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Title Limited Evidence Suggests Oral Health Providers Should Observe Caution When Treating Post-Menopausal Women Taking Aromatase Inhibitor (AI) Drugs or Estrogen Modulating Agents
Clinical Question Is there an increased risk of alveolar bone loss and dental-related complications in post-menopausal women taking aromatase inhibitor drugs or estrogen/progesterone modulator agents?
Clinical Bottom Line Special consideration should be taken regarding the treatment of post-menopausal women taking aromatase inhibitor (AI) drugs. In particular, this includes monitoring periodontal disease, patients undergoing dentoalveolar surgery, and monitoring bone density. Evidence suggests appreciable loss of vertebral bone and increased risk of fracture with prolonged use in limited cases. In addition, conjunctive use of bisphosphonates has been utilized, so thorough consideration of MRONJ should also be appreciated prior to dental treatment.
Best Evidence (you may view more info by clicking on the PubMed ID link)
PubMed ID Author / Year Patient Group Study type
(level of evidence)
#1) 22986813Taichman/201345 articles Narrative review
Key resultsThere is considerable evidence to indicate aromatase inhibitors (AI) may generate osseous concerns. Dental-specific considerations remains an understudied topic and the implications are currently unknown. This narrative review included 45 articles from a search on postmenopausal women with breast cancer taking AI drugs and oral health considerations. Of the 45 included articles, none of them explored as association of AI drugs and oral health. Seven looked into bisphosphonates, and overwhelmingly there was no research into oral health. "Periodontal diseases, alveolar bone density, tooth loss, and conditions of the soft tissues of the mouth have all been associated with menopausal status supporting the hypothesis that the soft tissues and bone of the oral cavity could be negatively affected by anti-estrogen therapy. The structures of the oral cavity are influenced by estrogen; therefore, anti-estrogen therapies may carry the risk of oral toxicities. Oral health care for breast cancer patients is an important but understudied aspect of cancer survivorship."
#2) 16100521 Lester/2005Breast cancer patients taking AI drugsNarrative review
Key resultsAI drugs (aromatase inhibitors) may exacerbate bone loss. "The increasing use of systemic adjuvant therapies has considerably improved the prognosis from early breast cancer. However, some of these therapies affect bone metabolism, resulting in osteoporosis. Aromatase inhibitors lower circulating oestrogen levels to almost unrecordable levels in postmenopausal women, predisposing them to bone loss with an increase in fracture risk."
#3) 24795759Pooleriveetil/2014postmenopausal women with early breast cancer taking bisphosphonates and aromatase inhibitor drugsMeta-Analysis
Key resultsUse of conjunctive bisphosphonates in women who used AI drugs showed better bone-mineral density (BMD) results. "A total of six eligible studies reported the BMD T score of LS at 12 months and from that 3 trials of Zoledronic acid compared the change in BMD in immediate ZOL versus delayed ZOL done with subgroups like patients with normal BMD at baseline (OR = 5.402, 95% CI = 1.329-21.959, P value = 0.018) and osteopenic BMD at baseline (OR = 4.008, 95% CI = 2.249-7.143, P value = 0.0002). Both had a significant decrease in BMD that favoured the delayed ZOL; 3 trials of risedronate and ibandronate also had a significant decrease in BMD in AIs alone group. Conclusion. Third generation bisphosphonates has an effect on BMD of patients who are on treatment of AIs in breast cancer. Furthermore, the patients treated with immediate ZOL had a significantly high risk of musculoskeletal ADR's than patients with delayed ZOL."
Evidence Search (("Aromatase Inhibitors"[Mesh] AND "Oral Health"[Mesh]) AND ("postmenopause"[MeSH Terms] OR "postmenopause"[All Fields])) AND ("breast neoplasms"[MeSH Terms] OR ("breast"[All Fields] AND "neoplasms"[All Fields]) OR "breast neoplasms"[All Fields] OR ("breast"[All Fields] AND "cancer"[All Fields]) OR "breast cancer"[All Fields])
Comments on
The Evidence
There is currently no literature to support any direct association regarding AI drugs and oral health complications. The literature that does exist is weak regarding clinical relevance at this time and consists mostly of medical and dental opinion. One author, Taichman, has recently concluded a study (2015) that looks at the drugs and periodontal considerations. Much of the information provided is a proposed association to oral health due to bone changes elsewhere in the body from taking the drugs. A direct relationship demonstrating the results of these effects on patient’s oral health is currently not available. There is a lack of investigation into the effects of adjunctive cancer therapy and oral health.
Applicability A significant number of patients will unfortunately develop breast cancer in their lifetime. Dental practitioners should familiarize themselves with adjunctive cancer treatments and potential oral health considerations. Dentists should exercise caution related to dentoalveolar surgery and potential increased risk of fractures, periodontal considerations and oral health planning. Dental practitioners should familiarize themselves with bone mineral density (BMD) values. Because of the prevalence of breast cancer dentists should expect to treat patients who are taking aromatase inhibitors (AI) and estrogen modulator drugs. Due to the clinical relevance and ability to improve the prognosis for these patients we need to determine the potential oral health precautions for AI and related agents.
Specialty/Discipline (Public Health) (Oral Medicine/Pathology/Radiology) (General Dentistry) (Oral Surgery) (Periodontics) (Basic Science)
Keywords Aromatase inhibitors (AI), Bone loss, alveolar bone, oral heath, cancer patients, postmenopausal women, Breast cancer, bisphosphonates, MRONJ, dental, BMD, fracture.
ID# 2949
Date of submission: 11/09/2015spacer
E-mail mortoni@livemail.uthscsa.edu
Author Isaac Morton, DMD
Co-author(s) e-mail
Faculty mentor/Co-author Ernie Luce, DDS
Faculty mentor/Co-author e-mail LUCE@uthscsa.edu
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