Elective Extraction and Implant Planning in a Long-Term Oral Bisphosphonate User
A 67-year-old woman requests replacement of her lower right first molar (46), which she has been told is 'beyond saving'. The tooth has deep distal caries extending below the gingival margin, class II furcation involvement, an 8 mm distal pocket and grade II mobility; the adjacent 45 has a 5 mm pocket but is otherwise sound. She has taken alendronate 70 mg weekly for six years for postmenopausal osteoporosis, with calcium and vitamin D, and no corticosteroids or other medication. She has never received intravenous bisphosphonates and has no history of cancer, diabetes or smoking. Three years ago, already on alendronate, she had an upper premolar extracted and healed uneventfully. She is adamant that she wants an implant 'like her friend had' rather than a removable denture, and asks whether the tablet should be stopped before surgery. She has read on the internet that extractions in her situation cause 'dead jaw'.
1. Estimate her MRONJ risk, decide whether the tooth should be extracted, and set out the surgical protocol including the question of a drug holiday.
Read the worked answer
Risk estimate. Oral alendronate for six years, no corticosteroid, no diabetes, no smoking, no antiangiogenic drug. Under AAOMS stratification, oral bisphosphonate beyond four years places her in a slight-risk category. The published incidence of MRONJ after extraction in oral bisphosphonate users is low - broadly of the order of 0.01-0.1% - and orders of magnitude below the intravenous/oncological setting. Her uneventful extraction three years ago is reassuring but not a guarantee.
Should the tooth go? Yes. It is unrestorable: caries below the gingival margin, furcation involvement and an 8 mm pocket. Retaining it risks an acute abscess and an urgent, poorly controlled extraction in worse circumstances - which is a higher-risk scenario than a planned procedure.
Protocol
- Discuss with her physician and document the conversation; do not stop alendronate unilaterally.
- A drug holiday is not mandatory. The evidence that it prevents MRONJ is weak. AAOMS suggests that with more than four years of oral bisphosphonate, a holiday of about two months may be considered if the systemic condition permits and the physician agrees.
- Surgically: minimally traumatic extraction, avoid extensive periosteal stripping, remove sharp bone edges, achieve primary mucosal closure, 0.12% chlorhexidine rinse, and antibiotics only if there is active infection.
- Review at 1, 4 and 8 weeks to confirm mucosal healing, and give her written warning signs (non-healing socket, exposed bone, pain, paraesthesia, discharge).
2. How would you sequence replacement of the tooth, and how would your advice change if she were on denosumab or on intravenous zoledronic acid for malignancy?
Read the worked answer
Sequencing. Stage the treatment: extract, allow three to four months of socket healing with primary mucosal closure, then reassess bone and soft tissue before implant placement. There is no absolute contraindication to an implant in an oral bisphosphonate patient, but the priority is the least traumatic extraction with the best closure. Combining extraction with immediate implant increases surgical trauma and the consequences of failure. Discuss the alternatives honestly: a bridge from 45 and 47 requires preparing sound teeth; a removable partial denture is the least invasive; doing nothing leaves a shortened arch with drifting of 47.
If she were on denosumab 60 mg six-monthly for osteoporosis: the risk is broadly comparable to oral bisphosphonates, but the pharmacology differs. Denosumab is not incorporated into bone, so risk falls after cessation, yet stopping causes a rebound in bone turnover and a vertebral fracture risk, so the decision belongs to the physician. Timing surgery midway between injections is often discussed but is not strongly evidence-based.
If she were on intravenous zoledronic acid for malignancy, or an antiangiogenic such as bevacizumab: this is a high-risk patient. Elective dentoalveolar surgery should be avoided. Consider endodontic retention of the tooth even if restorative compromise is needed, and if extraction is unavoidable, plan it with the oncology team under an agreed protocol. That is a materially different risk and a different consent conversation - neither scenario should be managed with the reassurance appropriate to her current oral alendronate.
3. Write the core of the consent discussion you would have with her, including how you would handle the 'dead jaw' concern.
Read the worked answer
Structure the discussion around her actual question.
What MRONJ is: a rare complication in which bone fails to heal and becomes exposed after trauma such as an extraction. It is not 'jaw death' in the sense she has read; most cases in oral bisphosphonate users are limited and manageable, but it can be persistent.
Her numbers, stated honestly: with oral alendronate, the estimated risk after extraction is of the order of 1 in 1,000 to 1 in 10,000; her duration beyond four years and her age are the relevant modifiers. Avoid both false reassurance ('it never happens') and alarmism.
The alternative risks: leaving an unrestorable infected tooth carries a real risk of abscess and of an emergency extraction without any of these precautions.
Early warning signs to report within days, not months: non-healing socket, visible bone, pain, numbness, discharge, loosening of the adjacent tooth.
Alternatives to extraction and to implant: bridge, removable partial denture, no replacement - with the consequences of each, and the fact that the implant is a separate decision made only after the socket has healed.
The drug holiday question: explain that you will speak to her physician, that stopping is not proven to prevent the problem, and that the decision is shared.
Document her questions, the physician discussion, the written information given, and her decision in her own words. Do not guarantee an outcome, and note that antibiotic prophylaxis is not indicated for the extraction or for implant placement absent a specific cardiac indication.