Precautions for patients undergoing bone-invasive dental procedures

Bone-invasive dental procedures (eg tooth extractions, difficult surgical extractions, implant placement, periapical or radicular surgery, periodontal flap surgery) require careful consideration in patients at risk of medication-related osteonecrosis of the jaw.

Assess the risks and benefits of the dental procedure and the patient’s risk of medication-related osteonecrosis of the jaw—this requires a thorough medical history (see History taking to assess the risk of medication-related osteonecrosis of the jaw). Determine the patient’s risk of medication-related osteonecrosis of the jaw using Assessing the risk of medication-related osteonecrosis of the jaw before a bone-invasive dental procedure in a patient treated with an antiresorptive drug, antiangiogenic drug or romosozumab. For patients at high risk of medication-related osteonecrosis of the jaw, the dentist should seek expert advice and refer the patient to an appropriate surgical specialist. Patients at low risk of medication-related osteonecrosis of the jaw can undergo bone-invasive dental procedures in a general dental practice—see Management advice for patients at risk of medication-related osteonecrosis of the jaw undergoing a bone-invasive dental procedure for management advice.
Note: Antibiotic prophylaxis is not recommended to reduce the risk of medication-related osteonecrosis of the jaw.
Figure 1. Management advice for patients at risk of medication-related osteonecrosis of the jaw undergoing a bone-invasive dental procedure
  • Inform the patient of the risk of medication-related osteonecrosis of the jaw and obtain consent for the procedure.
  • See advice on Drug holidays and scheduling of procedures.
  • Do not use antibiotic prophylaxis to reduce the risk of medication-related osteonecrosis of the jaw—there is insufficient evidence to support this practice. However, an active infection should be treated.
  • Ensure optimal oral hygiene before and after the procedure.
  • Reduce the plaque load with mechanical debridement and pre- and post-procedural chlorhexidine mouthwash.
  • Minimise trauma and periosteum stripping, and close any mucosal flaps that are raised with sutures.
  • Monitor the oral wound until it heals—healing may be slow.
  • Do not debride nonhealing wounds.
  • Refer to a specialist if bone is still visible at 8 weeks.