Journal of the World Federation of Orthodontists xxx (2018) 1e7

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Journal of the World Federation of Orthodontists

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Effect of bisphosphonates on orthodontic tooth movement in

osteoporotic patients: A review
Mary Luz Arbelaez a, Sergio Marino Viafara Garcia b, c, *, Juan Pablo Lopez d, Daniel Avila e,
Juan Carlos Munevar b, f, Andres Pauwels g
a
Private practice, Orthodontist, Oral and Maxillofacial Dental Research, Department of Oral Health Service, Hospital Universitario Fundación Santa Fe de
Bogotá, Bogotá, Colombia
b
Research Scientist, Oral and Maxillofacial Dental Research, Department of Oral Health Service, Hospital Universitario Fundación Santa Fe de Bogotá,
Bogotá, Colombia
c
MSc in Biomedical Sciences, Unit of Oral Basic Investigation, School of Dentistry, Universidad El Bosque, Bogotá, Colombia
d
Private Practice, Dentist, Oral and Maxillofacial Dental Research, Department of Oral Health Service, Hospital Universitario Fundación Santa Fe de
Bogotá, Bogotá, Colombia
e
DMD Student, School of Dentistry, Universidad El Bosque, Bogotá, Colombia
f
Associate Professor, MSc in Biological and Medical Sciences, Unit of Oral Basic investigation, School of Dentistry, Universidad El Bosque, Bogotá
Colombia
g
Oral and Maxillofacial Surgeon, Oral and Maxillofacial Dental Research, Professor and Department Head, Department of Oral Health Service, Hospital
Universitario Fundación Santa Fe de Bogotá, Bogotá, Colombia

a r t i c l e i n f o a b s t r a c t

Article history: Background: This review discusses the side effects of bisphosphonates (BPs) in orthodontic tooth
Received 19 January 2018 movement (OTM) with the main focus on suggesting key aspects for the clinical management of patients
Accepted 14 March 2018 with osteoporosis by orthodontists.
Available online xxx
Methods: Studies were selected through a search of the PubMed electronic database. The keywords used
for the search were BPs, tooth movement, orthodontics, osteoporosis, and bone remodeling. The search
Keywords:
was restricted to English-language articles published between 2001 and 2017.
Bisphosphonates
Results: This article provides updated information about the mechanism of action of BPs; their effects on
Bone remodeling
Orthodontics
bone metabolism, particularly with regard to OTM; oral radiographic considerations in the osteoporotic
Osteoporosis patient; and the potential use of bone turnover biomarkers from oral fluid as predictors of bone
Tooth movement remodeling and key aspects for the clinical management of patients with osteoporosis by orthodontists
and dentists.
Conclusions: The interactions of BPs and oral/maxillofacial tissues with a high bone turnover rate such as
maxilla or jaws can influence the success rate of dental procedures that involve bones around the teeth,
such as extractions, periodontal surgery, and OTM.
Ó 2018 World Federation of Orthodontists.

1. Introduction has increased. Therefore, for orthodontists, the management of

The application of orthodontic force to a tooth leads to a
sequence of events in the dentoalveolar complex [1]. Bone
resorption induced by orthodontic treatment on the side of the
alveolar bone undergoing compression is a key and essential step in
orthodontic tooth movement (OTM) (Fig. 1). In the past few de-
cades, the number of adult patients seeking orthodontic treatment
* Corresponding author: Department of Oral Health Service, Hospital Uni-
versitario Fundacion Santafe de Bogota, Carrera 7, No. 117 e 15. Bogotá 110111,
Colombia.
E-mail address: viafarasergio@gmail.com (S.M. Viafara Garcia).
osteoporotic patients is currently an important challenge because
most patients are managed with prescription drugs that can in-
fluence the outcome of orthodontic treatment in relation to the
reduction of bone remodeling [2]. Such drugs include bisphosph-
onates (BPs), one of the most popular groups of antiresorptive
drugs.
Osteoporosis (OPO), a “condition of porous bone,” is clinically
defined through the estimation of bone strength by assessment of
bone mineral density. It is characterized by low bone mass and
microarchitectural deterioration of bone tissue, leading to
enhanced bone fragility and a consequent increase in fracture
risk [3].

2212-4438/$ e see front matter Ó 2018 World Federation of Orthodontists.

https://doi.org/10.1016/j.ejwf.2018.03.001

Please cite this article in press as: Arbelaez ML, et al., Effect of bisphosphonates on orthodontic tooth movement in osteoporotic patients: A
review, Journal of the World Federation of Orthodontists (2018), https://doi.org/10.1016/j.ejwf.2018.03.001
2 M.L. Arbelaez et al. / Journal of the World Federation of Orthodontists xxx (2018) 1e7

Fig. 1. (A) The biological responses of hard tissue to biomechanical load around the tooth are different between a tension area and a compression area. (B) In the resorption area,
blood flow is altered in response to compression within the periodontal ligament (PDL), and the mechanical forces are transduced to the PDL cells, which triggers the biologic
response via an aseptic transitory inflammatory process. (C) After the PDL and vascular response in the compression area, several local inflammatory mediators are involved in
recruiting osteoblasts and OCLs to remove and deposit bone on the pressure and tension sides of the root.

BPs are synthetic analog pyrophosphates that are highly selec-
tive for osteoclasts (OCLs) [4], and they have recently received much
attention in the dental literature. These drugs are used to treat
various diseases, such as OPO, osteopenia (OP), Paget disease, ma-
lignant hypercalcemia, and some cancers [5]. Although the most
common dental side effect of BPs is medication-related osteonec-
rosis of the jaw (MRONJ), other oral complications that are not
completely clear can occur, including the inhibition of OTM. Insuf-
ficient information is available on the role of the orthodontist in the
treatment of patients with a current history of BP use. The

Please cite this article in press as: Arbelaez ML, et al., Effect of bisphosphonates on orthodontic tooth movement in osteoporotic patients: A
review, Journal of the World Federation of Orthodontists (2018), https://doi.org/10.1016/j.ejwf.2018.03.001
 M.L. Arbelaez et al. / Journal of the World Federation of Orthodontists xxx (2018) 1e7
objectives of this review were to provide updated information on
the effects of BPs on oral tissues and particularly on OTM and to
suggest key aspects for the clinical management of patients with
OPO by orthodontists.
2. Bone remodeling with aging
As result of continuous bone remodeling, resorption and neo
bone formation are closely coupled since both processes require the
temporary assembly of the basic multicellular unit (BMU). The BMU
maintains the size, shape, and internal organization of new bone for
many months through a controlled direction, with the help of
circulating calciotropic hormones and local factors [6]. The
resorption/neo bone formation imbalance has been defined as a
multifactorial bone metabolism disorder, of which one key etiologic
factor is the loss of the suppressive effects of estrogens, such as
17b-estradiol, which reduce the production of cytokines that
hyperactivate OCLs, including receptor activator of nuclear factor
kappa-B ligand, interleukin-1b, interleukin-6, and tumor necrosis
factor a [7]. Another potential explanation for this imbalance is the
loss of other complementary actions that can increase the preva-
lence of osteocyte and osteoblast apoptosis due to the loss of sur-
vival signals that are induced directly by estrogens and androgens
via the nongenotropic activity of estrogen and androgen receptors
[7,8]. In addition, vitamin D and calcium (Caþ) deficiencies
contribute to bone loss in elderly men and women due to decreased
intestinal Caþ absorption with age and decreased synthesis of
endogenous vitamin D [6].
3. BPs as bone remodeling modulators
BPs have been used for more than 25 years to slow or prevent
bone damage, especially in patients with OP or OPO [5]. These types
of “bone-strengthening” drugs act on bone metabolism as synthetic
analogs of inorganic pyrophosphates that have a high affinity for
Caþ. The drug will get incorporated into the bone matrix as a result
of mineralization, and carry BP molecules to become part of the
structure and are naturally reabsorbed during natural skeletal
remodeling [9]. These drugs are deposited at sites with the highest
bone metabolism, mainly involving the maxilla, because the
maxillary bone metabolism is 10-fold higher than that in the tibia
and 5-fold higher than that in the mandibular canal. The higher
bone metabolism observed in the maxilla is associated with its
constant masticatory function [4].
4. Pharmacology of BPs and usual dosages
BPs are of two types, and both types inhibit bone resorption but
act by different pathways: those that prevent protein lipidation by
inhibiting the production of isoprenoids in the mevalonate pathway
are called the nitrogenous type [10], whereas the non-nitrogenous
BPs act through OCL apoptosis and inhibition of protein synthesis
[10,11].
The types and dosages per type for the BP types used in OPO are
compared in Table 1.
5. Short-term and long-term administration and its
implications in bone remodeling
BPs are used for the long-term treatment of OPO and OP by
millions of adults who might also seek orthodontic treatment [4].
BPs are one of the most prescribed drugs in primary long-term OPO
treatment that reduces morbidity and mortality; however, some
research also has described adverse effects in bone remodeling.
Most recent studies have considered those patients using
Please cite this article in press as: Arbelaez ML, et al., Effect of bisphosphonates on orthodontic tooth movement in osteoporotic patients: A
review, Journal of the World Federation of Orthodontists (2018), https://doi.org/10.1016/j.ejwf.2018.03.001
3
Table 1
Commonly used medications
Drug Primary indication Route Dose
Risedronate (Actonel) OPO Oral 35 mg/wk
Ibandronate (Boniva) OPO IV 150 mg/mo
Alendronate (Fosamax) OPO Oral 70 mg/wk
Zolendronate (Zometa) Bone metastases, OPO IV 5 mg/y
IV, intravenous; OPO, osteoporosis.
intravenous (IV) BPs or oral BPs for a prolonged period (more than
2 years) [12,13] as high risk, because BPs might also decrease the
activity of osteoclastic progenitor cells that could contribute to
MRONJ, the most reported complication while perfoming extrac-
tion in these patients [14]. More quality research is required to
understand the long-term adverse effects of BPs in orthodontic
procedures.
Regarding the short-term use of BPs, orthodontics has studied
BPs as agents to enhance retention and also as enhancers of the
ability of the anchor tooth to resist displacement [15,16]. Most
studies with the short-term approach use an oral, local, or topical
route administration because it has been proposed as the preferred
mode of drug administration in animal models and also the
regimen likely to be clinically acceptable [15e17]. The use of BPs per
day or weeks has offered an alternative to enhance the stability of
the tooth movement after orthodontic treatment and even
reducing the amount of inflammatory root resorption [18].
6. Biomarkers of bone turnover in oral fluids
Despite the ability of dental radiography to identify signs of
metabolic bone disease, recent studies have demonstrated that oral
fluids also can provide potential biomarkers for the diagnosis,
monitoring, and prognosis of many chronic diseases, such as OPO
[19,20]. Although X-ray absorptiometry or ultrasound techniques
have been widely used as non-invasive quantitative diagnostic
methods for measuring bone fragility or bone mineral density, the
reliability of diagnosis could be improved by using these techniques
in combination with biochemical methods to assess bone turnover
or the risk of bone fracture and to monitor responses to therapy
[21]. Type I collagen represents 90% of the organic matrix of bone
[22] and requires cross-linking molecules, such as pyridinium (PYR)
and deoxypyridinium (D-PYR) [23]. In addition, osteocalcin, the
most abundant noncollagenous protein of mineralized tissues, is
considered a valid serum bone turnover biomarker in oral fluids
[20]. With regard to human saliva, McGehee and Johnson [20]
identified significant correlations among age, body mass index, D-
PYR, and osteocalcin concentrations and calcaneus T scores (P <
0.05), suggesting that saliva could be used to assay human bone
turnover biomarkers; however, further scientific investigations are
needed.
7. BPs and OTM
OTM depends on osteoclastic activity [20], and although an
inhibitory effect of BPs on tooth movement has been reported in
non-human animals, it has not been quantified in humans. Ortho-
dontists generally accept that OTM is reduced after BP adminis-
tration, and this reduction has mainly been attributed to a decrease
in OCLs. Several animal experiments have reported a decrease in
OTM following BP administration, sometimes in a dose-dependent
manner [20,24,25]. Some human studies have reported a decrease
in OTM [26e28], whereas others have reported contradictory
findings [4] or have not evaluated OTM [29]. However, before
analyzing these human and animal reports, we consider it
4 M.L. Arbelaez et al. / Journal of the World Federation of Orthodontists xxx (2018) 1e7
important to understand the pathophysiology aspects of OTM in
patients under BP therapy.
8. The pathophysiology behind retardation of tooth
movement
The drugs prescribed for metabolic bone diseases are considered
as local and systemic factors that seem to affect OTM. The anti-
resorptive activity of BPs through reduction in number of OCLs
interfere with alveolar bone remodeling associated with tooth
movement resulting in its reduced pace, impaired bone healing,
and even induced MRONJs in the maxilla and the mandible [30].
Once the drug is in the bloodstream, approximately half is prefer-
entially bound to the surfaces of high bone turnover [31] Alveolar
bone has shown up to a 10-times greater bone turnover than bone
in any other region due to the constant masticatory forces [32] and
therefore contributes to the high BP bone incorporation and slow
drug elimination [33,34]. In orthodontic treatment, wherein high
bone turnover is a characteristic feature, it is reported that more BPs
could be bound and incorporated around the teeth than in other
bone areas of the body, explaining the longer duration for tooth
movement observed in these patients consuming BPs [35]. Some
authors even suggest an alveolar bone metabolism imbalance in
patients under BPs and conventional nonsurgical orthodontic
therapy could affect the bone healing inducing MRONJ. However,
this disclosure is controversial and requires long-term studies with
proper methodology for confirmation.
After more than 30 years of clinical use, the molecular
mechanisms through which BPs act remains an ambiguity and
the same applies for OTM also. It is suggested that reduction in
number of OCLs by BPs remains tha main pathway [15,36] but
structural changes in the cell, which include undulating margins,
cytoplasmic polarity, are also contributory.
9. Critical appraisal of animal studies until now
This section critically analyzes the available scientific evidence
about the effect of BP application in orthodontic therapy with
studies conducted on experimental animals for evaluating its
pharmacologic effects as well as effect on OTM.
The orthodontic literature concerning BPs concentrates pri-
marily on the ability of these drugs to stabilize teeth posttreatment
or with focal topical application to a localized area during therapy.
In fact, several animal experiments have reported slower tooth
movement, partly in a dose-dependent manner [24,25,37]. Sub-
periosteal injections adjacent to the molar (topical administration)
[15,38] or subcutaneous injections (systemic administration)
revealed a significant decrease in OTM in experimental animals
[15]. More over the published reports are abound with low level
evidence and data with inadequate size of study sample subgroups,
absence of method error analysis, and absence of blinding in
measurements [27]. They will always contain assumptions and
controversies, confusing the readers. There observed a lack of ready
reckoner for clinicians to understand not only the mechanism of
action of BPs, but also their clinical applicability, side effects, vari-
ation in presentation, and dosage.
So as in any scientific research, we suggest that professional
staff (scientists and clinicians) be aware about the updates on this
topic. Results yielded by studies on BPs with animals must be
more focused with proper sample size and subjected to appro-
priate methods that define aspects of experimental animal study,
clinical, or in vitro investigation.
Please cite this article in press as: Arbelaez ML, et al., Effect of bisphosphonates on orthodontic tooth movement in osteoporotic patients: A
review, Journal of the World Federation of Orthodontists (2018), https://doi.org/10.1016/j.ejwf.2018.03.001
10. Human interventions and effect on tooth movement
Due to the absence of clinical trials, this section deals with the
case reports [4,29,35,39e41] and cohorts [2] published on BPs ef-
fect on OTM. The literature still remains ambiguous with lack of
clarification on altered bone metabolism and the following con-
sequences to orthodontic therapy. There remains only statements
regarding dental surgical therapies in patients undergoing BP
therapy with no guiding principles for clinical orthodontists
[12,42e44].
In the analyzed articles, MRONJ occurred in only one high-risk
patient suffering from multiple myeloma who was treated with IV
zoledronate and chemotherapy [35]. This is in concordance with a
consensus document of The American Society of Bone and Mineral
Research, because one of their conclusions, among others, was that
the high risk of MRONJ in patients with cancer treated with high
doses of IV BPs than with oral BP therapy.
Nevertheless, most of the studies offer a low amount of scientific
evidence and does not allow the precise prediction of the interac-
tion between orthodontic treatment and BP therapy. Part of this
insufficient evidence may be explained by the different methodo-
logical criteria used, different sample sizes, and the heterogeneity of
the study populations. Thus, the findings have been contradictory
as far as credibility and clinical application of the results are con-
cerned. Also, the current state of knowledge does not allow or-
thodontists to identify which patients are vulnerable to
osteonecrosis or retardation in OTM. In a recent systematic review,
only 11 trials were considered appropriate for inclusion, and their
protocols were too variable to proceed with a quantitative synthesis
[28]. This reflects the state of the published scientific research on
this topic and our limited understanding, demanding the devel-
opment of focused research on the influence of BPs over tooth
movement, including clinical and experimental trials.
11. Effect of different BPs
The literature revealed few human and animal studies that have
been done on orthodontic patients who underwent BP medication
[2,27,28,30]. The conclusions reveal longer treatment duration or
higher chance of incomplete extraction space closure at the end of
treatment in patients or animals under BP administration (Table 2).
Some of the few described human studies, reporting consump-
tion of alendronate or zoledronate have reported decreased move-
ment [2,4,35]. However, this evidence is not consistent because there
exists other reports which mention that alendronate did not affect
OTM [4,40]. Several animal experiments also have reported slower
tooth movement, partly in a dose-dependent manner after sub-
periosteal injections adjacent to the molar tooth under study [15,17].
Risedronate appears to be the most effective in reducing OTM, fol-
lowed by 4-amino-1-hydroxybutylidene-1,1-bisphosphonate, then
clodronate besides other BPs (risedronate, alendronate, and zole-
dronic acid) which also showed significant effect in the OTM but by
systemic administration (subcutaneous) [15,45].
12. Considerations for the orthodontist
According to the published literature, orthodontists must un-
derstand the following key aspects to offer and optimize OTM in
patients under BP medications.
12.1. Osteonecrosis risk level
Dentists and orthodontists must be aware of the risk of anti-
resorptive agenteinduced MRONJ. In many cases, MRONJ has been
associated with invasive dental procedures, such as tooth
 M.L. Arbelaez et al. / Journal of the World Federation of Orthodontists xxx (2018) 1e7 5

Table 2
Effect of different BPs medication on tooth movement, a compiled of humans and animals studies

Study type Sample, anamnesis Drug Route Tooth movement

Case report [35] Female, Addison disease
(primary adrenal insufficiency)
Case report [35] Female, sacral plasmacytoma
Case report [4] Female, osteoporosis
prevention
Case report [4] Female, osteoporosis
prevention
Case report [4] Female, osteoporosis
prevention
Case report [28] Female, osteoporosis
prevention
In vivo experiment [15] 126 male Wistar rats aged 9
e10 wk divided in two groups
In vivo experiment [18] 72 rats aged 9e10 wk divided in
two groups
In vivo experiment [17] 42 male Wistar rats aged 7 wk
divided between groups
killed at 0.5 and
10 days
In-vivo experiment [38] 26 male Wistar rats
aged 7 wk
In vivo experiment [36] 19 male C57B1 rats aged 8 wk
In vivo experiment [45] 15 male Wistar rats aged 40 wk
Alendronate Oral, 1/wk 70 mg Decelerated
Zolendronate 1/mo Decelerated
500 mg IV
Alendronate Oral, dose Decelerated
not specified
Alendronate Oral, dose Decelerated
not specified
Alendronate Oral, dose not specified Not decelerated
(drug holiday 3 mo before
beginning and during
orthodontic
treatment)
Alendronate Oral, 1/wk 70 mg Not decelerated
Risedronate Local injection, 0, 125, 250, or Inhibition of dose-dependent
500 mmol/L tooth movement up to 49.6%
AHBuBP Subcutaneous injection, 0.02, Inhibition of dose-dependent
0.1, or 0.5 mg/kg in experiment tooth movement after
1 and 2. Injection 50 mm3 of subcutaneous injection;
AHBuBP solution (0.1 mmol/L) inhibition of tooth movement
in subperiostal area every after topical administration
3 d (topical administration)
Pamidronate IV, 1.5 mg/1.0 mL/kg 1 d before The administration of
withdrawing band bisphosphonates reduced
orthodontic movement
Clodronate Local injection every 3 days of Dose-dependent and significant
50 mL clodronate at 0, 2.5, 10, reduction of up to 56% of
or 40 mmol/L orthodontic movement
Pamidronate Subcutaneous injection of 70% reduction in the number of
pamidronate at doses of osteoclasts and 34% inhibition
5 mg/kg 1 for 8 d of tooth movement (latter not
statistically significant)
Alendronate, zoledronic acid Subcutaneous administration, A reduction of 58.3% of OTM
group 1: 2.5 mg/kg alendronate was found in Group OTMþA
(OTMþA), group 2: 0.02 mg/kg and 99.6% in group OTMþZ,
zoledronic acid (OTMþZ) when compared with group
OTM

AHBuBP, 4-amino-1-hydroxybutylidene-1,1-bisphosphonate; IV, intravenous; OTM, orthodontic tooth movement.

extraction, and has been reported spontaneously or in patients with
minor mucosal irritation, such as those who wear dentures.
Therefore, although there is no direct evidence demonstrating that
OTM causes MRONJ, orthodontists should consider its possibility as
an important complication.
Most recent studies have reported that patients using IV BPs or
oral BPs for a prolonged period (more than 2 years) and patients
with other comorbid risk factors, such as diabetes, smoking,
previous history of MRONJ, or history of using these drugs with
immunosuppressants or glucocorticoids as high risk groups for
development of osteonecrosis [12,13].
Bone cancer, such as multiple myeloma or metastatic breast
cancer treated with IV BPs, is an important contraindication for any
orthodontic treatment or elective dental surgical procedures [46]
due to the high incidence and severity of MRONJ, which is likely
secondary to the 12- to 50-fold higher systemic BP dose given to
treat bone cancer compared to that used to treat OPO [47]. How-
ever, study limitations, such as small sample size, a retrospective
study design, inadequate study duration, and issues associated with
the voluntary reporting of cases have hindered accurate estima-
tions of the incidence and prevalence of MRONJ in the general
population.
12.2. Length of continuous oral BP treatment
Known risk factors for MRONJ development depend upon spe-
cific characteristics of the BPs taken (type, dose, duration of use, and
administration route) and those of other medications taken in
parallel. Although MRONJ has rarely been reported, the length of
continuous oral BP use and the type of dental procedure are
important to note. Most MRONJ cases have occurred in patients
who had been taking oral BPs continuously for more than 3 years
and who underwent extractions [12,13,46]. After 3 years of
continuous oral BP use, the incidence of MRONJ can increase from
1:300 to 1:20 [48], mainly when dental extractions are performed.
With regard to OTM as a risk factor for MRONJ, no definitive evi-
dence of an association exists. However, we believe that although
the risk of MRONJ appears to be lower in OTM, MRONJ may take
longer to develop following extractions. Unfortunately, no cohort
studies have evaluated OTM and MRONJ over time. Therefore, for
patients using oral BPs, including those who have taken oral BPs
continuously for less than 3 years, dentists and orthodontists must
ensure that the risk of MRONJ is low [12,13,46]. However, even low-
risk patients can exhibit side effects, such as incomplete space
closure, poor root parallelism, an extended treatment duration, and
crown tipping instead of bodily movement [2,4,35].
Regarding IV BPs, the incidence of MRONJ after long-term IV BP
use for OPO treatment is unknown but presumed to be low [4]. IV
BP use involves a longer interval between doses, which should
result in lower active drug levels retained on the bone surface and
allow higher levels of normal cellular function to return between
doses [4]. One 5- to 10-year study of routine dental screenings re-
ported that the use of both IV and oral BPs for OPO treatment
resulted in similar numbers of rare occurrences of MRONJ [4].

Please cite this article in press as: Arbelaez ML, et al., Effect of bisphosphonates on orthodontic tooth movement in osteoporotic patients: A
review, Journal of the World Federation of Orthodontists (2018), https://doi.org/10.1016/j.ejwf.2018.03.001
6 M.L. Arbelaez et al. / Journal of the World Federation of Orthodontists xxx (2018) 1e7
However, orthodontists should proceed with caution regarding
decreased OTM and bone formation after intermittent IV BP
administration for OPO because higher effective systemic doses are
noted with IV administration than for oral administration, leading
to inhibition in OTM. During orthodontic treatment, concurrent IV
BPs could reduce the amount of bone remodeling around the teeth
due to increased drug incorporation, which might limit the pace of
OTM rapidly and profoundly.
12.3. Drug holiday
The American Association of Oral and Maxillofacial Surgeons has
recommended a drug “holiday” 3 months before and after surgical
interventions before any dental procedures, other than routine root
canal treatment, root scaling, or tooth restorative procedures, in
patients undergoing BP therapy [43]. However, it is unclear how
drug holidays affect the risk of fracture. In orthodontics, drug hol-
idays are a controversial subject for OTM due to the long half-life of
BPs in bone (10e12 years) [4] and the anti-angiogenic effects of BPs
on soft tissue, including the vascular system, which might continue
to affect OTM.
13. Conclusions
Considering the increasing numbers of older patients, an
intensive examination of the patient’s medical history before
treatment should be obligatory for the oral professional because of
the half-life of BPs. In patients who are under treatment with BP
agents, it is important for the patient and dentist be informed, and
both professionals must discuss possible complications with the
patient despite the low risk of developing MRONJ. Although the risk
cannot be eliminated, it can be minimized by maintaining excellent
oral hygiene, which is an essential part of risk management.
Therefore, open communication regarding treatment options is a
fundamental requirement, especially with the longer durations
associated with orthodontic treatment. Orthodontists treating
these patients must take into consideration the, decelerated OTM,
incomplete space closure, and poor root parallelism, which might
affect treatment outcome while planning mechanotherapeutics for
patients under BP medication.
Acknowledgments
This study was supported in part with funding from the Oral
Health Service, Hospital Universitario Fundación Santafé de Bogotá,
Colombia. The authors declare no conflicts of interest.
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Please cite this article in press as: Arbelaez ML, et al., Effect of bisphosphonates on orthodontic tooth movement in osteoporotic patients: A
review, Journal of the World Federation of Orthodontists (2018), https://doi.org/10.1016/j.ejwf.2018.03.001