Anti-resorptive drugs and implant therapy

Clinical questions

More and more low-dose anti-resorptive drugs (ARDs) like bisphosphonate and denosumab are prescribed around the world to treat the effects of osteoporosis. Patients being treated with ARDs often come to practices looking for implants. What are the risks?
Implant patients receiving low-dose oral bisphosphonates are at risk of MRONJ, although the risk factor appears to be low.

Does the duration of the ARD intake have an impact on the occurrence of MRONJ?
Yes. In all patients taking low-dose ARDs (bisphosphonates and denosumab), the risk of MRONJ increases with intake duration. In 71% of patients with MRONJ, the reaction occurred more than 36 months after they commenced drug intake.

A ‘drug holiday’ has been recommended in some published clinical guidelines. Does the interruption of ARD intake have an effect on the incidence or risk of MRONJ?
The evidence supporting this is lacking, so the recommendation remains unclear.

Is there an increased risk for early or late implant failures in these patients?
Higher rates of implant loss have not been reported in patients taking low-dose ARDs than in the control groups. The longevity of implants was also not found to be compromised in those who were receiving low-dose ARDs. The possible effect of low-dose subcutaneous and intravenous ARD administration is unclear but appears to be comparable. Little data is available on the safety of bone grafting procedures performed at the time of implant placement, so conclusions cannot be drawn on this matter.

After reviewing the existing documentation, what should I do?
Low-dose ARDs cannot be considered a contraindication for implant placement, but there is insufficient data available supporting its use in bone grafting procedures.

In these patients, an individual assessment of risk factors (e.g. local factors, smoking, systemic diseases, co-medications, and duration of ARD intake) and prophylactic use of antibiotics and postoperative antiseptics (e.g. chlorhexidine) are recommended. A drug holiday should only be suggested following a consultation with the treating physician.

Implant therapy and/or bone grafting procedures are currently not recommended in patients on high-dose ARD intake.

Key points
  • 1. Patients receiving low-dose ARDs (bisphosphonates and denosumab) are at risk of MRONJ, although the risk factor is considered low
  • 2. The risk for MRONJ increases with the duration of drug intake. The effectiveness of drug holidays to mitigate this risk is unclear
  • 3. ARDs are not associated with higher instances of early or late implant failure
  • 4. Low-dose ARDs are not considered a contraindication for implant placement. There is no data available on bone grafting
  • 5. Implant therapy and/or bone grafting procedures are currently not recommended in patients on high-dose ARD intake