Non-healing extraction socket in a patient on denosumab
A 72-year-old woman attended 10 weeks ago for extraction of tooth 36. The socket has not healed; there is a 1 cm area of exposed, necrotic bone with mild purulent discharge and dull aching pain. She has type 2 diabetes (HbA1c 7.4%) and osteoporosis. She has received denosumab 60 mg subcutaneously every six months for four years; the last dose was three months ago. She does not smoke, has never had radiotherapy to the jaws, and has no history of malignancy. Radiographs show a sclerotic area and a sequestrum at the 36 site, with no jaw fracture. Adjacent teeth 35 and 37 are vital, with 4–5 mm periodontal pockets. She asks whether she should stop denosumab and whether the dead bone should be removed. She can open 40 mm, and there is no facial swelling or cervical lymphadenopathy.
1. What is the diagnosis and stage, and what risk factors are relevant?
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The diagnosis is medication-related osteonecrosis of the jaw (MRONJ). The definition requires exposed bone or bone probed through a fistula in the maxillofacial region persisting for more than eight weeks in a patient taking an antiresorptive or antiangiogenic agent, with no history of radiotherapy to the jaws and no obvious metastatic disease. This fits: 10 weeks of exposed necrotic bone after extraction, denosumab for four years, and no radiotherapy or malignancy. The staging is stage 2, because there is exposed bone with infection - purulent discharge and pain - but no stage 3 features such as bone extending beyond the alveolar process, extraoral fistula, pathological fracture, or sinus involvement. Risk factors include the antiresorptive drug, duration of therapy, a recent extraction, diabetes, and possibly poor glycaemic control. Denosumab is a RANKL inhibitor rather than a bisphosphonate, but it carries the same risk; because it is not incorporated into bone to the same extent, the risk may fall faster after stopping, but it does not disappear immediately.
2. How would you manage her now, and would you advise stopping denosumab?
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I would manage her conservatively at this stage. That means 0.12% chlorhexidine mouthwash twice daily, analgesia, and a course of antibiotics for the infection - amoxicillin with metronidazole, or clindamycin if penicillin-allergic - for seven to ten days. I would gently remove loose sequestra and irrigate, but I would avoid aggressive debridement or extensive surgery in the dental chair. I would refer her to oral and maxillofacial surgery for assessment and long-term follow-up. I would not stop denosumab myself. The decision belongs to her osteoporosis physician: stopping may reduce bone density and increase fracture risk, and the evidence that a drug holiday improves MRONJ outcomes is limited, particularly for denosumab. If infection cannot be controlled or stage 3 features develop, surgical resection or sequestrectomy under antibiotic cover may be needed. I would also optimise her diabetes control, because poor glycaemic control impairs healing and increases infection risk.
3. What would you do for her remaining teeth, and how would you plan future extractions?
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The aim is to prevent further MRONJ by eliminating dental infection before it requires extraction. I would complete a full dental assessment, restore caries, and provide non-surgical periodontal treatment for the 4–5 mm pockets, with review. Teeth 35 and 37 are vital and should be retained if possible; periodontal maintenance rather than extraction is the priority. If an extraction becomes unavoidable, I would plan it carefully: perform it atraumatically, with minimal bone removal, primary closure where possible, and antibiotic cover according to local protocol. For denosumab, some units advise extraction just before the next scheduled dose, when the drug effect is at its lowest, although the evidence is limited; I would discuss this with her physician. I would review healing at one, four, and eight weeks, and give her written information about symptoms that require urgent review. I would avoid elective surgery and emphasise meticulous oral hygiene and regular recall.