The aging population continues to grow, leading to an increased use of medications that influence bone metabolism. Among these, osteoporosis medications such as bisphosphonates, denosumab (Prolia®), and parathyroid hormone analogs like Tymlos® (abaloparatide) or Forteo® (teriparatide) are notable. While these medications are effective in reducing fracture risk, they also present unique and complex challenges for dental professionals, especially in the context of oral surgery, dental implants, and extractions.
As dental clinicians, we must take a thoughtful, evidence-based approach to managing patients on these therapies. This article provides a clinical guide to safe surgical planning, risk stratification, and interprofessional collaboration based on current best practices and my experience treating medically complex patients as a family and cosmetic dentist in Henderson, NV.
Understanding the Medications
1. Bisphosphonates (e.g., Fosamax®, Boniva®, Reclast®)
- Inhibit osteoclast-mediated bone resorption
- Long half-life in bone (years)
- Associated with osteonecrosis of the jaw (ONJ), especially IV forms
- Effects are partially reversible upon discontinuation
2. Denosumab (Prolia®)
- RANKL inhibitor reduces bone turnover
- Shorter half-life (~6 months) but still associated with ONJ
- Effects are reversible upon discontinuation
3. Anabolic Agents: Tymlos® (abaloparatide) & Forteo® (teriparatide)
- Stimulate new bone formation via parathyroid hormone analog action
- No direct link to ONJ, but caution is advised in surgical settings
- Often used after bisphosphonate failure or high fracture risk
“As clinicians, it’s essential to not only recognize the class of medication but understand its mechanism, duration, and implications for wound healing and bone turnover,” says Dr. Marielaina Perrone, DDS.
Clinical Risks: The ONJ Factor
Osteonecrosis of the jaw (ONJ) is the most serious concern in patients taking antiresorptive therapies. While rare in patients taking oral bisphosphonates or denosumab for osteoporosis (incidence ~0.07%–0.1%), signicantly higher in cancer patients receiving high dose IV bisphosphonates (1-15%). The risk increases with surgical trauma, duration of therapy, and concurrent systemic conditions.
ONJ Diagnostic Criteria (AAOMS 2022):
- Exposed bone in the maxillofacial region lasting >8 weeks
- No history of radiation therapy to the jaws
- Current or prior treatment with antiresorptive or antiangiogenic agents
Preoperative Risk Assessment
Key Questions to Ask:
- What is the medication's name, dosage, and duration?
- Is the patient taking oral or IV therapy?
- Are they concurrently using corticosteroids or immunosuppressants?
- Have they had any prior dental complications or delayed healing?
“Patients don’t always realize the importance of disclosing medications like Prolia or Tymlos,” Dr. Marielaina Perrone, DDS notes. “It’s critical we ask the right questions and get a full medical history.”
Risk Stratification (Adapted from ADA & AAOMS Guidelines):
| Risk Level |
Patient Profile |
Management Strategy |
| Low |
<4 years of oral bisphosphonates or denosumab, no comorbidities |
Proceed with standard precautions |
| Moderate |
>4 years of therapy or use with corticosteroids |
Consider drug holiday; consult physician |
| High |
IV bisphosphonates or history of ONJ |
Avoid elective surgery; consider non-surgical alternatives |
Interprofessional Collaboration
Communication with the patient’s primary care physician or endocrinologist is essential—particularly when managing cases involving:
- Multiple extractions
- Implant placement
- Bone grafting procedures
Some providers may recommend a drug holiday, particularly with denosumab, where skipping a dose pre-surgery may reduce ONJ risk. However, this should always be done in coordination with the prescribing provider.
“We don’t change a patient’s systemic medications without physician input,” says Dr. Perrone. “But we do facilitate that dialogue to ensure safe outcomes.”
Surgical Considerations & Postoperative Protocol
Intraoperative Strategies:
- Atraumatic technique: Gentle tissue handling, minimal flap reflection
- Primary closure: Promote fast epithelial coverage
- Antibiotic prophylaxis: Controversial but commonly used in moderate- to high-risk patients
- Avoid implants in high-risk cases without medical clearance
- Use Of AntiBacterial Rinse like chlorhexidine gluconate 0.12% BID
Postoperative Monitoring:
- Frequent follow-ups (1 week, 2 weeks, 1 month)
- Watch for signs of delayed healing, infection, or exposed bone
- Reinforce meticulous oral hygiene and antimicrobial rinses (e.g., chlorhexidine)
“Wound management is everything in these cases,” Dr. Perrone explains. “You want to avoid anything that could prolong bone exposure or lead to infection.”
Elective vs. Emergency Care
For patients at moderate or high risk, elective extractions or implant placement should be carefully considered—or delayed when possible. But surgical intervention should not be withheld for emergency procedures, such as infection or severe pain.
“In urgent cases, we take every precaution but proceed with treatment to protect the patient’s overall health,” says Dr. Perrone. “Infections left untreated can be far more dangerous.”
Conclusion: Treat with Caution, Not Fear
The presence of osteoporosis medications doesn't mean surgery is off the table-it simply means we must be informed, thorough, and collaborative in our approach. We must be prudent and careful in our treatment decisions, always prioritizing patient safety.The presence of osteoporosis medications doesn’t mean surgery is off the table—it simply means we must be informed, thorough, and collaborative in our approach.
“Our role is to assess risk, plan accordingly, and guide patients through safe, evidence-based treatment,” Dr. Perrone concludes. “Good communication and surgical care can achieve excellent outcomes—even in complex cases.”
About the Author
Dr. Marielaina Perrone, DDS, is an experienced general and cosmetic dentist in Green Valley, Henderson NV, with over 20 years of clinical experience. She provides advanced restorative care, cosmetic smile design, dental implants, and treatment for patients with complex medical conditions. Dr. Perrone is passionate about the intersection of dental and systemic health and educating patients and professionals.