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)

Abstract

Antiresorptive therapy is the main form of prevention of osteoporotic or fragility fractures. Medicationrelated osteonecrosis of the jaw (MRONJ) is a relatively rare but severe adverse reaction to antiresorptive and antiangiogenic drugs. Physicians and dentists caring for patients taking these drugs and requiring invasive procedures face a difficult decision because of the potential risk of MRONJ. The aim of this study was to discuss the risk factors for the development of MRONJ and prevention of this complication in patients with osteoporosis taking antiresorptive drugs and requiring invasive dental treatment. For this goal, a task force with representatives from three professional associations was appointed to review the pertinent literature and discuss systemic and local risk factors, prevention of MRONJ in patients with osteoporosis, and management of established MRONJ. Although scarce evidence links the use of antiresorptive agents in the context of osteoporosis to the development of MRONJ, these agents are considered a risk factor for this complication. Despite the rare reports of MRONJ in patients with osteoporosis, the severity of symptoms and impact of MRONJ in the patients' quality of life make it imperative for health care professionals to consider this complication when planning invasive dental procedures.

Evaluation of Preventive Treatment Protocols for Patients under Antiresorptive Therapy Undergoing Tooth Extraction at a Swiss University Clinic

“…For ARONJ prevention, most authors agree that a perioperative antibiotic prophylaxis should be given when performing a tooth extraction [ 3 , 7 , 13 , 19 , 22 , 23 , 24 ]. In this case, the antibiotic administration starts prior to surgery and is prolonged after the intervention, usually until mucosal healing is completed [ 13 , 25 ]. However, there is great variation regarding recommendations for the choice, dosage schedule and particularly the duration of antibiotic prophylaxis in the literature [ 13 , 26 ].…”

Long-term consequences of osteoporosis therapy with denosumab

“…ONJ is a rare but serious complication of antiresorptive therapy, which can occur with either BPs or DMAb use. It is more commonly observed in patients with neoplasms treated with higher doses than used for osteoporosis ( 23 , 24 ). In the 10-year follow-up of the FREEDOM study and its extension, seven cases of ONJ occurred in the prolonged treatment group and six cases in the crossover group ( 5 ).…”

“…It should be noted that in addition to the use of drugs, other factors can enhance the risk of ONJ, such as diabetes mellitus, rheumatoid arthritis, systemic arterial hypertension, smoking and poor oral health (dental infection, trauma, or invasive procedures). These other risk factors should always be considered by healthcare professionals, who should advise patients on oral hygiene ( 24 ). In patients who develop ONJ during therapy with BPs, 82% had a history of dental procedures prior to the injury ( 25 ).…”

“…From these, 0.68% developed ONJ in comparison with 0.05% in those who did not have a dental procedure ( 26 ). The duration of antiresorptive therapy has also been reported as an additional risk factor for ONJ ( 5 , 24 ). However, it should be noted that there is no evidence that discontinuing antiresorptive drugs before dental procedures reduces the risk of ONJ ( 24 ).…”

“…Epidemiological data on ONJ are difficult to obtain, given its low prevalence, together with limitations in sample size and study design ( 24 ). The risk of this complication occurring with DMAb was slightly higher than that observed with ZOL in patients with osteoporosis (0.04% and 0.5% in the 2 and 7-year extensions of FREEDOM, respectively ( 3 , 5 ), vs. 0.017% ( 27 ) with ZOL).…”