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

Our 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 local dentists 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 I.V. These drugs work by inhibiting osteoclasts (cells that break bone down) thus minimizing the bone from deteriorating at a faster rate.

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What's the Big Deal?

Patients taking these medications coupled with a tooth extraction have a greater propensity in developing Medicaiton-Related Osteonecrosis of the Jaw (MRONJ)—where the jaw bone dies. Though the risk of having MRONJ is currently rare: 1 in 140 for I.V. bone density drugs and 1 in 1,000 for those taking them in pill form, the risk is great enough where the consequences are very drastic and destructive if you do get MRONJ. For cancer patients this number is 1 in 10!

How Does One Get Osteonecrosis of the Jaw?

MRONJ can occur mainly from tooth extraction(s) but can also be caused from dental cleanings or other dental procedures that induce bleeding. MRONJ 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 MRONJ 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 5x higher risk than bisphosphonates medications in spurring on MRONJ.

What are the Signs and Symptoms?

MRONJ 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 may entail longterm use 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 is recommended if MRONJ cannot be controlled. 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 MRONJ?

We do not have the means yet to predict who will and won't acquire MRONJ, 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

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Dental Recommendations if Considering Bone Density Drugs

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 bisphosphonate pill but know that either form will linger in your system for seven years after the last medication taken. That is seven years where MRONJ can still occur even after mild dental treatment. Denosumab medications only last six months in your body but their dental consequences may be more severe. 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.