Bisphosphonates and denosumab: what your dentist needs to know
The consultation went well. He left with a prescription, a date for the first administration and a recommendation I didn’t expect: “Make an appointment at the dentist before starting.”
It seems out of place, but there’s a reason. Bisphosphonates and denosumab protect bones and are used in osteoporosis and the follow-up of some cancers, including breast cancer. In rare cases, however, they can affect the way the jaw bone heals after a dental procedure.
In this article about bisphosphonates and dentists, we explain what information should lead to a consultation and what care should be assessed before dental treatments.
Inform the dentist about the medication you are taking or have taken previously. The assessment should consider the drug, reason for prescription, duration of treatment and intended dental procedures.
In this October, Rosa, we answer the most frequent questions they ask us: what is the risk, what should be done first, whether you can treat teeth or put on implants and why you should never stop medication on your own.
Contents approached
What are they and why does the dentist come into this story?
Osteonecrosis of the jaws is rare but severe: an area of the bone becomes exposed in the mouth and heals with difficulty. The risk depends on dose, frequency and duration. In osteoporosis is very low: generally below 0.1% with bisphosphonates and between 0.04% and 0.3% with denosumab. In the oncological schemes it is higher, about 1% in the larger studies, with great variation.
Receiving this medication does not mean, by itself, that the cancer has reached the bones, and the scheme is always decided by the medical team.
Osteonecrosis of the jaws: what is it and what is the risk?
Let’s move on to the most concerning: osteonecrosis of the jaws. It is a rare but severe injury, in which an area of the bone becomes exposed in the mouth and heals with difficulty, sometimes with pain, swelling, or infection.
The word “rare” has numbers. In osteoporosis, estimates are very low: generally below 0.1% with bisphosphonates and between 0.04% and 0.3% with denosumab. In the schemes used in oncology, the risk is higher, about 1% in larger studies, with great variation between studies. In practice, the vast majority of people will never have this problem, but prevention weighs more heavily when doses are higher.
These numbers don’t say what will happen to you, and mouth health also influences the risk. So the right question is not “will this happen to me?” but “what can I do to prevent it from happening?”
Bisphosphonates and dentist: care before starting medication
The most common answer of international guidelines is simple: a dental evaluation before starting, especially when treatment is oncological, with clinical examination and X-rays. The goal is to get to the start of treatment with the mouth in order:
- Identify problems that should be treated before starting, whenever the state of health allows;
- Understand which teeth can be maintained and which do not have a good prognosis;
- Reduce the likelihood of needing surgery or extractions during treatment;
- Plan, with the medical team, the healing time when surgery is needed.
This does not mean extracting teeth as a precaution; it is what needs treatment and only what does not have a good prognosis. And there is a golden rule: you never postpone oncological treatment on your own initiative to resolve dental issues first. Deadlines are defined by the teams that follow the case, in conjunction with your dentist.
If treatment has already started, it’s not too late. The sooner the mouth is assessed, the better, and regular maintenance with surveillance appointments and professional oral hygiene continues to make a difference.
Can I do extractions or implants?
Bisphosphonates and dental extraction: necessary care
Can I still go to the dentist? Yes, and you should. Surveillance appointments and cleanings continue to be recommended, and many restorative treatments remain. Not taking care of your mouth does not eliminate the risk: it only makes it more difficult to manage when a problem arises.
When we talk about bisphosphonates and dental extraction, it is important to understand what medication takes, why and how long, to assess the care needed in your case. When it is necessary to intervene in the bone, the approach is more conservative: whenever possible, one tries to save the tooth (for example, with endodontic treatment or keeping roots without infection). But an infection or an emergency should not go unanswered for fear. It is up to the dentist to assess the risk and, when necessary, coordinate with the medical team or refer for oral surgery.
The relationship between bisphosphonates and dental implants is not just a “yes” or “no”: the decision depends on the medication, the reason for treatment, and the clinical evaluation.
And the implants? The answer depends on the treatment. In oncological treatments with high doses, the main international guidelines discourage the placement of implants while they are taking place, except for individual evaluation by a specialist, in conjunction with oncology. In osteoporosis, implants are not contraindicated, but the data is limited: the plan is individualized, with clear information about the risk of osteonecrosis (low) and implant failure, and regular follow-up.
Having completed a treatment phase is not an automatic authorization: the medication history continues to count.
Denosumab and dentist: can I stop the medication?
It is the most natural question, and the answer is: no, on my own initiative. Stopping a drug “just in case” seems wise, but the evidence says otherwise.
Bisphosphonates remain in the bone for years, and there is no evidence that a break before dental treatment reduces the risk of osteonecrosis. The available guidelines do not recommend it routinely, and among experts the topic remains under discussion. With denosumab, the problem is another: stopping or delaying treatment in osteoporosis is associated with an increased risk of various vertebral fractures, which can arise in the first few months.
Therefore, do not miss an administration or change the medication to make it coincide with a consultation. In some cases, the prescriber and dentist may agree on the best time for a non-urgent procedure regarding the next administration, but this is always a joint decision.
What to bring to the consultation?
Reply “what are you taking?” seems easy, until the treatment is an injection given in the hospital every six months, which is not in any box at home. It is the information that is most easily forgotten, and one of the most important.
Take if you can:
- the name of the medicinal product and dose;
- the frequency and dates of administrations;
- an indication that you have received this medication in the past, even if treatment has ended or is scheduled to begin;
- the list of remaining drugs and the doubts that it has not yet been able to clarify.
Finishing treatment does not erase this information: for bisphosphonates, previous use continues to count in the risk assessment.
What signs should not wait for the next consultation?
- A wound that does not heal, visible bone in the mouth, persistent pain or swelling, pus, teeth swaying without explanation or new numbness should be reported to the dentist and medical staff. Don’t wait for the next routine appointment.
These signs do not by themselves confirm osteonecrosis: they need evaluation to understand the cause and decide on follow-up. The sooner they are seen, the simpler the answer tends to be.
Ultimately, the goal is not to choose between treating bones and caring for teeth; it is to plan the two together. This October Rosa, the mouth also deserves a place in the plan. If you are about to start, are receiving or have already received biphosphonates or denosumab, share this information with your consultation at A Clínica Dr. Pedro Mota in Vila Franca de Xira and bring medication records.
This article is for informational purposes and does not replace an individual clinical evaluation. Do not discontinue or change the medication without a prescription from your doctor.
Sources consulted:
- SDCEP: Oral Health Management of Patients at Risk of Medication-related Osteonecrosis of the Jaw
- AAOMS: Position Paper on Medication-Related Osteonecrosis of the Jaw, atualização de 2022
- MASCC/ISOO/ASCO: Clinical Practice Guideline sobre osteonecrose dos maxilares relacionada com medicação (2019)
- American Dental Association: Oncology agents and MRONJ
- American Dental Association: Osteoporosis medications and MRONJ
- MHRA: Denosumab 60 mg (Prolia), risco de fraturas vertebrais múltiplas após suspender ou atrasar o tratamento
Seek expert help
Will be evaluated by the specialist dentist in our clinic. We listen to your needs and plan your treatment according to your wishes. In our clinic, we do not sell treatments, we return smiles.
We plan the smile, clarify your doubts and execute with precision.
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