Volume 217 - Issue 5
Vertebral fractures after denosumab discontinuation for dental procedures: a consequence of distorted perceptions of risk
Author: Alastair Goss
Med J Aust 2022; 217 (5): 268-268. || doi: 10.5694/mja2.51681
Published online: 5 September 2022
Published online: 5 September 2022
To the Editor: Khatri’s and Stuckey’s1 article, Vertebral fractures after denosumab discontinuation for dental procedures: a consequence of distorted perceptions of risk, sums up the authors’ knowledge and experience of medication‐related osteonecrosis of the jaws (MRONJ) in the latter part of the title. They quote the risk of MRONJ as being very low and equal for denosumab and oral bisphosphonates. This is incorrect. The risk of MRONJ is 0.3%.2 In our study we found the risk following extractions at 1.8%.3 The recent 2022 update of the position paper on MRONJ4 found that the risk with denosumab is an order of magnitude higher than for bisphosphonates.
There is no discussion in Khatri’s and Stuckey’s article1 of the effect of MRONJ on patients. A patient with stage 3 or end‐stage MRONJ has months of severe pain and requires jaw resection with or without microvascular reconstruction similar to that required for advanced jaw cancer.4,5 The impact of this is similar to vertebral collapse, both largely avoidable disasters.
The current Australian recommendations for dental extractions for patients taking denosumab for osteoporosis are to delay extractions to 6 months after the last injection of denosumab and then to allow 4weeks for initial socket healing before the next injection.6 The risk is greater if the patient has been taking antiresorptives for more than 4years and if they are immunocompromised.4,7
We would agree that education and communication between prescribers, patients and dentists are key. This can only be achieved by close, mutually respectful communication and understanding between medical, dental, oral and maxillofacial surgeons and patients. However, this is easier to say than put into meaningful practice. Most definitive articles on MRONJ are in oral and maxillofacial surgery journals, which are not commonly read by physicians who prescribe antiresorptives. The most likely reason that the patient was taken off denosumab for 5 months was that the dental plan was not only to extract the teeth but to replace them with dental implants. Implants require time for osseointegration.8
Hopefully, this letter helps correct the distorted precepts expressed by Khatri and Stuckey for prescribers of this, otherwise, useful drug.
Competing interests
No relevant disclosures.
References
- Khatri NS, Stuckey BGA. Vertebral fractures after denosumab discontinuation for dental procedures: a consequence of distorted perceptions of risk. Med J Aust 2022; 216: 283‐284. https://www.mja.com.au/journal/2022/216/6/vertebral‐fractures‐after‐denosumab‐discontinuation‐dental‐procedures
- Bone HG, Wagman RB, Brandi ML, et al. 10years of denosumab treatment in postmenopausal women with osteoporosis: results from the phase 3 randomised FREEDOM trial and open‐label extension. Lancet Diabetes Endocrinol 2017; 5: 513‐523.
- Colella A, Yu E, Bereza S, et al. The management of patients on denosumab for osteoporosis requiring dental extractions. A prospective single centre cohort‐controlled study. Poster ANZAOMS Hybrid Meeting; Melbourne (Australia), 16–17 Nov 2021.
- Ruggierio SL, Dodson TB, Aghaloo T, et al. American Association of Oral and Maxillofacial Surgeons’ position paper on medication‐related osteonecrosis of the jaws — 2022 update. J Oral Maxillofac Surg 2022; 80: 920‐943.
- Carlson ER. Management of antiresorptive osteonecrosis of the jaws with primary surgical resection. J Oral Maxillofac Surg 2014; 72: 655‐657.
- Goss AN. Evidence‐based guidelines for patients on antiresorptive medications for osteoporosis requiring dental extractions. Australian Dental Association News Bulletin 2021; 515: 22‐24.
- Ng TL, Tu MM, Ibrahim MFK, et al. Long‐term impact of bone‐modifying agents for the treatment of bone metastases: a systematic review. Support Care Cancer 2021; 29: 925‐943.
- Smith S, Finn B, Goss AN. Medication‐related osteonecrosis of the jaws: a single centre, Far North Queensland case series. Aust Dent J 2022; https://doi.org/10.1111/adj.12905 [Epub ahead of print].