Management of Osteonecrosis of the Jaw in Patients with Osteoporosis

Rationale for Avoiding Standard Sequential Therapy

Bisphosphonates significantly increase the risk of ONJ progression and should be absolutely avoided in patients with existing ONJ, as stated by the National Comprehensive Cancer Network and Annals of Oncology 1, 2, 3
The European Society for Medical Oncology (ESMO) guidelines explicitly state that patients with pre-existing ONJ should avoid invasive dental procedures during bisphosphonate therapy, and if invasive dental surgery is necessary, therapy should be deferred until complete healing 3
Multiple myeloma guidelines note that ONJ occurs in 1-2% of patients on bisphosphonates, and most patients who develop ONJ have pre-existing dental problems, according to the Journal of the National Comprehensive Cancer Network 1

If the patient's fracture risk has significantly improved after 2 years of teriparatide, implement a drug holiday with calcium (1000-1200 mg/day) and vitamin D (800 IU/day) supplementation, as recommended by the Annals of Oncology, Annals of the Rheumatic Diseases, and Annals of Internal Medicine 3, 5, 6
The European League Against Rheumatism (EULAR) and European Federation of National Associations of Orthopaedics and Traumatology (EFORT) guidelines recommend adequate calcium intake of 1000-1200 mg/day together with vitamin D 800 IU/day when managing osteoporosis 5

Maintain excellent oral hygiene and ensure regular dental/oral surgery review throughout any bone-targeted therapy, as recommended by the Annals of Oncology 3
The ESMO guidelines emphasize that oral hygiene, baseline dental evaluation for high-risk individuals, and avoidance of invasive dental surgery are essential to reduce ONJ risk, according to the Journal of the National Comprehensive Cancer Network 1
Perform DEXA scans to assess bone mineral density response and guide treatment decisions, as recommended by Praxis Medical Insights 4
Monitor serum calcium levels, particularly if considering any future bone-targeted therapy, as recommended by the Journal of the National Comprehensive Cancer Network and Annals of Internal Medicine 1, 6