Holding Prolia (Denosumab) Prior to Deep Dental Work
Ideally, complete all necessary deep dental work before initiating Prolia, but if already on treatment, perform dental procedures 6-7 months after the last injection and delay the next scheduled dose until complete healing of the surgical site. 1
Optimal Timing Strategy
For Patients Already on Prolia
The safest window for dental extractions is 6-7 months after the last denosumab injection, as data from 76 patients who had extractions during this timeframe showed zero cases of osteonecrosis of the jaw (ONJ). 1
Do not resume the next denosumab dose until the extraction site has completely healed, as early resumption significantly increases ONJ risk. 1
The risk of developing ONJ in patients on denosumab for osteoporosis undergoing dental extractions is 2.3%, which is 7.7 times higher than patients on oral bisphosphonates (0-0.3%). 1
Pre-Treatment Protocol (Before Starting Prolia)
All patients should undergo a mandatory dental examination with preventive dentistry before initiating denosumab therapy. 2
Complete any planned invasive dental procedures (extractions, implants) before starting denosumab whenever possible, as this eliminates the elevated ONJ risk entirely. 2
Critical Risk Factors to Consider
Patient-Specific Risk Modifiers
The number of extractions directly increases ONJ risk (odds ratio 1.35 per additional extraction), so consolidating multiple extractions into a single procedure during the safe window is preferable. 1
Additional risk factors for ONJ include concurrent chemotherapy, corticosteroid use, poor oral hygiene, periodontal disease, and dental abscess. 2
Pharmacologic Considerations
Unlike bisphosphonates, denosumab does not accumulate in bone and has no prolonged duration of action, meaning its antiresorptive effects are fully reversible within months of the last dose. 2
However, abruptly discontinuing denosumab without follow-on therapy causes rapid rebound bone resorption, increased bone turnover markers, and elevated risk of multiple vertebral fractures. 2, 3, 4
Perioperative Management
During the Procedure
Prophylactic antibiotics are advised when tooth extraction cannot be avoided in patients on denosumab. 2
Maintain excellent oral hygiene and ensure regular dental/oral surgery review throughout treatment. 2
Post-Procedure Monitoring
Suspend denosumab until healing of the tooth socket appears complete, which typically requires clinical and radiographic confirmation. 2
The overall incidence of ONJ with denosumab remains low (1-3%) even with long-term use, but vigilance is essential. 2, 3
Common Pitfalls to Avoid
Do not simply hold one dose and resume on schedule—the timing must be individualized based on healing status, as premature resumption increases ONJ risk. 1
Do not discontinue denosumab indefinitely without transitioning to alternative therapy, as this creates a rebound effect with rapid bone loss and fracture risk that can occur within 6-12 months. 2, 4, 5
The 6-month dosing interval of denosumab creates a natural opportunity for dental work in the later months of each cycle, which should be leveraged strategically. 1
Alternative Approach for High-Risk Scenarios
For patients requiring urgent dental surgery who cannot wait 6-7 months, consider transitioning to a bisphosphonate before the procedure, though this requires careful planning given denosumab's rebound effect. 2
In patients with renal disease where bisphosphonates are contraindicated, the risk-benefit calculation may favor proceeding with necessary dental work during denosumab therapy with aggressive preventive measures. 2, 3