Jawbone death a rare side-effect
DEAR DR. ROACH: I am taking Fosamax for osteoporosis. One of the side effects is osteonecrosis of the jaw. Does this only happen if you have major dental work, such as pulling teeth or root canals, or can it happen with routine cleanings, fillings?
ANSWER: The word osteonecrosis literally means “bone death,” so osteonecrosis of the jaw is a serious condition involving poor blood flow that results in death of the bone cells in the jaw. It may affect either the top portion (maxilla) or bottom (mandible).
ONJ can happen in people who aren’t taking medications, especially people with certain conditions such as having had radiation to the jaw or sickle cell disease, but it is often associated with some kinds of medications used to treat osteoporosis, such as the alendronate (Fosamax) you take. It is more common with intravenous medications than with pills.
Additional risk factors include steroid use (such as prednisone), active cancer, smoking, diabetes and pre-existing dental disease. However, dental extractions and implants also increase risk of ONJ. Regular dental care, such as cleanings, probably decreases the risk of ONJ by improving dental health.
ONJ is not common in people taking oral medications such as Fosamax. The estimate is that for a person taking an oral bisphosphonate for five years, about one in 20,000 people will develop ONJ.
That risk is significantly greater in people with additional risk factors, but still is only about one in 2,000 people.
Most experts who use Fosamax and similar medications will hold off on treating patients with these medicines if they have dental work such as extractions or implants planned. The delay is typically a few months, until after healing of the jaw is complete.
DEAR DR. ROACH: I’m in my 60s and am noticing many people — mostly women — with crossed toes. It looks painful. Why don’t their doctors send them to a podiatrist? Why do people just let this go? It can’t be money, because many of the folks who I see have plenty of that! Could you enlighten me? I live in a warm climate, so I see lots of feet.
ANSWER: There are many common deformities of the toe, including crossover toe, hammertoe, bunions and claw toe. Both men and women get these, but women may be more likely to get them if they are putting their feet into pointy-toed, high-heeled shoes, which make a person’s feet more prone to tendon damage.
I’ll bet many of the people you see have been to a podiatrist — at least, I hope so, because podiatrists are the experts on feet. But not every problem of the foot or toes needs surgery to be fixed. Proper footwear, orthotics, “buddy taping” a toe into place and using toe spacers all can help this condition.
More advanced cases need further treatment, sometimes including physical therapy or injection.
Surgery is considered only when less invasive treatments have failed and the person continues having symptoms that are severe enough to make surgery worthwhile.
DEAR DR. ROACH: In November 2021 my son, who is 30, was diagnosed with Addison’s disease and was treated with cortisol. He was doing well on that regimen. In March, his blood sugar went up (300+), and he was diagnosed with Type 1 diabetes. As late as January his blood sugar was normal! We are told that it happens sometimes with Addison’s.
Now I am wondering what is next. He had had problems for the past 10 years. Anytime we ended up in emergency he would be told to drink fluids and eat the BRAT diet. He was always tired, but when we told the doctors that, it was blamed on being a college student and possibly lifestyle. I wonder how many people never reach crisis so that they are diagnosed.
ANSWER: Both Addison's and Type 1 diabetes are autoimmune diseases, where the body's immune system destroys important tissues. In Addison’s, it’s the adrenal cortex, a gland that sits on top of each kidney and makes cortisol. In Type 1 diabetes, it's the islet cells in the pancreas, which makes insulin.
Autoimmune diseases often run together. Others to watch out for include autoimmune thyroid disease and pernicious anemia, caused by destruction of stomach cells that make "intrinsic factor" that allows vitamin B12 to be efficiently absorbed. Vitiligo is another. In vitiligo, the skin pigment cells are destroyed.
The diagnosis of Addison’s disease can be tough to make. Fatigue is the major symptom, and so many things can cause that. When symptoms of fatigue persist beyond what is common, it should be on the list a physician thinks about.