Denosumab affects the reabsorption of bone, preventing resorption and leading to bone strengthening. Often, it is well-known that osteonecrosis of a jaw is a rare potential side effect of denosumab use (occurs in 0.5% to 2% of the population on denosumab)(1). However, majority of oncologists believe the benefit of denosumab outweighs the risks.
Considerations exist when performing dental work on a patient on denosumab to further prevent osteonecrosis of the jaw. A critical prevention strategy against osteonecrosis of the jaw is to avoid dental procedures that include drilling and removing teeth. Tooth extraction is considered the most common dental procedure responsible for osteonecrosis of the jaw in patients on denosumab, responsible for 70-80% of cases (2). Tooth extraction is associated with a 33-fold higher risk in osteonecrosis of the jaw (3).
However, prevention of osteonecrosis of the jaw in dental procedure is fairly success at reducing the severity and incidences of this complication. Preventive dental intervention includes any dental management, i.e., completion of dental treatment before commencing denosumab, use of antibiotics before and after a surgical procedure, and maintenance of good oral health (5,6,7). Additionally, reducing the risk of infection is important thus, dental plaques and periodontitis should be treated in conservative procedures and invasive dental procedures should be avoided.
Data assessing risk of osteonecrosis of the jaw indicates that patients receiving denosumab for 4 years or less have lower risk of osteonecrosis of the jaw during dental procedures than those treated with denosumab for more than 4 years (8). Other risk factors include the use of corticosteroids, prior radiation therapy to the head/neck, periodontitis, smoking, dentures that don't fit properly, poor oral hygiene, and diabetes.
Patients who receive denosumab may require a break before and after their dental procedure. When a dental procedure is required, certain providers suggest denosumab should be discontinued (drug holiday) for a minimum of 3 months before any surgical procedure as long as the disease permits (8, 9).
However, your doctor will evaluate your level of risk and the duration of time denosumab is discontinued which may be individualized based on your level of risk. Consult with your doctor before any dental procedures.