Among people taking bisphosphonate tablets for osteoporosis, jaw osteonecrosis is rare: Australian osteoporosis guidance from the RACGP puts the reported rate at between 1 and 100 per 100,000 patient-years, only a little above the rate in people not taking these medicines. Even after a tooth is removed, a 2015 meta-analysis by Gaudin and colleagues put the rate for people on osteoporosis tablets at around 0.15 percent. The picture changes for people on the much higher doses used in some cancer treatment, where the risk is roughly 100 times greater and the same meta-analysis found about 3 percent after an extraction. So the first thing a dentist wants to know is not only which medicine you take, but why.
How a bone-protecting medicine can slow jaw healing
Bisphosphonates such as alendronate, risedronate and zoledronic acid, and the injection denosumab, all slow the cells that break bone down. That is how they reduce fractures in osteoporosis and protect bone in some cancers. The jaw turns bone over quickly, especially around the teeth, and in a small number of people this slower turnover means a wound, usually an extraction socket, does not heal over.
The condition is called medication-related osteonecrosis of the jaw, or MRONJ. The American Association of Oral and Maxillofacial Surgeons defines it as exposed jawbone, or bone that can be probed through a gum opening, lasting more than eight weeks in someone who has taken one of these medicines and has not had radiotherapy to the jaw or cancer spread there. Some cases start without any dental procedure, often near an infected tooth or a rubbing denture.
Why the reason you take it matters most
Osteoporosis treatment uses relatively low doses: a weekly tablet, a yearly zoledronic acid infusion, or a denosumab injection every six months. Cancer treatment to protect bone from metastases uses far higher doses, given much more often. That difference explains most of the gap in risk.
Within each group, a few other things push risk up. Bisphosphonate use beyond about four years, long-term steroids, diabetes, smoking and existing gum or tooth infection are the main ones. Infection is the factor dentistry can do most about, which is why keeping gums healthy matters so much for people on these medicines. Our article on gum disease treatment explains what that care involves.
Stopping the medicine is rarely the answer
It can seem logical to pause a bone medicine before an extraction. For bisphosphonates, guidance differs, and the evidence that a short break lowers MRONJ risk is weak, partly because the drug stays bound in bone for years. Stopping without medical advice can raise fracture risk, and a hip or spinal fracture is a far more serious event for most people than the small jaw risk.
Denosumab needs particular care. Its effect wears off within months, and stopping or delaying doses without a plan has been linked to a rebound in spinal fractures. Rather than stopping it, Australian osteoporosis guidance from the RACGP suggests timing invasive dental work for just before the next six-monthly injection, when the medicine's effect is waning, with the next dose given once the area has begun to heal. That timing is a decision for your doctor and dentist together. Please do not change your medicine on your own.
A dental check before starting helps most
The lowest-risk time to deal with a doubtful tooth is before the medicine begins, especially for cancer treatment. If your doctor has mentioned starting a bisphosphonate or denosumab, a dental examination with X-rays first can find teeth that are likely to need removal and gum problems that need treatment. At Lumi Dental we can take an OPG or 3D scan on our Orthophos X-ray unit to look at the roots and bone, and our oral health therapists focus on keeping gums healthy over the long term.
If a tooth does need to come out
For most people on osteoporosis doses, an extraction can go ahead with care: removing the tooth as gently as possible, managing any infection, often closing the socket, and checking healing until the gum has covered the bone. Where a tooth can reasonably be kept, saving it is often preferred, which is one reason our comparison of root canal versus extraction may be useful. People on cancer doses usually need closer coordination with their oncology team, and surgery may be referred to an oral and maxillofacial surgeon.
Let your dentist know promptly if, weeks after an extraction, you notice bone showing in the socket, a gum sore that does not close, a bad taste, swelling, numbness or a heavy feeling in the lip, or a tooth nearby that has become loose. Early MRONJ may be managed with antiseptic rinses and close review, although some surgeons favour earlier removal of the affected bone, so the approach is decided case by case.
Implants are a case-by-case decision
Implants are not automatically ruled out for people on osteoporosis doses, but the risks need a careful discussion first, and they are approached with much more caution, and often avoided, for people on cancer doses. If you are weighing up how to replace a tooth, our articles on dental implants and on implants, bridges and dentures set out the options, which your dentist will weigh against your medication history.
If you take a bone medicine, or are about to start one, bring the name, dose and start date to your next visit. Our dentists and OHTs can plan care around it and work with your doctor where needed. Our general dental care page has more about the practice in Melrose Park, and offers are listed on our current deals page. This article is general information and not a substitute for personal dental or medical advice.
