Dental extractions and bisphosphonates: the assessment, consent and management, a proposed algorithm

Bisphosphonate-associated osteonecrosis of the jaws (BONJ) is recognised as a significant complication related to the use of bisphosphonates and currently is gaining importance due to the increasingly widespread use of these medications. Patients are placed into low or high risk groups of developing BONJ depending on the systemic condition for which they have received bisphosphonates. Numerically, the largest group worldwide is patients receiving bisphosphonates for osteoporosis and these generally fall into the low risk group for BONJ. The high risk group, while numerically smaller, is composed of those patients receiving bisphosphonates in the management of malignancy affecting the skeleton, either primary or secondary (metastatic disease). A number of additional systemic and local risk factors are proposed, which have the effect of increasing the risk of BONJ following an extraction. These risk factors may have the effect of moving a low risk categorised patient into a medium, or perhaps more realistically an unknown risk category. An example of a systemic risk factor is the concurrent use of corticosteroids and a local risk factor is mandibular molar extraction. The purpose of this paper is to define and validate an algorithm to guide clinicians in the area of patient information, consent and management for patients currently taking or having previously taken bisphosphonates who require dental extractions.