What kinds of dental work do you particularly worry about and try to avoid in patients on bisphosphonates?

Firstly, the incidence of BRONJ (bisphosphonate-related osteonecrosis of the jaw) is very low with all drugs of this class. However, many patients and dentists are concerned about the possibility of this problem. Generally, BRONJ occurs after an extraction and subsequent poor healing at the extraction site followed by a secondary bacterial infection. BRONJ has also rarely been described in the hard palate in the absence of any dental procedure. Whenever possible, I advise patients to have their extraction-related procedures (including preparation for an implant) before starting on anti-resorptive therapy. If a patient is on such treatment already with zoledronic acid and the procedure is elective I would advise the patient to wait to have their dental procedure until near the end of their regular dosing interval (usually one year) and not to have their subsequent infusion until their extraction site has healed. The same advice holds for the non-bisphosphonate denosumab which is dosed on an every six-month schedule, but in that case, I tell patients to have their subsequent denosumab no more than seven months after their prior injection even if their extraction site is not yet fully healed. As far as oral bisphosphonates, many dentists and patients elect to hold those drugs for several months before the procedure although there is no evidence that such advice has any biologic justification given the half-life of these drugs. I remind patients that antibiotic mouth rinses after the procedure is recommended as a general good practice measure. I assure patients that other non-extraction dental procedures do not require the cessation of their osteoporosis medications. If a patient has an emergency extraction, I again recommend the antibiotic mouth rinse and review the low incidence of BRONJ with the patient and their dentist to try to allay their concerns. These recommendations apply to osteoporosis treatment regimens and not for patients who may be receiving intravenous bisphosphonates as part of a cancer treatment protocol.

Yes, we routinely recommend chlorhexidine for our patients. Thanks for your comments.