Dental work while on Reclast

@hlp123 You may want to ask for a more detailed explanation as to why the root of the tooth should be removed. Did the tooth break off because it had decay inside and was weakened? Had the tooth already been cracked, and fell apart? If there is a clear path that could lead an infection through the root of the tooth into the jaw bone, then it makes sense to remove it.

I can tell you that as a kid, I broke my teeth and one was broken off at the gum line. That did not cause decay or infection inside the tooth root, and it was unchanged for many years. My orthodontist, moved it downward, so there was a stub that could be crowned. For several years, it wasn't crowned because the temporary cap kept falling off when I was a kid. It was only after decay began from under the edge of a permanent crown from failing cement that it became an issue. The crowns had been redone after removing decay, and I had a root canal that plugged the tooth and a few of the neighboring teeth. The infection inside a tooth evades antibiotics because of bacteria inside of very small tubules in the dentin portion of the tooth, and no blood supply there that can deliver antibiotics systemically. The dentist cleans it out as best they can and plugs it to seal it off during a root canal. Eventually, a root canal can fail, and that happened to me after many years. It did send an infection into my jawbone and that required oral surgery to clean it out and save the tooth. The infection ate away the bone, and I needed a bone graft. It healed well, but a few years later, there was a problem with adjacent teeth and failing root canals, and I opted to remove the teeth with root canals, and get dental implants. At that point, it had been 50 years since I broke my teeth as a kid.

I don't have osteoporosis and I'm not on medications for that, so I don't know how that affects dental work or oral surgery. Sometimes patients who have undergone other surgeries such as knee replacement are prescribed antibiotics to prevent infections while having dental work. You could opt for a second opinion with another oral surgeon. There probably is a lot to consider in the decision, and most important is to keep an infection out of the jaw bone, so an accurate assessment is needed of how big a risk there is for an infection and why. Did the oral surgeon have an opinion about Reclast and your bone quality?

Thank you so much for your reply ! The oral surgeon said that he was sure that the root, from my broken off tooth would become infected and that it was much better to remove it under controlled circumstances in which he would start me on antibiotics and an oral rinse before he removed the tooth and for five days after. Then he would keep monitoring it to be sure it would heal. He said the "Risk vs. the Benefit" dictate that the root should be removed soon. He did not comment on the condition of my bones, but he does know that I am on Reclast. I really do not know who to trust at this point.
I will continue to keep you updated.
I would really like to print out your helpful information. Is there a way that I can print this ?
Thank you

@hlp23 You can copy and paste the text to something like word and print it from there. Highlight the text with your mouse, and the copy command is Control C (or Command C) on a Mac, and click into a Word file to put the cursor there. Paste is Control V (or Command V). You can also pick Copy or Paste from the file menu in word.

Do you know why the tooth broke? Did you have a trauma or impact that broke it? If it just broke on its own perhaps it was weakened for some reason such as decay or mineral re-absorption.

A tooth has a natural seal around it from the periodontal ligament around the socket. If that ligament is damaged, or there is periodontal disease, it may provide a pathway for bacteria into the socket, but that might be something else to ask about. If the ligament is intact, then the only open route is through the exposed interior of the tooth or decay on the root surface if you have recession. I think what happens when you break a tooth is that the pulp (blood vessels and nerves) recedes a bit deeper toward the root. My tooth was in that state for years with no problems.

You do want to avoid an infection. The bone graft to replace bone lost to my infection in the jaw was around $1000, and my dental insurance wouldn't pay for that even though they covered the surgery which doesn't make any logical sense. Are you considering work to replace a tooth after removal? Sometimes a bridge is done, but that carves up teeth on each side of the missing one. A dental implant with a crown on it replaces a singe tooth. No replacement is as good as the original. Crowns also present a decay risk when the cement fails under them. That has happened twice to me. There is only so much drilling and filling, and replacing crowns that can be done before there isn't enough left of an original tooth under it to attach something to. In all fairness, this process began for me as a kid, and I had a bad dentist that did the first crowns where the margin didn't fit right, so it had a shelf that trapped debris and caused decay.

With dental implants, they don't want actual contact between its crown and the opposing tooth because it can loosen the implant which is depending on bone growth around it to secure it. You can get a bone infection around a dental implant. There is a seal around it, but not as good as the periodontal ligament. I had that happen and the oral surgeon had to do a debridement near the implant and replace a bit of bone. I am vigilant about flossing and oral hygiene. You have to be if you end up with implants because they can fail.

You probably have a lot of questions now for your oral surgeon. One of my fellow mentors, Lori @loribmt , here on Connect may be able to share a lot of information with you about dental issues and oral surgery. Also make sure that you discuss all medications that you are taking with your oral surgeon. There are other discussions here where patients are talking about not being able to have oral surgery while on osteoporosis medications. Here is a link:
https://connect.mayoclinic.org/comment/746048/

The patient said they called the drug manufacturer and asked about this risk. That might be another good source of information.

Will you be seeking a second opinion?

Hi @hlp123, @jenniferhunter brought me into your conversation. I have a dental background and can maybe offer a little more information on your situation.

I’m wondering how far down this tooth has broken off below the gum line and if there was decay involve. If the nerve is involved it will not shrink and be fine. Usually when this happens the nerve dies and can become infected if the damaged tissue isn’t removed. (It would become an abscess at the bottom tip of that root)

That’s when a root canal treatment is done. It removes the dead nerve tissue in the root, while preserving the actual root itself. The nerve chamber inside the root looks like a tiny hollow straw, inside of that tube is the nerve. The tube is essentially cleaned out and the old nerve tissue is removed, replaced with a sterile sealant.
Where I’m going with this is, if there isn’t extensive decay on that root and the bone around that root is sound, you might be able to have a root canal treatment to preserve the root of the tooth for future use. A post could be inserted into the root and a permanent replacement tooth (crown) cemented on top. That way you would not need a dental implant in the future.

If, however, the oral surgeon is seeing quite a bit of damage to the tooth root with decay, which may be why it broke off at the gum line, he is making the right call to remove that damaged root now. As far as the Reclast injection and your having an extraction done. You should be fine. I read your comments regarding the oral surgeon’s plan for pre and post extraction. It is a ‘risk vs benefit’ situation as he stated. Your risk of osteonecrosis is minimal and he’s doing all he can to minimize infection and promote healing.

Are you feeling any discomfort with this broken tooth? Can you tell me is this an upper or lower tooth and where is it located in your mouth?

Thank you so much for all of your information !
I did consult another doctor yesterday and he said to go ahead with having the root removed as soon as I can. It is a tooth on the upper left side, I believe #11.
There is only a tiny point left protruding from the gum. There is no decay involving the root. I am very cautious about having this procedure because I had an infusion of Reclast in March. It is very reassuring to have you reinforce that there is minimal risk of the osteocecrosis. I did make an appointment for October 13th. Please share with me any more information that will help me decide to go ahead with the procedure. I really appreciate you help and expertise!
Thank you,

As far as having the tooth extracted while on the Reclast, you’ve had 2 dentists tell you to go ahead with the procedure. From everything that I looked through while searching for specific data for you is that very few people who had events of osteonecrosis, 8 women, had extenuating health circumstances. The necrotic tissue was removed and they made a full recovery from the surgery. So if this were me and I needed dental treatment, with the odds being very low…I’d go ahead with it. Again, it falls to the risk/benefit. You don’t want an abscess to form at the end of that root.

I’m not a dentist but I was a certified dental assistant for 30+ years, now retired. So I’m relying on my experience in that field and also the recommendations of two dentists you’ve talked to about this.

My concern lies in the fact that #11 is a Canine tooth. (Eyetooth). It will have a nice long root and it is generally referred to as an anchor tooth. It’s sad to lose that anchoring root if it can be saved at all. And by saving, I mean with the root canal treatment I mentioned previously, which would save the root to be used as an anchor for a crown with a post. But if both of the dentists made the assessment to remove the root they have a good reason behind their judgment. They may not feel it’s sound enough to support a post with a crown.

If it’s removed, it will need to be replaced with an implant or, less expensively with a tooth in a partial denture. That doesn’t mean other teeth need to be removed. Just one tooth could be mounted to that appliance. The more permanent and less annoying route would be the implant.

Tooth #11, being in the front of your mouth, you’ll have a gap in that space when you smile for quite some time. You can ask to have a Flipper made. It’s a plastic ‘partial denture’ with a porcelain tooth on it. It won’t hold up well with chewing like a real partial denture, but it will at least complete your smile. 🙃
I’ve posted a photo below of what it might look like.
I hope this helps you feel a little more reassured about going ahead with your needed treatment.
Don’t hesitate to pop back with more questions. I’m here for you. ☺️

Thank you so very much ! I really appreciate your empathy and expertise !
It means the world to me that you are willing to help and share your information, and even posting a photo, so I will know what a Flipper looks like.
I have secured an appointment to have the extraction on October 13th. I will absolutely return to you for help or more answers as my questions arise. Right now I have only four teeth remaining on my upper jaw. Plus the tiny point of what is remaining of #11. So my options are limited. I am told that I will need to get dentures, but I have no idea how long I need to wait after my final and I hope last infusion of Reclast, that I received in March of 2022, to remove the remaining four teeth. I understand that Reclast remains in your system for 3 to 5 years. Any information you have about this time period would be most helpful for me.
Thank you,
I am so grateful that you are willing to help me !

You just gave me the answer as to why the dentists aren’t considering holding onto that root…you’re having a full upper denture. Now I understand and I’m sorry, I should have asked right away about the condition of the surrounding teeth. This changes what I mentioned about a root canal and a flipper for a temporary. 🙂

I’m anticipating what will happen next, is the oral surgeon will extract #11 for you and then let that area recover, making sure the socket heals well and fills in with new bone.

How loose are the other 4 teeth? If all goes smoothly with the extraction of this tooth, you may not have to wait until after your next Reclast injection to continue with the other four teeth. (It might be good to have the remaining work done before the next shot.) The oral surgeon and the dentist who will do your denture might decide to go ahead with removing those last remaining teeth to avoid any infections.
Some good questions for you to ask your oral surgeon, dentist/prosthodontist would be:
What would be a feasible plan going forward?
How soon would I be able to have the other 4 teeth removed?
Would I be able to have an immediate denture or do I have to wait for the sites to heal?
Will I need to have Implant anchored dentures or would I be able to have a standard denture which is sometimes held in with adhesive?
( Implanted anchor dentures work really well and have no plastic over the palate area. They can be very expensive.
A standard denture will work if you have a stable upper arch. Your dentist will be able to tell you about these options)

For now, have the cuspid root removed and let that site heal. And exhale…I think you can let yourself relax. 🙂

Thank you so very much !
I do not intend to have another infusion of Reclast in March of 2023 !
I am counting on the one infusion I had on March of 2022 protecting me from the rebound of stopping Prolia ! I really want to be off of all bisphosphonates!
I had one year of Prolia and could not tolerate the side effects. I am printing out all of your wonderful advice and information ! Do you know how long Reclast stays in your system ? How long should I wait before continuing on with extractions ?
Again, Thank You so very much !!!!

Good morning, @hlp123 I read through a number of studies last night, along with the manufacturer’s site about how long Reclast (zoledronic acid) is effective in the body and were no definitive time frames…without going into the complex scientific data that’s way above my pay grade. 😂

Endocrinology Advisor had this article of the latest studies at the time…in 2014 about 1 dose “Effective for 3 Years in Frail Women With Osteoporosis”. https://www.endocrinologyadvisor.com/home/topics/bone-metabolism/zoledronic-acid-safe-effective-for-3-years-in-frail-women-with-osteoporosis/#:~:text=Zoledronic%20Acid%20Safe%2C%20Effective%20for%203%20Years%20in,Bone%20and%20Mineral%20Research%20%28ASBMR%29%202014%20Annual%20Meeting.

We know it’s given annually for treatment of osteoporosis and every 2 years to prevent it. But the articles didn’t say if the product was still active at the end of that period or if it’s the residual of the bone density left behind while it was active.
Basically, the drug reduces bone cell turnover…meaning it impedes the breakdown of old bone cells and builds new bone. However, that break down and regrowth is a key process in successful bone building. So if someone is having major bone loss, halting it with a product like Reclast can help to stabilize the density.
But that can have impact on extractions and how quickly the bone regenerates in that area. That’s why the doctor will have follow ups to make sure the extraction site is healing properly.
I can’t answer how long you should wait before continuing on with treatment. That can only be answered by your dentist and oral surgeon. But if this current extraction site has no issues then it may signal them that it’s ok to proceed with the remaining extractions.
How are your lower teeth? Are you planning on full mouth dentures?