He blamed it on the Fosamax that I have been taking for many years. Will it do me any good to stop taking Fosamax or is the irreparable damage already done to my bones for the rest of my life?

  • Anonymous

    There is no guarantee taking any osteoporosis drug will prevent a fracture or break. So why load us up on more poison. I was taking it for 3 yrs and called my doctor and told her i am getting off of it. Who knows what more problems down the line it will cause. I would like to know how long it takes to get out of the body system. I have since put myself on Calcium Carbonate/D supplement.
    Later in life many dental procedures may be needed for anyone and dentist will not want to perform them. Some dentists now refuse to treat a person on Fosamax. Hello, get on the back of the greedy pharmaceutical companies pushing drugs without more research to the safety of patents.
    Are there any symptoms to look for that we as users can be aware of before we hit the dentist chair?

  • Anonymous

    What does turn over in the jaw mean? Half life time?

  • Anonymous

    From another writer: “How many of you actually KNOW someone who has the hump on their back or who has died of a bone injury?” My view: The reason you might not see alot of these people is because they are usually elderly or dead and if their bone disease has reached this level of deformity, they are usually residents of a nursing home, not people out in the communtiy. First of all, I have taken Fosamax for about 4 years, but have stopped. I am torn as my mother is in a nursing home with the BENT posture, from multiple spinal franctures. Her height went in a period of about 4 years from 5’4″ tall to about 4’5″ tall, with many complications to her functioning due to the trunk-deformity, ie: lung, stomach, intestinal crushing, etc. Her bone loss though was from extensive radiation in the 60′s due to uterine cancer at age 45, and no subsequent hormones. My Dad, at 88 broke a hip in July 1999, and was dead from the complications in 7 months, Feb. 2000. SO…there ARE bent people, and dead people from osteoporsis and its complications.
    THAT SAID, I do feel that the pharmaceutical companies are cashing in on the baby-boomers who are in the menopausal age range. Fosamax was never meant as a preventative, but only for a diagnosis of actual osteoporosis and if a fracture had occured. But it is BIG money to make us think we need it as a preventative. For me, after 4 years on the drug, my scans had minimal improvement, but I had a lot of bone pain, and the onset of arthritis (?), who knows maybe caused by the Fosamax? Anyway, now with the potential jaw necrosis risk after taking it for years, I decided to stop it. Recent bone scan showed NO bone loss and I have been off it for 2 years. Am trying increased Calcium, and related supplements for absorbtion, and weight-bearing excercise, and will repeat the scan in 6 months. I am 54.

  • Anonymous

    Any evidence on the effectiveness of Fortical used off-label for a pre-menopausal woman?

    I’m 30 & have mild osteopenia in my femur. My MD prescribed it, but I’m not convinced. I take 1500 mg calcium citrate + D daily.