Bisphosphonate Drugs**Updated 2026** Must read if taking or considering taking!!

Our recent patient had a tooth flapping in the wind and wanted it taken out. It could be easily pinched and removed in a flash. Since this patient had been taking bisphosphonates (I.V. form) we referred him to the oral surgeon and in turn the surgeon referred him to OHSU to have it extracted. What?! Why couldn't any of us dentists here in the Medford valley remove it???

What are Bone Density Drugs?

Bone density drugs are given to patients who usually have bone deficiencies like osteoporosis or cancer that has spread to the bone. These may include bisphosphonates or denosumabs, and can be taken by either pill or injection. These drugs work by preventing osteoclasts (cells that break bone down) thus minimizing the bone from deteriorating at a faster rate.

What's the Big Deal?

Patients taking these medications coupled with a tooth extraction, have a greater propensity in developing osteonecrosis of the jaw (ONJ)—where the jaw bone dies. Though the risk of having ONJ is currently rare: 1 in 500 for IV bone density drugs and 1 in 2,000 for those taking them in pill form, the risk is great enough where the consequences are very drastic and destructive if you do get ONJ. For cancer patients this number is 1 in 16!

How Does One Get Osteonecrosis of the Jaw?

ONJ can occur mainly from tooth extraction(s) but can also be caused from dental cleanings or other dental procedures that induce bleeding. ONJ can occur weeks or even years after treatment and even the smallest form of trauma like from a toothbrush, chewing hard foods, or a denture sore spot can aggravate ONJ to initiate the destructive process. As of 2026, uncontrolled periodontal disease can be just as big a risk as taking a tooth out. Also, newer medications like denosumabs now generally carry a higher risk than bisphosphonates medications in spurring on ONJ.

What are the Signs and Symptoms?

ONJ begins in the bone near a tooth extraction site and is either asymptomatic or has an intermittent dull toothache type of pain deep into the bone. This can progress to expose bone in the mouth with the gingiva unable to close over it. This can be nearly impossible to reverse without aggressive surgery. Destruction can be asymptomatic or painful, never seal, and introduce more infection.

Treatment Options

Treatment may be long and difficult. Palliative treatment entails potentially a lifetime of 1) applying Peridex mouthrinse to the site 3x/day 2) taking penicillin 4x/day and 3) daily doses of vitamin E. We highly suggest monthly dental visits to monitor the size of the exposure. A hyperbaric chamber of 16+ visits ($1,000+) post dental treatment can be encouraged but the jury is still out on its effectiveness. If the site fails to heal, surgery or hospitalizations would be the next step. The surgeon would likely remove the compromised bone, which often means cutting out most of the jaw and placing metal plates in lieu of bone, screws, and grafts for reconstructive surgery.

Who is Vulnerable to Getting ONJ?

We do not have the means yet to predict who will and won't acquire ONJ, but there are increased risk factors if you have any of the following conditions when taking bone density drugs:

• Cancer, especially when it metastasizes to bone

• Comorbidities (2-plus ailments)

• Immunocompromised

• IV bisphosphonate use for at least 2 years

• Older than 65-years old

• Poor oral hygiene

• Smoking

• Wear dentures

Dental Recommendations if Consider Bisphosphonates

Dr. Nelson is not saying whether to take bisphosphonate drugs--this is outside of our scope of practice. What we do say is to be aware of consequences regardless if you take the pill or I.V. form. We obviously favor the pill form but know that either form will linger in your system for 7 years after the last medication taken. That is 7 years where ONJ can still occur even after mild dental treatment. If a tooth extraction is needed, leaving the compromised tooth is a weighed decision. In the meantime, just take meticulous care of your teeth while on bone density drugs and avoid removing teeth if possible.

**If you are about to begin bone density drugs, make sure ALL pending dental treatment gets completed beforehand.

At Central Point Family Dentistry we care about you and your health and if you have further questions please reach out to us at (541) 664-8300.