Let's ignore the dosage for just a second and think about the effect of alendronate. in a simplified way of thinking this medication asked by reducing osteoclast activity. Bone mass is increased because osteoblasts remain active but osteoclasts diminish.

Osseointegration is a biologic phenomenon were bone forms adjacent to an implant. Alendronate allows this osteoblast activity to predominate in what is normally a constant remodeling process. There have been some high quality studies that have demonstrated a trend towards a beneficial or protective effect for dental implants in patients who use this and other bisphosphonate medications. I say trend because I don't think that any of those studies showed a significant difference although the trend was towards a protective effect for implants. Some studies have used oral medication and some studies have tried to dope the surface of the implant with the medication.

These responses relate to specific administration of the medication in patients for the purpose of assisting in the Osseo integration process.

In patients who take bisphosphonates for long periods of time and especially at high dosages such as patients who are using this drug for this group of drugs to address major medical conditions (metastatic bone disease would probably be the first one we would think of) represent an entirely different treatment goal and need to be excluded from this discussion.

Patients who have taken low-dose bisphosphonates for relatively short periods of time (usually thought of as less than 2 to 3 years) for the management of osteopenia or osteoporosis are at a slightly increased risk of developing osteonecrosis lesions of bone (bisphosphonate related osteonecrosis) in comparison to patients who don't take this medication. Remember there are people who develop Osteonecrotic lesions in bone who have never taken this medication.

Bisphosphonate related osteonecrosis is probably more associated with surgical intervention that can cause trauma to bone that is relatively hard to control. So removal of a tooth is much more traumatic than is the Surgical creation of an osteotomy.

So let us put all the qualifiers together. in patients who are to receive a dental implant where the implant placement is performed by a skilled clinician where trauma can be minimized (all surgery is traumatic at some level) and the patient has taken low-dose bisphosphonate therapy for less than two years the effect on Osseo integration appears to be statistically similar to that of patients who have not taken bisphosphonates although the research suggests that there might be a trend or tendency towards a slight improvement in Osseo integration achievement albeit not at a statistically significant level.

This description in the last paragraph is one that is a little hard for me to put down on paper because in the world of statistics it either is or it is not different. Either there is a statistically significant difference or not. we look at the two comparison groups, the case and the control, and our answer is yes or no based upon a alpha of 0.05 or less. The hard part is when you have a p value >0.05 but < 0.1 and when you realize that the sample size of the study/studies is generally small enough that we wouldn't see a difference unless the difference was huge. So although I hedge a little bit I guess I would stick with this response cc above.

Hi

I would entirely agree with the statement above, however there must be an higher risk of post-op complications in patients on intravenous bisphosphonates (periodical IV infusion)

I think that we need to be just a little bit cautious in how intravenous infusion of bisphosphonates is defined. There certainly are some low dose bisphosphonates that are infused anywhere from quarterly to annually. Generally when this is done for osteoporosis it remains a low-dose medication and the risk of bisphosphonate related osteonecrosis remains pretty low. When patients are taking intravenous infusions for lesions in bone that are related to metastatic disease, usually this is classically described as treatment for the management of multiple myeloma metastases, this becomes a completely different dosing schedule and a completely different level of a aggressive treatment in the management of malignancies and the effects of malignancies.

So we just want to be a little careful about making the statement that if it's intravenous it brings in a higher risk. In some instances based upon the dosage and the medication that is chosen there is a higher risk but based upon those same two variables just the fact that it's given intravenously does not condemn the patient to an exceedingly high risk for osteonecrosis.

Thank you for your comment.

However, according to widely available data: "The current estimate prevalence has ranged from 0.001% to 0.01% among oral bisphosphonate-treated populations, what is significantly inferior than the incidence observed in patients undergoing intravenous therapy" (Med Oral Patol Oral Cir Bucal. 2014 Mar; 19(2): e106–e111).

Madrid C, Sanz M. What impact do systemically administrated bisphosphonates have on oral implant therapy? A systematic review. Clin Oral Impl Res. 2009;20:87–95.

Shin EY, Kwon YH, Herr Y, Shin SI, Chung JH. Implant failure associated with oral bisphosphonate-related osteonecrosis of the jaw. J Periodontal Implant Sci. 2010;40:90–5.