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Osteonecrosis of the jaw (ONJ) is a serious complication for physicians prescribing bone resorption inhibitors to patients with osteoporosis. A session at the recent French Congress of Rheumatology (2024) in Paris, France, focused on this issue.

ONJ is defined as the intraoral exposure of necrotic bone for more than 8 weeks, significantly affecting quality of life due to chronic pain, infection, and other complications. In some cases, ONJ may appear as a simple fistula, while necrosis extends deeper in a concealed manner.

Medications associated with drug-induced ONJ include bisphosphonates, denosumab, anti-angiogenic agents (sunitinib, bevacizumab, and aflibercept), tumor necrosis factor inhibitors (adalimumab and etanercept), and romosozumab.

Drug-Related Risk

A major challenge is evaluating the risk for ONJ in patients receiving bone resorption inhibitors. Among patients with osteoporosis on these treatments, ONJ incidence ranges from 0.001% to 0.050%. However, in patients with cancer treated with the same medications, the incidence rises to 1%-15%.

The risk for ONJ slightly increases in patients treated with bisphosphonates for more than 5 years. However, because ONJ is rare, assessing its risk statistically remains difficult.

Corticosteroids and immunosuppressants are known to significantly increase ONJ risk.

Importantly, intravenous administration of bone resorption inhibitors does not pose a higher risk than oral administration.

No reliable biomarkers have been identified to predict ONJ risk, though researchers suspect a potential genetic predisposition.

Poor oral health is a well-established risk factor for ONJ. Infections, ill-fitting dentures that injure the jaw, peri-implantitis (inflammation around dental implants), and tooth extractions all contribute to ONJ. In many cases, ONJ may have already been present before the dental extraction.

Beyond Tooth Extractions

A pretreatment dental evaluation is essential to reduce ONJ risk in patients undergoing bone resorption inhibitors. This assessment helps educate patients on the bone and oral risks associated with their treatment and serves as a foundation for therapeutic education, particularly regarding nutrition.

Dental care for patients on bone resorption inhibitors extends beyond extractions. The priority is to maintain the integrity of the oral barrier, preventing a septic space (oral cavity) from communicating with an aseptic space (bone).

Loss of integrity may result from dental decay or endodontic contamination (inside the tooth). Treatment includes endodontic therapy, root canal treatment, and crown reconstruction, all of which promote bone healing and oral health restoration.

Restoring periodontal health is equally critical. Gingivitis causes reversible damage, while periodontitis, which affects deeper periodontal tissues, leads to irreversible destruction. Surgical treatment may involve restorative procedures or prosthetic rehabilitation.

Importantly, dental procedures should not delay the initiation of bone resorption inhibitors. These procedures can be performed during or immediately after starting therapy.

The use of bone resorption inhibitors does not contraindicate dental implant placement.

Long-term dental follow-up for patients on these treatments is conducted in outpatient settings, with no need for a therapeutic window.

Any oral or maxillofacial surgery should be performed as minimally invasively as possible and may be preceded by antibiotic prophylaxis. Both American and French guidelines provide recommendations for surgical protocols.

New radiological tools, such as cone beam computed tomography, are valuable for monitoring patients and may detect ONJ before clinical symptoms appear.

No Established Consensus

Currently, there is no universal consensus on the management of ONJ. A 2022 Cochrane review did not reach clear conclusions on the best treatment approach. However, key takeaways include the following:

• Discontinuing bone resorption inhibitors does not improve ONJ outcomes 
• ONJ often develops in patients with preexisting local or systemic comorbidities, such as ill-fitting removable prosthetics, active periodontal disease, or smoking 

While dental implants themselves are not direct sources of infection, peri-implantitis remains a known infection risk. However, very few ONJ cases are associated with dental implants in clinical practice.

Implant-based rehabilitation is not contraindicated in patients with osteoporosis who have been treated with bisphosphonates for less than 3 years. Stopping treatment is unnecessary, but regular periodontal monitoring is essential.

Coordination Is Important

Close collaboration between rheumatologists and dentists is critical to reducing ONJ risk and optimizing patient care.

Establishing trust and coordination between both specialties is essential, particularly through interprofessional training programs. By working together, rheumatologists and dentists can ensure safer and more effective treatment strategies for patients undergoing bone resorption inhibitor therapy.

This story was translated from Univadis France using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.