The Patient on Bisphosphonates Who Needs an Extraction

MRONJ risk is multifactorial. For this patient:

• Antiresorptive therapy (oral alendronate, 6 years): oral bisphosphonates carry a lower risk than IV formulations, but duration matters. Risk rises with time on therapy, and six years is a long exposure. Alendronate binds to bone and persists for years after cessation, so simply stopping it does not immediately remove the risk.
• Diabetes (HbA1c 8.4%): poorly controlled diabetes impairs healing and immune response, increasing both infection risk and the consequences of any surgical insult.
• Smoking (10/day): impairs microcirculation and wound healing.
• Recent oral corticosteroids: add to impaired healing and infection risk.
• Extraction itself: invasive procedures involving bone are a recognised trigger for MRONJ.
• No radiotherapy: this is protective - it rules out osteoradionecrosis as an alternative diagnosis.

Overall she is at elevated but not extreme risk. The decision is not 'never extract' but 'extract only with a considered plan'.

I would not extract today. The reasoning:

1. Informed consent requires time and information. She needs to understand MRONJ - what it is, her personal risk factors, and the alternatives. A same-day decision under time pressure is not adequate consent.
2. Alternatives exist. The tooth is periodontally involved and mobile. Non-surgical options (periodontal debridement, antibiotics if acutely infected, smoothing of sharp edges) may reduce symptoms and buy time.
3. The cruise is two weeks away. If MRONJ or a healing complication develops, she will be away from her treating clinician. This is a strong argument for deferring elective surgery until after she returns.
4. Medical liaison. I would contact her GP or physician to confirm the bisphosphonate history, discuss whether a drug holiday is appropriate (this is a medical decision, not mine), and confirm diabetes control.
5. If extraction is ultimately required, plan it as an atraumatic procedure: minimal bone trauma, primary closure where possible, pre-procedural chlorhexidine rinse, post-operative antibiotics per local protocol, and clear follow-up.

I would document the discussion, her wishes, and the agreed plan. If she insists on proceeding despite counselling, I would record informed refusal of the safer pathway and still recommend deferral.

Exposed bone persisting beyond eight weeks at a site in a patient on antiresorptive therapy is consistent with MRONJ (assuming no radiotherapy history and no obvious metastasis). At two weeks, it may simply be delayed healing, so the key is close monitoring and escalation rather than premature labelling.

Next steps:

• Assess: size of exposed bone, presence of infection (pus, erythema, swelling), pain, and any sinus tract. Stage accordingly - Stage 0 (no exposed bone but symptoms), Stage 1 (exposed bone, no infection), Stage 2 (exposed bone with infection), Stage 3 (extensive involvement, fistula, fracture).
• Conservative management first: chlorhexidine rinse, gentle debridement of necrotic debris, antibiotics if infected, and analgesia. Avoid aggressive surgery.
• Refer to an oral and maxillofacial service for staging and definitive management if it does not resolve or if infection is present.
• Medical liaison again - inform her physician; discuss the antiresorptive therapy.
• Document the timeline, findings, and advice given.

Reflect: the earlier decision to defer was correct. This outcome reinforces why same-day extraction under time pressure should have been resisted.