How long after a Prolia injection can you extract a tooth?

Tooth extractions in patients with osteoporosis using antiresorptive medication

The surgical technique to be performed should be minimally invasive and should provide primary closure of the dental socket ( 23 ). Alveoloplasty may facilitate primary closure of the socket after extraction, but surgeons have full discretion in deciding whether to perform it or not ( 23 ). The development of MRONJ seems to be related to cases in which the dental alveolus is not primarily closed in the immediate postoperative period, therefore requiring more healing time ( 23 ). Careful postoperative follow-up is required until the healing process is complete, which may take longer than usual ( 46 ). Another important recommendation is the completion of an informed consent form, which should make the patient aware of the low risk of dental extraction for the development of MRONJ, and the importance of complying with the recommendations on the postoperative follow-up ( 47 ). Figure 1 shows an example of an informed consent form for patients receiving osteoporosis treatment who will undergo invasive dental treatment.

Prevention and treatment of oral adverse effects of antiresorptive medications for osteoporosis – A position paper of the Brazilian Society of Endocrinology and Metabolism (SBEM), Brazilian Society of Stomatology and Oral Pathology (Sobep), and Brazilian Association for Bone Evaluation and Osteometabolism (Abrasso). Madeira M, Rocha AC, Moreira CA, Aguiar ÁMM, Maeda SS, Cardoso AS, de Moura Castro CH, D'Alva CB, Silva BCC, Ferraz-de-Souza B, Lazaretti-Castro M, Bandeira F, Torres SR. Creative Commons Attribution 4.0 International (https://creativecommons.org/licenses/by/4.0/).

Discussion

Dmab drug holiday may cause rebound bone turnover and precipitate an undesirable effect of seriously compromised bone structure (20). The recent treatment guidelines for osteoporosis do not recommend Dmab discontinuation without subsequent therapy with other antiresorptive agents to prevent this rebound phenomenon (3, 4). For bone metastasis patients, a study by Jacobson et al. (21) demonstrated that 35% of patients experienced ≥1 SRE following Dmab discontinuation. A retrospective cohort study by Hasegawa et al. (40) suggested that both the administration of Dmab and the discontinuation of antiresorptive medication did not result in a significant difference in MRONJ risk among patients receiving antiresorptive medication and undergoing dental procedures. The evidence from our study of Dmab treatment in bone metastasis patients also showed no differentiation in the risk of MRONJ between discontinuing and continuing medication during dental procedures, as well as no significant difference when compared to other types of antiresorptive agents or any discontinuation protocol in terms of MRONJ risk. Furthermore, the risk of MRONJ after Dmab injection for osteoporosis treatment, where the dosage is typically much lower than in malignancy treatment, is generally considered to be very low. These patients should presume tooth extraction if necessary, whereas avoiding tooth extraction can preserve the source of odontogenic infections, which are often associated with the development of MRONJ (41, 42).

Effects of discontinuing different antiresorptive regimens on medication-related osteonecrosis of the jaw in patients undergoing dental procedures: a systematic review and network meta-analysis. © the author(s). Creative Commons Attribution 4.0 International (https://creativecommons.org/licenses/by/4.0/).

4. Discussion

Ultimately, among the various approaches described in the literature for the prevention of MRONJ, drug holiday has been reported [74]. This strategy remains controversial and should not replace other preventive measures, such as atraumatic extractions and antibiotic prophylaxis. A drug holiday may be useful in the case of denosumab, due to its short half-life, whereas a short-term interruption of bisphosphonates may not appear to reduce the risk of MRONJ significantly. Indeed, bisphosphonates have a residual effect that persists for many years after treatment discontinuation because the drug remains bound to the bone [74]. Despite the lack of evidence supporting a bisphosphonate prophylactic drug holiday before tooth extraction, the SIPMO-SICMF position paper recommends discontinuing bisphosphonates one week before surgery until complete mucosal healing is achieved [2]. If authorized by the prescribing clinician, discontinuation is recommended for patients on high-dose therapy. For patients under treatment with low-dose therapy, a drug holiday is recommended if under treatment for more than three years or in case of systemic risk factors. This strategy could thus reduce antiangiogenic activity, oral mucosal toxicity, and the inhibition of epithelial cell proliferation and migration after tooth extraction [2,74].

Antibiotic Prophylaxis and Postoperative Therapy in Tooth Extractions for Patients at Risk of Medication-Related Osteonecrosis of the Jaw (MRONJ): A Scoping Review. © 2025 by the authors. Creative Commons Attribution 4.0 International (https://creativecommons.org/licenses/by/4.0/).