Oral Medicine · Osteoporosis
Osteoporosis medications such as Fosamax (Fosalan in Israel), Actonel, Aclasta and Prolia protect your skeleton from fractures, but they also affect the jaw bone. Most dental treatment is completely safe, while extractions, implants and oral surgery need proper planning to minimize the risk of jaw osteonecrosis. Dr. Andra Rettman, a specialist in Oral Medicine, builds each plan around the specific drug, treatment duration and medical history, in coordination with your physician.
In osteoporosis, bone resorption outpaces bone formation, so bones weaken and fracture risk rises. It is very common, especially in women after menopause, and is usually treated with long-term medication.
Most of these drugs work by slowing bone turnover. That is excellent for the skeleton, but in the jaw, which is exposed to dental infections and chewing injuries, slower turnover can impair healing after trauma, mainly after an extraction. In rare cases a condition called medication-related osteonecrosis of the jaw (MRONJ) develops.
Bottom line: the risk for osteoporosis patients is very low, and there is no reason to avoid dental care. What matters is telling your dentist which drug you take and for how long, and planning invasive procedures in advance.
| Drug (generic) | How it is given | What it means for dental care |
|---|---|---|
| Fosamax / Fosalan (alendronate) | Tablet, usually weekly | Low risk; increases with long-term use (over ~4 years) and other risk factors |
| Actonel (risedronate) | Weekly/monthly tablet | Similar to alendronate |
| Aclasta / Reclast (zoledronic acid) | Yearly infusion | Remains in bone for years; extractions and implants need planning |
| Prolia (denosumab) | Injection every 6 months | Reversible effect; invasive procedures are timed around the injection. Never skip a dose without your doctor's instruction |
| Evenity (romosozumab) | Monthly injection for a limited period | Jaw osteonecrosis has been reported; planning required |
| Forteo and similar (teriparatide) | Daily injection | Bone-building drug; not considered a risk factor for jaw osteonecrosis |
Cancer patients receive some of the same drugs (Zometa, Xgeva) at far higher doses, with a very different level of risk. See dental care for cancer patients.
According to the most recent position paper of the American Association of Oral and Maxillofacial Surgeons (AAOMS, 2022), the risk for osteoporosis patients on bisphosphonates or denosumab is very low, in the order of less than one case per thousand patients, and many times lower than at oncologic doses.
Almost all routine treatment is safe, with no need to stop your medication:
Never stop an osteoporosis drug on your own. Unplanned discontinuation, especially of Prolia, can raise the risk of spinal fractures. Any change is decided only with your treating physician.
When an extraction or implant is needed, planning makes the difference:
Many patients taking oral osteoporosis medication can have implants after a risk assessment and informed discussion. With Aclasta infusions, long-term treatment or additional risk factors the decision is more cautious, and a non-surgical restorative solution is sometimes preferable. The decision is made together with you, based on your full medical information.
The ideal time for a dental assessment is before starting osteoporosis medication. Teeth likely to need extraction can be treated first, gum disease stabilized and dentures adjusted, so treatment begins with a mouth free of infection.
Early diagnosis by an Oral Medicine specialist significantly improves outcomes.
Dr. Andra Rettman is a specialist in Oral Medicine and a senior physician in the Department of Oral Medicine, Sedation and Maxillofacial Imaging at Hadassah Ein Kerem, where she treats medically complex patients, including patients on bone medications, and teaches residents. The result is a treatment plan based on current guidelines that takes your full medical picture into account. Treatment is available in English and Hebrew.
Yes. Examinations, cleanings, fillings, root canals and crowns are safe and do not require stopping the drug. Extractions and implants need advance planning and a risk assessment.
Usually not. Guidelines do not recommend routine discontinuation; in selected cases, mainly long-term use or additional risk factors, a temporary break may be considered, only as a joint decision with your physician.
Usually toward the end of the dosing interval, about 3 to 4 months after the last injection, with the next injection after initial healing. Never delay or skip Prolia without your doctor's instruction, because of fracture risk.
Many patients can, after a risk assessment. It depends on the drug and duration of use, other risk factors and bone condition; sometimes a non-surgical restoration is preferable.
Very low, in the order of less than one case per thousand patients, according to the 2022 AAOMS position paper. Risk rises with extractions, long-term use, steroids, diabetes, smoking and oral infections.
The drug remains in bone for a long time, so extractions, implants and surgery are carefully planned. Routine care proceeds as usual. Tell your dentist the date of your last infusion and how many you have had.
Yes, that is the ideal time: problem teeth and gum disease can be treated first, so medication starts with a healthy mouth.
Exposed bone, a non-healing extraction site, pain, swelling, discharge, loose teeth or numbness in the lip. Seek an Oral Medicine specialist promptly.
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