Tooth extraction while taking bisphosphonates or denosumab: who is at higher risk for the jawbone?

Bone is a living tissue that is constantly broken down and rebuilt. Bisphosphonates (alendronate, risedronate, ibandronate, zoledronic acid) and denosumab suppress the cells that break bone down; this slows bone loss and lowers the risk of fracture. The American Dental Association (ADA) writes that the same effect is thought to slow the repair of small injuries in the jaw too, but that the mechanism is not fully understood. When a tooth is removed, the socket normally closes within weeks; in a small group of patients taking these medicines, however, the socket does not close and the bone underneath is left exposed.

This condition is called medication-related osteonecrosis of the jaw. MSD Manuals states that the diagnosis is made if a person taking the medicine has bone exposed in the jaw for at least 8 weeks and has not had radiotherapy to the head and neck. It can be painful or painless; as it progresses, pus can come from the exposed bone, teeth can become loose, and channels opening into the mouth or onto the face can form. MSD notes that about 75 per cent of cases are seen in the lower jaw, which is linked to the lower jaw's poorer blood supply. It can also develop spontaneously, but the most common triggers are tooth extraction and surgery that touches the bone.

The first thing that determines the size of the risk is why the medicine was given. According to the 2024 supplement of the Scottish Dental Clinical Effectiveness Programme (SDCEP), current estimates are generally under 5 per cent in cancer patients and under 0.05 per cent in osteoporosis patients. The same document reports that for osteoporosis, estimates are generally under 0.05 per cent for bisphosphonates, and between 0.04 and 0.3 per cent for denosumab in people taking it for up to 10 years. The ADA gives the rate as 0.001 to 0.01 per cent in osteoporosis patients taking bisphosphonates by mouth, and 1 to 10 per cent in patients with cancer that has spread to the bone taking bisphosphonates into a vein. The figures vary from source to source because the designs of the studies and the patient groups differ; but the large difference between the two groups is the same in every source.

The second determining factor is duration and accompanying conditions. In SDCEP's risk pathway, a patient taking bisphosphonates for osteoporosis counts as low risk if they have been taking the medicine for less than 5 years and are not also taking a steroid medicine (systemic glucocorticoid). Bisphosphonate use for more than 5 years, concurrent steroid treatment, taking the medicine because of cancer or having had osteonecrosis of the jaw before moves the patient into the high-risk group. The risk factors the ADA lists are similar: age over 65, gum disease, poor oral hygiene, surgery such as tooth extraction, use for more than 2 years or at high doses, smoking, chemotherapy, steroids, wearing a removable denture, and diabetes.

Pausing the medicine before an extraction, the so-called drug holiday, is the most asked-about topic and the one with the least evidence. The ADA states that there is not enough evidence to recommend a drug holiday or a waiting period before dental treatment to prevent osteonecrosis of the jaw with medicines used for osteoporosis. A multicentre study in Japan of patients taking bisphosphonates by mouth found no evidence that a short drug holiday before extraction reduced the risk. At Hacettepe in Ankara, in 51 patients receiving bisphosphonates into a vein because of cancer, there was also no significant difference between those who took a short drug holiday and those who did not; the authors explain this by the medicine staying in the bone for a long time. In a Japanese study of patients receiving denosumab at cancer doses, a short drug holiday was also not found to be protective.

Stopping the medicine has its own price. SDCEP's leaflet for osteoporosis patients answers the question of whether to stop the medicine with a clear no: it says that the benefit of the medicine is much greater than its risk, and suggests you discuss your questions with your doctor and your dentist. For denosumab the position is even clearer: one review reports that in roughly 1 in 14 patients who stop denosumab without then switching to another bone medicine, multiple spinal fractures develop as bone breakdown rebounds, and that delaying a dose by more than about 7 months on average is also risky. This is why the timing of the medicine is a decision not for the dentist but for the doctor who prescribes it.

So how is the extraction itself made safer? In the Japanese study of patients taking bisphosphonates by mouth, sectioning the roots, single-tooth extraction, advanced bone loss or advanced loosening, and leaving the wound open were associated with risk; the authors present the extraction technique that strains the bone least, smoothing sharp bone edges and closing the wound with tissue as standard recommendations. The ADA also recommends, where possible, a conservative surgical technique in which the wound is closed with tissue, and a chlorhexidine mouthwash until healing. SDCEP, on the other hand, recommends that in the low-risk group the extraction be done in the usual way, and that antibiotics not be given solely to reduce the risk of osteonecrosis of the jaw. It is also worth knowing that the evidence on this is limited: a 2022 Cochrane review concluded that the evidence is insufficient to prove or disprove the benefit of preventive methods.

The most effective measure is timing. MSD and SDCEP recommend that any necessary oral surgery be done, where possible, before the medicine is started, that hopeless teeth be removed without delay and that oral health be put in order when the medicine is started. SDCEP specifically asks that patients who are about to start the medicine because of cancer have a thorough dental examination before treatment. In other words, if one of these medicines has just been recommended to you, the first thing to do is to see your dentist.

The grouping below is based on the risk pathway of the Scottish guidance (SDCEP) and the ADA's risk factors. Your dentist decides which group you are in, together with your medication history.

The sequence below follows the pathway the guidelines recommend. If you have facial swelling that is growing quickly, a high fever, or difficulty swallowing or breathing, the emergency comes first: call 112 or go to the nearest A&E.

1. 1

   Taking a complete medication history

   The dentist asks the name of the medicine, why it was given, whether it is taken by mouth, into a vein or by injection, how long it has been taken and the date of the last dose. Steroids, chemotherapy and cancer medicines that suppress blood vessel formation also go on the list. Bringing a photo of your medicine boxes or your prescription makes this easier.

2. 2

   Determining and recording the risk group

   SDCEP recommends that the patient be placed in the low- or high-risk group and that this be recorded. Being a cancer patient, bisphosphonate use for more than 5 years, steroids and previous osteonecrosis of the jaw are high-risk criteria.

3. 3

   Looking at whether the tooth can be kept

   In the high-risk group, SDCEP recommends exploring alternatives to extraction; the ADA also says that root canal treatment should be preferred to surgery for a tooth that can be saved. In the low-risk group, on the other hand, SDCEP recommends that usual treatment not be changed.

4. 4

   Contact with the prescribing doctor

   If the timing or stopping of the medicine comes up, the decision belongs to the doctor who prescribed it. For osteoporosis, guidelines do not recommend a drug holiday; stopping denosumab unplanned raises the risk of spinal fractures. For cancer patients, the decision is made together with the oncologist.

5. 5

   An extraction that strains the bone little, and closing the wound

   The studies and the ADA recommend the technique that strains the bone least, smoothing sharp bone edges and, where possible, closing the wound with tissue. The ADA also recommends rinsing gently with chlorhexidine mouthwash before and after surgery until the socket has healed.

6. 6

   The antibiotic decision

   SDCEP recommends that antibiotics or antiseptics not be given after an extraction solely to reduce the risk of osteonecrosis of the jaw, but that they be given if there is another clinical reason. Practice on this varies between countries and institutions; ask your dentist for their reasoning.

7. 7

   Monitoring healing for 8 weeks

   Whether the socket has closed is seen at the check-up. SDCEP recommends referral to an oral surgery specialist for a socket that has not healed in 8 weeks where osteonecrosis of the jaw is suspected.

The options vary with the risk group. In the low-risk group, usual treatment can often continue, while in the high-risk group, routes that do not touch the bone come to the fore.

Fear of osteonecrosis of the jaw sometimes leads to decisions that do more harm than the osteonecrosis itself.

In most patients the socket closes in the usual way. The course below shows what you need to watch out for; your dentist's instructions take priority.

1. The first week

   Usual aftercare for an extraction applies. As the ADA recommends, you may be asked to rinse gently with chlorhexidine mouthwash until the socket has healed. Follow the other instructions your dentist gives you.

2. Weeks 2–4

   The top of the socket begins to close over with tissue. If you can feel a hard, rough surface with your tongue, or there is a bad taste coming from the socket, go without waiting for the check-up.

3. The 8-week check-up

   This check-up is critical, because the diagnostic criterion is 8 weeks. At this point, SDCEP recommends specialist referral for a socket that has not healed where osteonecrosis of the jaw is suspected.

4. After that

   Regular dental check-ups and good oral hygiene continue. For these patients, SDCEP recommends fluoride toothpaste and mouthwash, cutting down on sugary snacks, stopping smoking and limiting alcohol.

We do not give figures here. For a patient taking these medicines, the scope of an extraction or implant varies with the risk group and the general condition of the mouth. The items that determine the scope:

Risk group

In the low-risk group, usual treatment continues; in the high-risk group, a specialist oral surgeon's assessment and alternative treatments come into play.

Coordination between doctors

Correspondence with the prescribing doctor or the oncologist and, if needed, a change to the medication plan can lengthen the process.

Extraction technique and follow-up

Closing the wound with tissue and the follow-up appointments over 8 weeks are part of the procedure.

If osteonecrosis of the jaw develops

MSD recommends that treatment be carried out by an experienced oral surgeon with limited debridement, antibiotics and an antiseptic mouthwash; the duration and scope vary with the picture.