Evidence for Stopping Bisphosphonates Before Oral Surgery
There is insufficient evidence to support routine discontinuation of bisphosphonates before oral surgery, and the decision to stop therapy must balance the minimal protective benefit against the risk of skeletal complications. 1
The Evidence Against Drug Holidays
The most recent ASCO/MASCC/ISOO guideline (2019) explicitly states there is insufficient evidence to support or refute the need for discontinuation of bisphosphonates before dentoalveolar surgery, with only a weak strength of recommendation. 1 This represents the highest quality guideline evidence available.
The biological rationale for drug holidays is questionable because:
- Bisphosphonates remain in bone for years after discontinuation, making short-term interruptions unlikely to provide meaningful protection 2
- Some experts hypothesize a 2-month discontinuation may improve bone healing, but this remains unproven 2, 3
- The alternative view holds that brief interruptions have no effect given the prolonged skeletal retention of these drugs 2
Risk Stratification Is Critical
The risk of medication-related osteonecrosis of the jaw (MRONJ) varies dramatically by indication and route:
Oral bisphosphonates for osteoporosis:
- Incidence is very rare at <1 case per 100,000 person-years 1, 2
- Risk remains extremely low even with dental procedures 1
Intravenous bisphosphonates for cancer:
- Incidence ranges from 6.7-11% in multiple myeloma patients receiving monthly high-dose therapy 1, 2
- Risk increases substantially with duration beyond 2 years 1
Evidence-Based Prevention Protocol
The strongest recommendation is to complete all necessary dental work before initiating bisphosphonate therapy, which eliminates MRONJ risk entirely. 1, 2, 4
Before starting bisphosphonates:
- Perform comprehensive dental evaluation including radiographic examination 1, 4
- Complete all invasive dental procedures 1, 2
- Treat all active oral infections 3
- Correct vitamin D deficiency to prevent hypocalcemia 2, 5, 6
Management When Surgery Is Needed During Therapy
For patients on oral bisphosphonates for osteoporosis, the FDA labels for both alendronate and risedronate state that discontinuation of bisphosphonate treatment may reduce the risk for ONJ, with clinical judgment guiding management based on individual benefit/risk assessment. 5, 6
If dental surgery must proceed:
- Use perioperative prophylactic antibiotics 2, 3, 7
- Employ atraumatic extraction technique with primary closure 7
- Smooth bone edges and prepare tension-free mucoperiosteal flaps 7
- Leave sutures in place for 14 days minimum 7
- Schedule follow-up every 6-8 weeks until complete mucosal healing 1, 3, 4
- Defer resumption of bisphosphonates until healing is confirmed 3, 4
Critical Caveats for Cancer Patients
For patients receiving intravenous bisphosphonates at oncologic doses, interrupting therapy poses tangible risks:
- Pathologic fractures may occur during drug holidays 2
- Spinal cord compression risk increases 2
- At least 60% of MRONJ cases occur after dentoalveolar surgery, making prevention paramount 2, 8
The decision to interrupt IV bisphosphonates requires consultation with the oncologist to weigh skeletal event risk against MRONJ risk. 2, 4
Common Pitfalls to Avoid
- Do not confuse osteoporosis risk (<1/100,000) with cancer treatment risk (6.7-11%) when counseling patients 1, 2
- Do not perform extractions without antibiotic prophylaxis, as infection is a key MRONJ trigger 2, 3, 7
- Do not assume drug holidays are protective given the lack of evidence and prolonged skeletal retention 1, 2
- Do not proceed with elective procedures (implants, non-medically necessary extractions) during active high-dose bisphosphonate therapy 1
Ongoing Monitoring Requirements
Patients on bisphosphonates require: