Table 5.
Recommendations for dental management in specific conditions
| A.Dental procedures during antiresorptive therapy |
| Patients at low risk of ONJ |
| Conservative treatments (restorative treatment, non-surgical endodontic treatment, prosthodontic/orthodontic therapy) are safea |
| Elective dentoalveolar surgery, simple extractions, and procedures that do not involve osteotomy are considered to be of low risk (9) |
| Placement of dental implants entails small risk |
| Antimicrobial mouthwash before/after procedure is advised. Systemic antibiotics are also advised in nonconservative treatments (180) |
| Antiresorptive treatment management |
| Osteoporotic patients |
| Do not discontinue bisphosphonatesb |
| Do not discontinue denosumab—perform procedure preferably 5-6 mo following the last injection |
| Lower doses of antiresorptives (74)? No supporting evidence |
| Cancer patients |
| Do not discontinue bisphosphonatesb,c |
| Do not discontinue denosumab |
| Patients at high risk of ONJ |
| Mild conservative treatments (restorative treatment, removal of dental caries) are usually safe |
| Nonsurgical endodontic treatment has a small risk—could be an alternative to extraction (244)d |
| Root canal treatment and/or decoronation preferred over extraction (244) |
| Antimicrobial mouthwash, systemic antibiotics before/after the procedure, avoidance of anesthetic agents that contain vasoconstrictor, avoidance of gingival tissue damage |
| Denture wearing not prohibited (avoid exerting excessive pressure or friction) (79) |
| Antiresorptive treatment management |
| Osteoporotic patients |
| Bisphosphonates could be discontinued (at least 1 wk before and until surgical site healing) (84, 245)e |
| Do not discontinue denosumab—perform procedure preferably 5-6 months following last injection (245, 246)f—perform next denosumab injection 4-6 wk after the procedure but not > 4 wk later than it should be done |
| Consider replacing antiresorptives with teriparatideg |
| No data on romosozumab |
| Cancer patients |
| Personalized decision in agreement with treating oncologist, weighing risk of ONJ against risks of SREs |
| Bisphosphonates could be discontinued |
| Short-term denosumab discontinuation (eg, 3 wk before and 4-6 wk after dental procedure has been advised) (247)—no clear benefith |
| B.Antiresorptive treatment management in patients who develop ONJ |
| Consider discontinuing antiresorptives until complete soft-tissue closure after carefully weighing risk of ongoing ONJ with risk of fractures or SREsi |
| Consider teriparatide until complete soft-tissue closure (22) (in osteoporotic but probably not in cancer patients—individualized approach)j |
Abbreviations: ONJ, osteonecrosis of the jaw; SRE, skeletal-related event.
a A few, not well-documented cases of ONJ reported after nonsurgical endodontic procedures (248).
b Residual effect of bisphosphonates questions the effect of discontinuation on ONJ; in osteoporotic patients tooth extraction safely performed without bisphosphonate discontinuation (249); suspension of bisphosphonates not beneficial in animals (250) and humans (251, 252) who developed ONJ.
c Reduction in SRE risk is greater and the risk of ONJ lower in first years of bisphosphonate therapy (247).
d Soft-tissue damage during endodontic treatment has also been associated with initiation of ONJ process (253).
e Unknown optimal duration of off-treatment period.
f Based on denosumab pharmacokinetics, its effect on bone turnover is almost depleted around 6 months following the last injection (245, 246).
g Concerns: limited duration of teriparatide treatment (23); temporary decrease at least of hip bone mineral density (254); uncertain effect on rebound phenomenon after denosumab discontinuation (246).
h OPG-Fc discontinuation before tooth extraction ameliorated subsequent ONJ development in rodents (250); in contrast, in a multicenter retrospective Japanese study short-term denosumab discontinuation had no effect on ONJ risk (255).
i Concerns: denosumab discontinuation infers increased risk of multiple vertebral fractures (256, 257); discontinuation of either ZOL or OPG-Fc in rats with established ONJ did not lead to ONJ resolution (250).
j Teriparatide is theoretically contraindicated in cancer patients but a brief exposure (eg, 8 wk) should not activate quiescent malignant cells.