Drug holidays and scheduling of procedures
If a bone-invasive dental procedure cannot be avoided but is not urgent, temporary discontinuation of antiresorptive therapy (a ‘drug holiday’), or timing the procedure to coincide with a low serum drug concentration, have been suggested to reduce the risk of medication-related osteonecrosis of the jaw. These practices are based on extrapolation of the drug pharmacokinetics in the serum and on bone physiology; however, outcome evidence to support them is not available. Recommendations in international guidelines are inconsistent, and vary depending on the indication for antiresorptive drugs, the duration of therapy and the presence of additional risk factors123.
Clinical judgement of treating doctors and dentists is required to determine the appropriate management of each patient. The decision to alter therapy with an antiresorptive drug or romosozumab lies with the practitioner responsible for managing that drug.
For patients receiving antiresorptive drugs or romosozumab for osteoporosis, the benefits of continued therapy outweigh the low risk of medication-related osteonecrosis of the jaw in most patients—consider the following points:
- Although stopping bisphosphonates for a short period is unlikely to cause harm in a patient at low risk of fracture, there is no evidence that this approach reduces the risk of medication-related osteonecrosis of the jaw.
- Denosumab is a reversible antiresorptive administered every 6 months for osteoporosis. If it is possible to delay a bone-invasive dental procedure in a patient taking denosumab for osteoporosis, ideally schedule the procedure just before the next dose of denosumab. It is never appropriate to interrupt or delay the dose of denosumab; withdrawal of denosumab has been associated with an increased risk of spontaneous vertebral fractures.
- Interrupting treatment with romosozumab results in a loss of bone mineral density and potential risk of fracture.
For patients with cancer, the decision to alter antiresorptive therapy lies with the specialist managing the cancer.