Should treatment with teriparatide (teriparatide) be delayed pending dental clearance in a patient with no insurance coverage for dental services?

Teriparatide Treatment Should Not Be Delayed Pending Dental Clearance in Patients Without Insurance Coverage for Dental Services

Treatment with teriparatide should proceed without delay for dental clearance in patients who lack insurance coverage for dental services, as delaying effective osteoporosis treatment poses greater risks to morbidity and mortality than the low risk of osteonecrosis of the jaw (ONJ).

Risk Assessment for ONJ with Teriparatide

Teriparatide differs significantly from antiresorptive medications in its mechanism of action and risk profile:

• Teriparatide is an anabolic agent that stimulates bone formation, unlike bisphosphonates or denosumab which inhibit bone resorption 1
• The incidence of ONJ with teriparatide is extremely low compared to antiresorptive agents
• Teriparatide has actually been shown to promote bone healing in medication-related ONJ in clinical trials 2

Clinical Decision Algorithm

1. Assess baseline risk factors for ONJ:

   • History of radiation therapy to jaw/neck
   • Pre-existing dental problems
   • Poor oral hygiene
   • Planned invasive dental procedures

2. If no high-risk factors are present:

   • Initiate teriparatide without delay
   • Provide oral hygiene education
   • Recommend routine dental care when financially feasible

3. If high-risk factors are present:

   • Consider basic oral examination by the prescribing physician
   • Provide calcium and vitamin D supplementation while initiating teriparatide
   • Refer to dental services with sliding scale fees or dental schools if available

Evidence Supporting Immediate Treatment

The risk of delaying osteoporosis treatment must be weighed against the minimal risk of ONJ with teriparatide:

1. Teriparatide safety profile:

   • Unlike bisphosphonates and denosumab, teriparatide has not been significantly associated with ONJ 1
   • Teriparatide increases BMD at most sites and decreases nonvertebral fractures more effectively than alendronate 3

2. Therapeutic benefits:

   • Teriparatide reduces vertebral fractures by approximately 70% and non-vertebral fractures by about 45% 4
   • Delays in treatment could result in preventable fractures with significant morbidity and mortality consequences

3. ONJ risk mitigation:

   • Basic oral hygiene measures can be implemented without formal dental visits
   • Patient education about maintaining oral health can be provided by the prescribing physician

Practical Recommendations

• Initiate teriparatide at the standard dose of 20 μg daily by subcutaneous injection

• Provide calcium (1000-1200 mg/day) and vitamin D (800-1000 IU/day) supplementation concurrently 1

• Educate patients on proper oral hygiene practices:

  • Regular brushing with fluoride toothpaste
  • Flossing daily
  • Avoiding tobacco products
  • Limiting alcohol consumption

• Advise patients to report any oral symptoms promptly (pain, swelling, numbness, loose teeth)

• Consider scheduling follow-up within 3 months to assess treatment response and oral health status

Important Considerations

While dental evaluation is ideal before starting any bone-modifying agent, the risk-benefit analysis strongly favors initiating teriparatide without delay in patients without dental insurance. The risk of ONJ with teriparatide is minimal, while the risk of fracture from untreated osteoporosis is substantial and associated with significant morbidity and mortality.

Unlike antiresorptive agents (bisphosphonates and denosumab) which have documented associations with ONJ, teriparatide has been shown to actually promote bone healing and has been used as a treatment for established ONJ in some cases 2.