Osteoporosis, Bisphosphonates, and Your Jaw

What Are Bisphosphonates and Related Medications?

If you take, or are about to start, a medication to strengthen your bones, this guide is for you. Bisphosphonates and related antiresorptive drugs are among the most widely prescribed medications in the world, with over 190 million prescriptions written globally. They are used to treat osteoporosis (to prevent fractures), and in cancer patients, to manage bone metastases, multiple myeloma, and other conditions where cancer weakens the bones.

Common medications in this category include:

• Oral bisphosphonates (pills): alendronate (Fosamax), risedronate (Actonel), ibandronate (Boniva)
• IV bisphosphonates (infusions): zoledronic acid (Zometa, Reclast), pamidronate (Aredia)
• Denosumab (injections): Prolia (for osteoporosis), Xgeva (for cancer)

These medications work by slowing down the natural process by which your body breaks down and rebuilds bone (a process called bone remodeling). By reducing bone breakdown, they help maintain bone density and reduce fracture risk. However, this same suppression of bone turnover can, in rare cases, lead to a complication in the jaw called osteonecrosis.

What Is Osteonecrosis of the Jaw?

Medication-related osteonecrosis of the jaw (MRONJ) is a condition in which a section of jawbone loses its blood supply and begins to die, resulting in exposed bone in the mouth that does not heal. According to the American Association of Oral and Maxillofacial Surgeons (AAOMS), MRONJ is defined as exposed bone, or bone that can be probed through an opening in the gum, that persists for more than 8 weeks in a patient taking antiresorptive medication, without a history of radiation therapy to the jaws.

MRONJ can cause pain, swelling, infection, difficulty eating, and in severe cases, jaw fractures. It most commonly affects the lower jaw (mandible) and typically occurs at sites where the bone has been exposed to the oral environment, whether through a dental procedure, an infection, or even spontaneously.

Understanding Your Risk

Not all patients taking these medications face the same risk. Your risk depends primarily on two factors: why you are taking the medication (the indication) and how long you have been taking it.

The 4-year threshold. For patients taking oral bisphosphonates for osteoporosis, the AAOMS identifies approximately 4 years of use as an important clinical milestone. Below 4 years, the risk of MRONJ is extremely low. Beyond 4 years, particularly when combined with other risk factors such as corticosteroid use, diabetes, or smoking, the cumulative drug exposure increases the risk, and additional precautions may be warranted.

Cancer patients are at substantially higher risk because they typically receive much higher doses of more potent IV bisphosphonates or denosumab, often in combination with chemotherapy or other medications that further suppress the immune system and bone turnover. The risk in this population can be 50 to 100 times higher than in osteoporosis patients.

The Critical Point: Infections Also Cause Osteonecrosis

This is one of the most important things for patients to understand: MRONJ is not caused only by dental procedures. Dental infections themselves, including periodontal (gum) disease and endodontic (tooth) infections, are a major trigger for osteonecrosis.

When bacteria from a gum infection or a tooth abscess invade the jawbone, they trigger an inflammatory response. In a patient on antiresorptive medications, the bone's ability to remodel and repair itself in response to this infection is suppressed. The combination of active infection and impaired bone turnover creates the conditions for osteonecrosis to develop, even without any surgical intervention.

Why This Changes the Treatment Equation

Because untreated infections can cause osteonecrosis on their own, the risk of leaving a dental infection untreated is often GREATER than the risk of treating it. This is why Dr. Yant or oral surgeon may recommend extracting a badly infected tooth, performing bone surgery to eliminate deep gum disease, or treating an abscessed tooth, even while you are taking bisphosphonates. The relative risk of the procedure is lower than the risk of allowing the infection to persist and potentially trigger osteonecrosis. Doing nothing is not always the safest option.

Dental Procedures: Understanding the Relative Risks

Different dental procedures carry different levels of MRONJ risk. Here is what the evidence shows:

The general principle: Any dental procedure that is focused on eliminating active disease or infection is still recommended for patients on bisphosphonates, because the risk of leaving the infection untreated is typically greater than the risk of the procedure itself.

Tooth Extractions

Extractions are the dental procedure most commonly associated with MRONJ. They are cited as a triggering event in the majority of reported cases. However, the risk must be weighed against the alternative. When a tooth is severely infected, fractured, or non-restorable, the ongoing infection itself poses a risk for osteonecrosis. In osteoporosis patients on oral bisphosphonates for less than 4 years, the risk of extraction-triggered MRONJ is extremely low, and the extraction can typically proceed with standard precautions.

Bone Grafting at the Time of Extraction

When a tooth is extracted, the empty socket is an open wound that exposes the underlying jawbone to the oral environment. One approach Dr. Yant may use to promote faster, more predictable healing is to place a bone graft material into the socket at the time of extraction. The graft acts as a scaffold that supports new bone growth and helps seal the socket from bacteria more quickly, reducing the window of time during which the bone is vulnerable.

Emerging research supports this approach. Preclinical studies have demonstrated that bone graft placement at extraction sites in bisphosphonate-treated subjects prevented the clinical manifestation of osteonecrosis, promoted significantly greater formation of healthy bone tissue, and reduced areas of dead bone compared to extraction sites left to heal without a graft.

Periodontal (Bone) Surgery

Osseous surgery (procedures that involve reshaping or removing diseased bone around the teeth) carries a risk because it exposes bone to the oral environment. However, the same logic applies: if significant periodontal infection is destroying the bone around your teeth, the ongoing infection is itself a risk factor for MRONJ. Treating the infection surgically, while managing the MRONJ risk with appropriate precautions, is often the safer course of action compared to allowing progressive bone destruction from untreated gum disease.

Dental Implants

Implant placement involves drilling into the jawbone and is considered a risk factor for MRONJ. For lower-risk osteoporosis patients on oral bisphosphonates for less than 4 years, implant placement may be considered with careful informed consent and monitoring. For higher-risk cancer patients, implant placement carries a more significant risk and requires thorough evaluation and discussion.

The Key Takeaway on Risk

The decision to proceed with a dental procedure in a patient on bisphosphonates is always a risk-benefit analysis. Your dental team weighs the risk of the procedure against the risk of doing nothing. In many cases, particularly when active infection is present, the risk of NOT treating is higher than the risk of treating.

Prevention Is Everything

This is the single most important message in this guide: the best way to avoid MRONJ is to prevent the dental problems that would require surgical treatment in the first place.

Before Starting Bisphosphonate Therapy

If you have not yet started your medication, you are in the ideal position. The AAOMS strongly recommends that all dental work be completed before beginning antiresorptive therapy. This includes:

• Having all necessary extractions, root canals, and periodontal treatments completed.
• Addressing any teeth with questionable prognosis. It is far better to extract a tooth now, before starting the medication, than to need an extraction later while on therapy.
• Having a thorough dental examination and cleaning, with any cavities filled and any gum disease treated.
• Ensuring dentures and other prosthetics fit well and are not causing tissue irritation.

The AAOMS states clearly: if systemic conditions permit, initiation of antiresorptive therapy should be delayed until dental health is optimized. Talk to both your prescribing physician and your dentist to coordinate the timing.

After Starting Therapy: Ongoing Dental Care

Once you are on bisphosphonate therapy, prevention becomes your most powerful tool:

• Maintain excellent oral hygiene. Brush twice daily with a soft-bristled brush, floss daily, and use any prescribed rinses. Good oral hygiene is your first line of defense against the infections that can trigger MRONJ.
• Come in for regular dental visits. Professional cleanings and examinations every 3–6 months allow your dental team to catch and address small problems before they become big ones.
• Report any dental symptoms immediately. Pain, swelling, loose teeth, bleeding gums, or numbness in the jaw should be reported to your dentist right away.
• Tell every dental provider about your medications. Every dentist, hygienist, periodontist, and oral surgeon you see must know that you are taking bisphosphonates or denosumab, including the specific medication name, the dose, and how long you have been taking it.

Drug Holidays: When and Why

A "drug holiday" is a temporary break from your bisphosphonate or denosumab therapy, usually arranged in coordination with your prescribing physician and your dental team before a planned surgical procedure.

The idea behind a drug holiday is that by pausing the medication, the bone's natural remodeling activity may partially recover, potentially reducing the risk of MRONJ following a surgical procedure. However, the evidence on whether drug holidays actually reduce MRONJ risk is still mixed. The AAOMS notes that strong clinical evidence supporting or refuting the benefit of a drug holiday is currently lacking.

What is clear is that drug holidays are more commonly considered in certain situations:

• Osteoporosis patients on oral bisphosphonates for more than 4 years who require an invasive dental procedure (extraction, implant, bone surgery). A typical drug holiday involves stopping the medication for 2–3 months before surgery, proceeding with the procedure, and then restarting the medication once the surgical site has healed.
• For denosumab (Prolia/Xgeva), the timing is different because the drug does not accumulate in bone the way bisphosphonates do. The surgical procedure may be scheduled at the end of a dosing interval when osteoclast inhibition is waning, and the medication is then restarted 6–8 weeks after surgery once healing is confirmed.
• For cancer patients on IV bisphosphonates, the decision to interrupt therapy is more complex and must be made in close coordination with the oncologist, weighing the risk of skeletal events against the risk of MRONJ.

Important: Never Stop Your Medication on Your Own

Do not stop taking your bisphosphonate or denosumab without consulting both your prescribing physician and your dental team. Stopping these medications abruptly, particularly denosumab, can lead to a rapid rebound in bone loss and an increased risk of vertebral fractures. Any drug holiday must be carefully planned and monitored.

What You Should Do

• If you are about to start bisphosphonates: Get a complete dental examination and have all necessary dental work done first. Tell your prescribing physician that you want to coordinate timing with your dentist.
• If you are already on these medications: Maintain excellent oral hygiene, come in for regular dental visits, and report any oral symptoms promptly. Prevention is your best protection.
• If you need a dental procedure: Don't panic. Your dental team will assess your specific risk level based on your medication, dose, duration, and the procedure needed. In many cases, the procedure can be performed safely and is actually the safer option compared to leaving an infection untreated.
• Tell every provider: Make sure every dental and medical professional you see knows exactly which bone medication you take, the dose, and how long you've been on it.

Sources

This guide is based on the AAOMS 2022 Position Paper and peer-reviewed medical research.

• Ruggiero, S. L., et al. (2022). American Association of Oral and Maxillofacial Surgeons' Position Paper on Medication-Related Osteonecrosis of the Jaws: 2022 Update. Journal of Oral and Maxillofacial Surgery, 80(5), 920-943.
• Khan, A. A., et al. (2015). Diagnosis and management of osteonecrosis of the jaw: a systematic review and international consensus. Journal of Bone and Mineral Research, 30(1), 3–23.
• Alsaleh, K., et al. (2022). Medication-related osteonecrosis of the jaw: a review. Saudi Dental Journal, 34(3), 167–176.
• AAOMS. (2022). Position Paper: Medication-Related Osteonecrosis of the Jaw.
• Pereira, R. S., et al. (2021). The role of bone grafts in preventing medication-related osteonecrosis of the jaw. Craniomaxillofacial Trauma and Reconstruction, 15(4), 41.