What precautions should be taken for a patient with osteoporosis taking bisphosphonates (bone density medication) who needs a dental procedure to minimize the risk of osteonecrosis of the jaw (ONJ)?

Dental Procedures in Patients Taking Bisphosphonates for Osteoporosis

Patients with osteoporosis on bisphosphonates should undergo comprehensive dental evaluation and complete all necessary invasive dental work before starting bisphosphonate therapy whenever possible, as this eliminates ONJ risk entirely. 1

Pre-Treatment Prevention Protocol (Ideal Scenario)

Before initiating bisphosphonates:

• Complete comprehensive dental evaluation of both hard and soft tissues, including radiographic examination 1
• Perform all necessary invasive dental procedures (extractions, periodontal surgery, implant placement) before starting bisphosphonates 1
• Treat all active oral infections and eliminate high-risk dental sites 2
• Correct vitamin D deficiency prior to bisphosphonate initiation to avoid hypocalcemia 2, 3
• Ensure adequate calcium (800-1000 mg/day) and vitamin D (800 IU/day) supplementation 2, 3

Risk Stratification by Bisphosphonate Type and Indication

The risk of ONJ varies dramatically based on route of administration and indication:

Oral Bisphosphonates for Osteoporosis (Lowest Risk)

• Incidence: <1 case per 100,000 person-years (0% to 0.5%) 2, 4
• This represents a 10- to 100-fold lower risk compared to cancer treatment regimens 4

IV Bisphosphonates for Osteoporosis (Intermediate Risk)

• Incidence: 0% to 1% when dosed every 6 months 4
• Substantially lower than cancer treatment dosing 4

IV Bisphosphonates for Cancer (Highest Risk)

• Incidence: 6.7% to 11% in multiple myeloma patients receiving monthly high-dose IV bisphosphonates 1, 4, 5
• Risk increases with duration: 1.1% in first year, 3.7% in second year, 4.6% per year thereafter 5

Management When Dental Procedure is Needed During Treatment

For Patients on Oral Bisphosphonates for Osteoporosis

The evidence on drug holidays remains controversial and inconclusive:

• Option 1 (Conservative approach): Some experts hypothesize stopping bisphosphonates 2 months prior to oral surgery may allow better bone healing, with resumption delayed until adequate healing occurs 2
• Option 2 (Alternative view): A short break in bisphosphonate administration may have no effect, as bone effects persist for years after stopping 2
• Most recent evidence (2025): A nationwide cohort study of 152,299 osteoporotic patients found that risk of ONJ is substantially lower when treatment is paused for more than 90 days, and lowest when the pause exceeds one year 6

Given the conflicting guideline evidence but the most recent high-quality research showing benefit, the recommended approach is:

1. For routine extractions in patients on oral bisphosphonates <3 years: Proceed without drug holiday, using the surgical protocol below 2
2. For patients on oral bisphosphonates >3 years or multiple extractions: Consider pausing bisphosphonates for 90 days to 1 year before procedure, balancing fracture risk against ONJ risk 6
3. For patients on IV bisphosphonates (any duration): Pause for >1 year if medically feasible, as risk reduction is more consistent with longer pauses 6

Evidence-Based Surgical Protocol for All Patients

When proceeding with dental extraction:

• Administer prophylactic antibiotics perioperatively 2
• Use atraumatic extraction technique with primary closure 2
• Ensure excellent oral hygiene before and after procedure 1
• Monitor healing closely with follow-up every 6-8 weeks until complete mucosal healing 2
• Defer resumption of bisphosphonates until the dentist confirms complete healing 2

Patient Education and Ongoing Monitoring

All patients on bisphosphonates must:

• Be informed of ONJ risk, especially with tooth extractions and invasive dental procedures 1
• Inform their dental practitioner of bisphosphonate treatment 1
• Maintain excellent oral hygiene with dental check-ups every 6 months once therapy has commenced 2
• Avoid invasive dental procedures during active therapy whenever possible 2

Critical Risk Factors That Increase ONJ Risk

At least 60% of ONJ cases occur after dentoalveolar surgery, particularly tooth extractions 2, 4

Additional risk factors include:

• Longer duration of bisphosphonate exposure (risk increases with cumulative dose) 1, 4
• Higher frequency and dose of administration 1
• Concurrent chemotherapy or corticosteroid use 1, 2
• Poor oral hygiene with periodontal disease and dental abscess 1, 2
• Poor baseline dental health 1

Management of Suspected ONJ

If ONJ is suspected:

• Refer immediately to a dental practitioner or oral surgeon with expertise in treating ONJ 1, 2
• Consult recent guidelines from the International Task Force on Osteonecrosis of the Jaw, American Association of Oral and Maxillofacial Surgeons, or American Dental Association 1

Common Pitfalls to Avoid

• Do not confuse the low risk in osteoporosis patients (<1 per 100,000) with the much higher risk (6.7-11%) in cancer patients receiving high-dose IV bisphosphonates 2, 4
• Do not perform extraction without antibiotic prophylaxis, as infection is a key risk factor for ONJ 2
• Do not assume very young patients (age ≤40 years) on ovarian suppression have truly postmenopausal estrogen levels 1
• For patients with active cancer and bone metastases, interrupting IV bisphosphonate therapy poses tangible risks of pathologic fractures and spinal cord compression—this decision requires oncology consultation 2

Laboratory Monitoring Requirements

Before starting bisphosphonates:

• Measure serum calcium 1
• For IV bisphosphonates (zoledronic acid): Monitor renal function before starting treatment 1

During IV bisphosphonate treatment:

• Monitor serum calcium and increase in serum creatinine throughout treatment 1
• IV bisphosphonates are generally not recommended in patients with creatinine clearance <30 mL/min due to risk of acute renal failure 3