What should be done for a patient who has taken Prolia (denosumab) and Reclast (zoledronic acid) and now requires a tooth extraction?

Management of Tooth Extraction After Prolia and Reclast Therapy

Direct Recommendation

Proceed with the tooth extraction using prophylactic antibiotics and atraumatic surgical technique, as the patient has already transitioned from denosumab (Prolia) to zoledronic acid (Reclast) and the benefits of extraction outweigh the medication-related osteonecrosis of the jaw (MRONJ) risk in this clinical scenario. 1, 2

Critical Context: Sequential Therapy Increases Risk

Your patient's medication history creates a significantly elevated MRONJ risk because:

• Switching from zoledronic acid to denosumab increases MRONJ risk 4-fold (HR 4.36,95% CI 1.63-10.54), with incidence reaching 16.3% versus 5.4% for zoledronic acid alone 3
• While your patient switched in the opposite direction (Prolia to Reclast), the additive bone effects of sequential therapy still apply 3
• Tooth extraction after starting bone-modifying agents increases MRONJ risk nearly 5-fold (HR 4.86,95% CI 2.75-8.36) 3
• Denosumab itself carries 2-3 times higher MRONJ risk than zoledronic acid (HR 2.34-2.89) 4, 3

Pre-Extraction Protocol (Mandatory Steps)

Dental Assessment

• Confirm the extraction is absolutely necessary - conservative management should be exhausted first, as extraction is the single most consistent risk factor for MRONJ 1
• Obtain panoramic radiograph to assess bone quality and plan surgical approach 2
• Document baseline oral hygiene status 2

Medical Optimization

• Verify vitamin D sufficiency - correct any deficiency before proceeding, as this increases hypocalcemia risk and may impair bone healing 1
• Ensure adequate calcium (800-1000 mg/day) and vitamin D (800 IU/day) supplementation 1
• Check serum creatinine if not recently done, particularly given prior zoledronic acid exposure 5, 6

Surgical Execution Protocol

Perioperative Antibiotics

• Administer prophylactic antibiotics starting immediately before the procedure 1, 2
• Continue antibiotics for several days post-operatively 2

Surgical Technique

• Use atraumatic extraction technique with minimal bone manipulation 1
• Achieve primary closure with sutures whenever possible 1
• Apply gauze soaked in tranexamic acid to the socket if available 5

Post-Extraction Management

• Do NOT resume Reclast until the extraction site demonstrates complete mucosal healing 1, 2
• Schedule follow-up every 6-8 weeks until complete healing confirmed 2
• Instruct patient on chlorhexidine mouthwash use twice daily 7

Drug Holiday Controversy: The Evidence

The decision about stopping bone-modifying agents before extraction remains controversial and unproven:

• Some experts hypothesize a 2-month drug holiday before oral surgery may improve bone healing 1, 2
• However, bisphosphonates persist in bone for years after discontinuation, making short drug holidays potentially ineffective 1, 2
• Denosumab's effects reverse within months of stopping (unlike bisphosphonates), theoretically making a drug holiday more rational for prior Prolia exposure 7
• No high-quality evidence proves drug holidays prevent MRONJ 1, 2

Given your patient already received Reclast doses, a drug holiday now is moot - the bisphosphonate is already incorporated into bone matrix 1, 2

Critical Monitoring for MRONJ

Instruct the patient to immediately report:

• Non-healing extraction site beyond 8 weeks 6
• Exposed bone in the mouth 6
• Pain, swelling, or numbness in jaw 6
• Loosening of adjacent teeth 6
• Purulent discharge 7

If MRONJ develops, refer immediately to oral surgeon with MRONJ expertise 1

Common Pitfalls to Avoid

• Do not confuse osteoporosis MRONJ risk with cancer treatment risk - your patient's risk is intermediate given sequential therapy but lower than cancer patients receiving high-dose IV bisphosphonates (6.7-11% incidence) 1
• Do not perform extraction without antibiotic prophylaxis - infection is a key precipitating factor 1, 2
• Do not resume Reclast prematurely - wait for dentist confirmation of complete healing 1, 2
• Do not neglect vitamin D status - deficiency compounds both MRONJ and hypocalcemia risk 1

Risk-Benefit Balance

The extraction should proceed because:

• Retaining a non-restorable or infected tooth poses greater harm than MRONJ risk 1
• With proper surgical protocol, MRONJ risk can be minimized though not eliminated 1, 2
• Delaying necessary extraction allows ongoing infection/inflammation, which itself increases MRONJ risk 1