Timing of Dental Extractions After Evenity (Romosozumab)
There is no established waiting period for dental extractions in patients taking Evenity, as no specific guidelines or high-quality evidence address this medication and dental procedures. However, based on the mechanism of action as an anabolic bone agent (not an antiresorptive), the osteonecrosis risk profile differs substantially from bisphosphonates and denosumab.
Risk Context and Clinical Approach
Understanding Evenity's Unique Profile
Evenity (romosozumab) is a sclerostin inhibitor that stimulates bone formation rather than suppressing bone resorption, distinguishing it mechanistically from bisphosphonates and denosumab that carry well-documented osteonecrosis of the jaw (ONJ) risks 1.
The medication-related osteonecrosis of the jaw (MRONJ) risk with antiresorptive agents varies dramatically by drug class: oral bisphosphonates for osteoporosis carry a very rare risk (<1 case per 100,000 person-years), while denosumab for osteoporosis carries a 2.3% risk following dental extractions, and intravenous bisphosphonates for cancer treatment carry a 6.7-11% risk 1, 2.
Practical Management Algorithm
Since no evidence-based guidelines exist for Evenity specifically, apply the following approach:
Complete comprehensive dental evaluation before initiating Evenity whenever possible, identifying and treating all teeth with poor prognosis, periapical disease, or moderate-severe periodontal disease 1.
Perform all necessary invasive dental procedures before starting Evenity, as this eliminates any theoretical ONJ risk entirely 1.
If dental extraction becomes necessary during Evenity treatment, proceed without mandatory drug holiday, as:
- No evidence supports stopping Evenity before dental procedures
- The anabolic mechanism differs from antiresorptive agents where drug holidays are debated 1
- Delaying necessary dental care may increase risk of delayed wound healing (waiting >2 months before extraction increases delayed healing risk with OR 7.23) 3
Use perioperative antibiotics for all extractions in patients on bone-active medications, as this reduces infectious complications and may lower ONJ risk 1, 4.
Monitor extraction sites closely with follow-up every 6-8 weeks until complete mucosal healing is confirmed 1.
Critical Caveats
Do not confuse Evenity's risk profile with denosumab or bisphosphonates, as the anabolic mechanism theoretically poses lower ONJ risk than antiresorptive agents, though formal studies are lacking 1, 2.
Avoid unnecessary delays in dental treatment, as postponing extraction for ≥2 months significantly increases the risk of delayed wound healing beyond 8 weeks (OR 7.23,95% CI 2.19-23.85), which itself is a risk factor for developing ONJ 3.
The number of teeth extracted in a single episode increases ONJ risk (OR 1.35 per additional tooth), so consider staging multiple extractions when feasible 2.
Maintain excellent oral hygiene throughout Evenity treatment with dental check-ups every 6 months and prescription-strength topical fluoride if salivary function is compromised 1.
Key Differences from Antiresorptive Agents
Unlike bisphosphonates where bone effects persist for years after discontinuation, Evenity's anabolic effects are time-limited, making theoretical drug holidays even less relevant than for antiresorptives where they remain unproven 1.
The strongest evidence-based recommendation remains completing all necessary dental work before initiating any bone-active medication, including Evenity, as this approach eliminates ONJ risk entirely regardless of the specific agent used 1.