Is a C-TELOPEPTIDE (C-terminal telopeptide) serum level of 293 pg/mL appropriate for tooth extraction?

CTX Level of 293 pg/mL is Appropriate for Tooth Extraction

A serum CTX level of 293 pg/mL is well above the 150 pg/mL threshold and indicates low risk for bisphosphonate-related osteonecrosis of the jaw (BRONJ), making tooth extraction appropriate to proceed. 1, 2

Risk Stratification Based on CTX Values

The critical threshold for BRONJ risk assessment is CTX < 150 pg/mL, which defines the "risk zone" for developing osteonecrosis after dentoalveolar surgery 1, 2:

• CTX ≥ 150 pg/mL: Low risk - proceed with extraction under standard protocols 1, 2
• CTX < 150 pg/mL: Elevated risk - consider drug holiday if medically appropriate before extraction 1, 2

Your patient's CTX of 293 pg/mL places them in the low-risk category, nearly double the safety threshold 1.

Evidence Supporting the 150 pg/mL Threshold

A large prospective study of 950 patients undergoing 2,461 extractions demonstrated that CTX < 150 pg/mL had 100% sensitivity for predicting BRONJ development 1. All four patients who developed BRONJ in this cohort had CTX levels below 150 pg/mL, while patients with CTX > 150 pg/mL had only a 0.13% risk compared to 0.42% risk for those below the threshold 1.

Multiple studies confirm this threshold 3, 2, 4:

• CTX < 150 pg/mL carries a 5.3-fold increased odds ratio for BRONJ development (P = 0.004) 4
• The "risk zone" extends from 150-200 pg/mL, with values below 150 pg/mL representing highest concern 2

Clinical Context: Bisphosphonate Use

This CTX threshold applies primarily to patients on oral bisphosphonates for osteoporosis 1, 2. The risk profile differs significantly:

• Oral bisphosphonates: BRONJ risk approximately 0.2-0.4% after extraction when CTX < 150 pg/mL 1
• Intravenous bisphosphonates (for cancer): Much higher risk (51.8% in one study), and CTX testing may be less predictive 4

Important Caveats About CTX Testing

While your patient's CTX level is reassuring, recognize these limitations:

• CTX does not predict individual patient risk definitively - it identifies population-level risk stratification 2
• Radiographic findings may be more sensitive: periodontal ligament widening around the tooth to be extracted was present in 83% of BRONJ cases versus only 11% of normal healing cases 3
• CTX values vary with multiple factors including time of day, fasting status, renal function, and specific bisphosphonate type (alendronate associated with lower CTX than risedronate) 2

Recommended Extraction Protocol

For your patient with CTX 293 pg/mL, proceed with extraction using these precautions 1, 2:

• Perform extraction under local anesthesia with conservative surgical technique 1, 4
• Prescribe perioperative antibiotics for 7 days 4
• Consider perioperative chlorhexidine mouth rinses (before procedure and three times daily for 5 days postoperatively) 5
• Ensure primary closure when possible and minimize bone trauma 1
• Follow until complete healing is confirmed 1

When to Consider Drug Holiday

A drug holiday is not indicated for your patient given the CTX of 293 pg/mL 1, 2. Drug holidays should only be considered when:

• CTX < 150 pg/mL AND
• Medically appropriate to discontinue bisphosphonate (no contraindication from osteoporosis severity or fracture risk) 1, 2

If a drug holiday were needed, CTX increases approximately 25 pg/mL per month after bisphosphonate cessation 2.