For how long should bisphosphonates be ceased prior to teeth extractions to minimize the risk of osteonecrosis of the jaw (ONJ)?

Bisphosphonate Discontinuation Before Tooth Extraction

Routine discontinuation of bisphosphonates prior to tooth extraction is not necessary, as evidence for its efficacy in reducing the development of medication-related osteonecrosis of the jaw (MRONJ) is limited. 1

Risk Assessment and Management Approach

Risk Factors for Osteonecrosis of the Jaw (ONJ)

• The most consistent risk factor for ONJ is recent prior dental surgery or extraction 2
• Risk increases with:
  • Frequency, dose, and duration of bisphosphonate administration 2
  • Intravenous administration (higher risk than oral) 2
  • Concurrent chemotherapy or corticosteroid use 2
  • Poor oral hygiene and pre-existing dental infections 2

Pre-Extraction Recommendations

• Complete a comprehensive dental evaluation before starting bisphosphonate treatment whenever possible 2
• Perform any necessary invasive dental procedures before initiating bisphosphonate therapy 2
• Correct vitamin D deficiency prior to bisphosphonate therapy to avoid hypocalcemia 2
• For patients already on bisphosphonates:
  • Antibiotic prophylaxis before extraction is recommended 3, 4
  • Maintain good oral hygiene 2

Discontinuation Considerations

• Some experts have hypothesized that stopping bisphosphonates 2 months prior to oral surgery may allow better bone healing 2
• However, the alternative view is that a short break in bisphosphonate administration will have no effect, as bone effects of bisphosphonates are maintained for years after treatment stops 2
• Research shows that tooth extraction can be performed safely without discontinuing bisphosphonates 3, 1, 5

Evidence on Extraction Outcomes

Safety of Extraction During Bisphosphonate Treatment

• A prospective study of 700 patients on oral bisphosphonates undergoing 1,480 tooth extractions showed no cases of ONJ when using appropriate surgical protocols 5
• Another study of 132 patients continuing oral bisphosphonate therapy during extraction showed delayed healing with longer duration of therapy but no development of ONJ 3
• A comparative study found no significant difference in MRONJ incidence between patients who continued bisphosphonates (1 case out of 179 patients) and those who discontinued them (0 cases out of 286 patients) 1

Healing Time Considerations

• Long-term oral bisphosphonate therapy for >5 years significantly delayed healing of extraction sockets compared to administration for <5 years 3
• The risk of ONJ is very high after twelve months of oral administration and six months of intravenous administration in patients who have a trigger point in the jaws area 6

Practical Extraction Protocol

Recommended Approach

• Use atraumatic extraction techniques to minimize trauma to both soft and hard tissues 5
• Provide antibiotic coverage before and after extraction 4, 5
• Consider closure by secondary intention rather than primary closure for better outcomes 5
• Regular follow-up to monitor healing 3

Post-Extraction Monitoring

• Monitor for signs of delayed healing or infection 3
• If bisphosphonates are discontinued, consider restarting after complete osseous healing has occurred 2

Important Caveats

• The incidence of ONJ is very rare with oral bisphosphonates (<1 case per 100,000 person-years) 2
• Intravenous bisphosphonates carry a higher risk of ONJ than oral formulations 2
• Patients receiving bisphosphonates for cancer treatment are at higher risk than those taking them for osteoporosis 2
• It is not tooth extractions themselves, but rather prevailing infectious conditions that may be a key risk factor for ONJ development 4