Taking Osteoporosis Medicine? What to Tell Your Dental Team Before Surgery in Singapore

The Oral Maxillofacial Practice (OMP) prepared this guide for patients in Singapore who take osteoporosis medicine and are considering a tooth extraction, dental implant or another procedure involving the jawbone.

Taking one of these medicines does not automatically mean that dental surgery is unsuitable. However, your dental team needs an accurate medication history so that it can assess your individual circumstances, explain the relevant considerations and, where appropriate, coordinate with the doctor managing your osteoporosis.

Which osteoporosis medicines are relevant to dental surgery?

Some osteoporosis medicines reduce the rate at which bone is broken down. These are known as antiresorptive medicines and include:

• Oral bisphosphonates such as alendronate and risedronate
• Intravenous bisphosphonates such as zoledronic acid
• Denosumab, which is administered by injection at scheduled intervals

These medicines help reduce bone loss and fracture risk. Because they also affect normal bone remodelling, they may be relevant when planning procedures that involve the jawbone.

The medicine’s name is only one part of the assessment. Its dose, how it is administered, why it was prescribed and how long it has been used may also matter. Bring a complete medication list even if you are unsure whether a particular medicine is relevant.

What is MRONJ?

Medication-related osteonecrosis of the jaw, usually shortened to MRONJ, is an uncommon complication in which an area of jawbone does not heal as expected.

It has been associated with antiresorptive medicines such as bisphosphonates and denosumab. MRONJ may occur after a tooth extraction or another procedure involving bone, although it can occasionally develop without a recent dental procedure.

For people receiving these medicines for osteoporosis, the risk is considered very low. Singapore’s Agency for Care Effectiveness describes MRONJ as extremely rare in osteoporosis treatment. The risk may be different when antiresorptive medicines are administered at higher doses or more frequently for cancer-related conditions.

The fracture-prevention benefits of osteoporosis treatment generally outweigh the low risk of MRONJ. The aim of dental assessment is therefore to plan care thoughtfully—not to create unnecessary fear about the medicine.

Does osteoporosis medicine rule out an extraction or dental implant?

Not necessarily.

According to guidance summarised by the American Dental Association, osteoporosis-dose antiresorptive treatment is not automatically a contraindication to dental implant placement. However, implant suitability still depends on the person’s oral health, bone condition, treatment history and the proposed procedure. Longer-term evidence about implant outcomes in patients taking these medicines remains limited.

For an extraction, implant or bone-grafting procedure, your dental team may consider:

• The exact medicine, dose and route of administration
• Whether it was prescribed for osteoporosis or another condition
• How long you have received treatment
• The dates of your previous and upcoming doses
• The presence of gum disease, dental infection or poorly fitting dentures
• Other medical conditions and medicines
• Any previous problem with delayed oral healing or MRONJ
• The type and extent of the proposed procedure

The American Association of Oral and Maxillofacial Surgeons advises that the operative plan does not need to be altered for most patients receiving antiresorptive treatment for a non-cancer condition. Assessment should nevertheless consider the treatment schedule, duration, other medical factors, infection or inflammation and the extent of surgery.

If a tooth may be preserved predictably with non-surgical care, your dentist may discuss that option. If removal is necessary, the surgical approach and follow-up plan will be based on the individual clinical situation.

Should I stop the medicine before dental surgery?

Do not stop, postpone or change osteoporosis treatment on your own.

There is not strong evidence that routinely interrupting bisphosphonate treatment before dental surgery prevents MRONJ. Bisphosphonates can also remain within bone for an extended period, so a short interruption may not remove the relevant effect. Current guidance therefore does not support a routine “drug holiday” for every patient.

Denosumab requires particular care because delaying or stopping it without an appropriate medical plan may cause rapid bone loss and increase fracture risk. The Endocrine Society advises that denosumab should not be delayed or stopped without subsequent treatment being arranged where appropriate.

If changing the timing of treatment is being considered, the decision should be made by the prescribing doctor and dental team after weighing both fracture risk and dental considerations. Recommendations given to another patient may not be suitable for you.

What should I bring to my consultation?

Before your oral and maxillofacial surgery consultation, prepare the following information:

• The name and dose of each osteoporosis medicine
• Whether it is a tablet, injection or infusion
• When you started treatment
• The date of your most recent dose
• The date of your next scheduled dose
• Why the medicine was prescribed
• The name and contact details of the prescribing doctor
• A list of your other medicines and supplements
• Details of previous osteoporosis medicines, if known
• Any previous difficulty with dental healing

Photographs of the medicine box, a prescription record or information from Singapore’s HealthHub app may help if you cannot remember the exact name.

What happens during the assessment?

Your dentist or oral and maxillofacial surgeon will usually review your medical and dental history, examine your mouth and assess the tooth or proposed implant site. Dental imaging may be recommended when clinically appropriate.

The discussion may cover:

• Whether the procedure is necessary
• Whether the tooth can reasonably be retained
• Alternatives to the proposed surgery
• The expected benefits and material risks
• Measures for managing existing infection or inflammation
• Whether coordination with the prescribing doctor is appropriate
• The follow-up needed to monitor healing

For implant treatment, the assessment will also consider available bone, gum health, the planned restoration and other factors that can affect implant suitability. You can read more about dental implant assessment in Singapore.

Looking after your oral health during osteoporosis treatment

Good oral hygiene and regular dental care can help reduce dental disease that might otherwise lead to an extraction. Tell your dentist about your osteoporosis treatment at routine appointments, not only when surgery is planned.

After an extraction or another oral procedure, follow the personalised aftercare instructions and attend scheduled reviews. Contact your dental team if the area does not appear to be healing as expected or if you develop persistent pain, swelling, discharge, exposed bone or altered sensation. These symptoms do not necessarily mean that MRONJ is present, but they warrant assessment.

Planning dental surgery with OMP

OMP provides assessment and treatment planning for oral and maxillofacial procedures, including tooth removal and dental implant surgery. When relevant, the team can review your medication history and communicate with your prescribing doctor as part of coordinated care.

If you take bisphosphonates, denosumab or another medicine for osteoporosis, share the details when making your appointment and bring an up-to-date medication list. You can arrange an assessment with OMP or speak with your dentist about an appropriate referral.

This article is intended for general education and does not replace individual medical or dental advice. Do not stop, delay or alter prescribed osteoporosis medicine unless advised by the healthcare professional managing your treatment.

Sources

1. Agency for Care Effectiveness, Singapore — Osteoporosis: Diagnosis and Management
2. American Dental Association — Osteoporosis Medications and Medication-Related Osteonecrosis of the Jaw
3. American Association of Oral and Maxillofacial Surgeons — Position Paper on MRONJ, 2022 Update
4. Endocrine Society — Pharmacological Management of Osteoporosis in Postmenopausal Women
5. HealthHub Singapore — Denosumab for Osteoporosis