The role of dental care providers in the management of patients prescribed bisphosphonates: brief clinical guidance

Dental care providers are likely to see patients who take bisphosphonates for various medical conditions, including osteoporosis, bony metastatic tumors, multiple myeloma, breast cancer, and prostate cancer. Bisphosphonates accumulate in areas of high bone turnover, leading to suppression of bone turnover and the aging of keratocytes. These adverse effects predispose the maxillary and mandibular bone to development of medication-related osteonecrosis of the jaw (MRONJ), specifically among oncology patients treated with intravenous bisphosphonate therapy. Studies have shown that stopping bisphosphonate therapy, temporarily (drug holiday) or permanently, is not significantly effective. The effectiveness of a drug holiday is likely limited due to the pharmacologic activity of bisphosphonates and their persistent, long-term effect on bone. Therefore, patients should not be discouraged from taking bisphosphonates for an existing medical condition. A dental health assessment by an oral surgeon, a dental specialist, or a well-trained general dental practitioner is highly recommended prior to treatment with bisphosphonate. The evaluating clinician must attempt to eliminate or mitigate risk factors to prevent the development of MRONJ. It is crucial for dental care providers to recognize the clinical signs and symptoms of MRONJ, including its radiographic appearance. In cases of any suspicious oral lesion, early referral to an oral surgeon is crucial. It is better to avoid dental extractions during the active period of treatment and to treat the tooth carefully with nonsurgical root canal treatment instead. This review provides brief clinical guidance for dental care providers regarding management of patients prescribed bisphosphonates and ways to help minimize patients' risk of developing MRONJ.