Risks and complications

Anti-resorptive drugs (ARDs) – such as bisphosphonates (BPs) and denosumab – are widely used to treat osteoporosis, because they help reduce pain and spontaneous fractures, and control bone metastases.

“Anti-resorptive drugs (ARDs) are widely used to treat osteoporosis”

There are three groups of ARDs: low dose used in osteoporosis; high dose used in cancer patients with metastases; and a new group of intermediate dose used as ‘adjuvant therapy’ in cancer patients without metastases (to decrease the risk of the cancer recurring).

Potential risks of dead bone and implant loss are related to dose and duration, not to the method by which the drugs are administered.

The most recent data for ARDs come from the EAO Consensus in 2018 (Schliephake et al. 2018). It was concluded that:

• patients receiving oral low-dose ARD do not have an increased risk of implant loss
• both low- and high-dose ARD patients are at risk of developing MRONJ irrespective of whether they undergo implant therapy. This risk increases with dose and duration of ARD intake
• the incidence of implant-associated MRONJ in low-dose ARD patients is unknown, either in cases involving oral, subcutaneous or intravenous administration
• the supposed benefits of ‘drug holidays’ are still unclear

“Both low- and high-dose ARD patients are at risk of developing MRONJ”

Some clinical recommendations were also drawn:

• in patients receiving low-dose denosumab or oral BP, implants can be placed as safely as in other patients with osteoporosis
• there is no data on low-dose subcutaneous and intravenous ARDs, but these are not expected to a have a higher risk than oral low-dose ARDs
• prophylactic antibiotics are recommended
• the patient’s risk factors should be evaluated individually: smoking, oral hygiene, local pathology, systemic co-factors, etc.
• implant therapy and bone grafting are currently not indicated in high-dose ARD patients
• five years of oral BP intake may be a ‘red flag’ for potential risks

[[slide-container]]