“My doctor says I have osteoporosis, and I need to see a dentist before I start my medication.” We hear some version of that often. Usually the person has also read something online about the jawbone, and they aren’t sure whether to take the medicine at all.
The short version: for osteoporosis, the jaw risk from these drugs is very low, and the medicine prevents far more broken bones than it causes jaw problems. At the stronger doses used for cancer, the risk is real and much higher. Either way, healthy teeth and gums are the best protection, which is why your doctor sent you to us.
Which medications are we talking about?
They’re called antiresorptive drugs. They slow down the cells that break bone down, which is how they make bones stronger. The common ones:
- Bisphosphonate pills for osteoporosis: Fosamax (alendronate), Actonel (risedronate) and Boniva (ibandronate).
- Bisphosphonate infusions: Reclast, given once a year for osteoporosis, and Zometa, given as often as every month for cancer that has spread to the bone. Both are zoledronic acid, at very different doses.
- Denosumab injections: Prolia, every six months for osteoporosis, and Xgeva, monthly for cancer. Newer versions of the same drug go by other names, such as Jubbonti and Wyost.
Evenity, a newer osteoporosis shot, carries a similar caution.
What can happen to the jaw
The condition is called medication-related osteonecrosis of the jaw, or MRONJ. A patch of jawbone loses its ability to heal and is left exposed in the mouth, most often after a tooth is taken out. To count as MRONJ, the bone has to stay exposed for more than eight weeks. It shows up in the lower jaw about three times as often as the upper.
It isn’t the drug alone. The research points to the drug combined with infection or injury in the bone. Most teeth that were taken out before a case of MRONJ already had gum disease or an infection at the root, and the extraction may have uncovered a problem that was already starting.
How likely is it?
That depends almost entirely on why you’re taking the drug.
- Osteoporosis, pills or a yearly infusion: fewer than 5 in 10,000 people. In the clinical trials, people taking a placebo had a rate of 0 to 2 in 10,000, so the two ranges overlap.
- Osteoporosis, Prolia: somewhat higher, up to about 3 in 1,000 after ten years of use.
- Cancer doses, Zometa or Xgeva: under 5 in 100 in most studies, and higher the longer the drug is given.
When you read a scary number online, check which group it came from. The cancer figures get quoted to osteoporosis patients all the time.
For osteoporosis, the medicine usually wins
A broken hip is not a small thing. Only about half of people who break a hip get back to the independence they had before. In the large trials, Reclast cut spine fractures by 70% and hip fractures by 41% over three years, and Prolia cut spine fractures by 68%.
The oral surgeons’ own position paper says it plainly: for osteoporosis, the benefit of preventing fractures outweighs the risk to the jaw. So if your doctor recommends one of these, please don’t turn it down because of your teeth. Talk to us, and talk to them.
The cancer doses are a different conversation
When cancer has spread to the bone, Zometa or Xgeva is given at a much higher dose, much more often. That’s when a dental exam before the first dose matters most. The guidelines advise taking care of problem teeth first and, when your health allows, letting the area heal before the drug starts.
We’ve seen what this looks like. One woman lost half her jaw. One man had an extraction site that never healed, and it was still open when he passed away. Both were being treated for cancer with Zometa by IV. Neither is what someone taking a weekly pill for osteoporosis should expect, and we share them so the cancer-dose risk gets the attention it deserves.
What we do when you come in
- A full exam with X-rays. We look for gum disease, infection at the roots, and teeth we’re unsure about.
- A conversation about the iffy teeth. Sometimes the right call is to treat or remove a questionable tooth before you start. Sometimes it’s to keep it and watch it. There’s no single rule, so we talk it through with you, case by case.
- If a tooth needs to come out, we mostly refer to an oral surgeon for patients on these drugs.
- Whether to pause the medicine around surgery is a decision we leave to the surgeon and the doctor who prescribed it. The research on these “drug holidays” is mixed, and the experts don’t agree.
- Everyday dental care stays the same. Cleanings, fillings, crowns and root canals are safe and encouraged. For someone on the cancer doses, saving a tooth with a root canal is often preferred over taking it out.
- Dentures get checked for sore spots, especially along the inside of the lower denture, where rubbing can start a problem. More on dentures here.
Implants are still possible for most people taking an osteoporosis dose, and the surgeon will go over the small added risk with you. For the cancer doses, the guidelines advise against them. How we plan implants is here.
Please don’t stop on your own
This matters most with Prolia. Stopping it, or going well past the due date for a shot, can lead to a quick loss of bone and a jump in spine fractures, sometimes several at once. Any change to your bone medicine is your doctor’s decision.
And tell every dentist you see about these drugs, including ones you took years ago. Bisphosphonates bind to the bone, which is why past use still counts.
Signs to call us about
- Bone showing through the gum, or a sore that won’t heal
- A socket that isn’t healing after an extraction
- Jaw pain or swelling, or a toothache with no clear cause
- Numbness or a heavy feeling in the jaw or chin
- A tooth getting loose for no clear reason
- A sore spot under your denture
Worth bringing up
If your doctor has sent you to us before starting a bone medicine, call 702-734-0776 or tell us what’s going on. Bring the name of the medicine and when you’re starting it, or the date of your last shot.
Figures are from the American Association of Oral and Maxillofacial Surgeons’ 2022 position paper and the clinical trials it cites. General education, and not a substitute for an exam or for your physician’s advice.