How should a 69-year-old woman who previously received denosumab (Prolia) and is currently being treated with romosozumab (Evenity) be managed when she requires three dental extractions?

Management of Dental Extractions in a Patient on Evenity (Romosozumab)

This patient should proceed with the dental extractions using a minimally invasive surgical approach with meticulous wound closure, while continuing Evenity without interruption, given that drug holidays do not reduce MRONJ risk and the primary osteoporosis indication takes precedence.

Risk Assessment for MRONJ

Your patient has moderate risk for medication-related osteonecrosis of the jaw (MRONJ) based on:

• Prior denosumab (Prolia) exposure: Creates cumulative antiresorptive burden 1
• Current romosozumab (Evenity) therapy: FDA labeling explicitly warns about ONJ risk and mandates informing dentists before dental work 2
• Sequential antiresorptive exposure: The combination of prior denosumab followed by romosozumab increases theoretical risk 1

However, romosozumab monotherapy appears to have lower MRONJ risk than high-dose denosumab or bisphosphonates. In a recent observational study of 201 patients undergoing 303 invasive dental procedures (231 extractions) during romosozumab therapy, only one case of MRONJ occurred, and this was in a patient with sequential denosumab-romosozumab-zoledronic acid exposure plus local infection—no clear causal relationship to romosozumab alone could be established 1.

Pre-Extraction Protocol

Oral Assessment and Optimization

• Examine extraction sites for pre-existing infection (periodontitis, periapical lesions, abscesses)
• Pre-existing inflammation is the strongest risk factor (OR 243.77) for post-extraction MRONJ 3
• If infection present: Start antibiotics immediately and extract promptly—do not delay as inflamed teeth should be removed urgently 3

Antibiotic Prophylaxis

• Initiate preoperative IV antibiotics before extraction 4
• Continue oral antibiotics postoperatively per standard protocols 5
• Use antibacterial mouth rinse perioperatively 5

Drug Holiday Decision

Do NOT discontinue Evenity for this procedure. Here's why:

• Drug holidays for denosumab show no significant protective effect against DRONJ after tooth extraction 3
• Romosozumab has a 12-month limited treatment window by FDA mandate—interruption wastes critical anabolic therapy time 2
• Stopping romosozumab risks rebound bone loss and vertebral fractures, similar to denosumab discontinuation 6
• The osteoporosis indication (fracture prevention) outweighs the low MRONJ risk from romosozumab 1

Surgical Technique (Critical for Prevention)

Use minimally invasive extraction technique with primary closure 4:

1. Atraumatic extraction: Minimize bone trauma, preserve periosteum and blood supply
2. Smooth bone edges: Remove sharp spicules that could perforate mucosa
3. Debride thoroughly: Remove all granulation tissue and infected material
4. Double-layered closure: Achieve tension-free primary wound closure to prevent secondary infection 4
5. Avoid additional procedures: No simultaneous implant placement or alveoloplasty

This approach achieved 92.5% healing rate (37/40 sites) in denosumab patients 4.

Post-Extraction Management

Immediate Postoperative Care

• Maintain meticulous oral hygiene with antibacterial rinses 5
• Continue calcium and vitamin D supplementation (required during Evenity therapy) 2
• Monitor for hypocalcemia symptoms (muscle spasms, paresthesias) 2

Follow-Up Schedule

• Week 2: Assess wound healing, suture removal if indicated
• Week 8: Dental specialist follow-up to evaluate for exposed bone or delayed healing 5
• Ongoing: Continue Evenity on schedule (monthly injections) without interruption

MRONJ Surveillance

Watch for signs of MRONJ (report immediately if present):

• Exposed bone persisting >8 weeks
• Pain, swelling, or purulent drainage at extraction sites
• Numbness or paresthesias (stage 3 disease) 5

Key Pitfalls to Avoid

1. Do not delay extraction if infection present—this increases MRONJ risk dramatically 3
2. Do not skip primary wound closure—exposed bone invites secondary infection 4
3. Do not discontinue Evenity—no protective benefit and risks rebound fractures 3, 6
4. Do not perform multiple invasive procedures simultaneously (avoid implants at this time)
5. Do not ignore systemic factors: Corticosteroid use (OR 73.50) and diabetes significantly increase risk 3

Communication with Prescribing Physician

Coordinate with the physician managing her osteoporosis to:

• Confirm she's taking adequate calcium (1000-1200mg) and vitamin D (800-1000 IU) daily 2
• Document the dental procedure in her medical record
• Plan transition to antiresorptive therapy (bisphosphonate or denosumab) after completing 12 months of Evenity 2

The evidence strongly supports proceeding with necessary extractions using proper surgical technique while maintaining osteoporosis therapy, as the fracture prevention benefits outweigh the low MRONJ risk in this clinical scenario 1, 4.