Denosumab Therapy in Dental Practice: Awareness, Risk Factors and Preventive Strategies

Denosumab is increasingly prescribed for osteoporosis and metastatic bone disease, leading to a parallel rise in reports of medication-related osteonecrosis of the jaw (MRONJ). Although the condition was first associated with bisphosphonate therapy, emerging evidence indicates that denosumab-associated MRONJ presents distinct epidemiological, clinical and management challenges. Despite an expanding body of research, awareness of MRONJ risk among general dental practitioners remains inconsistent, contributing to preventable adverse outcomes. This narrative review consolidates current knowledge on MRONJ in denosumab-treated patients by examining epidemiology, pathophysiology, clinical features, established risk factors and evidence-based preventive strategies. Numerous guidelines consistently emphasise early dental assessment, optimisation of oral health prior to the first denosumab dose and timely communication between physicians and dental clinicians. A planned dental intervention may be safer when coordinated around the denosumab dosing schedule, particularly by utilising a "window of opportunity" during periods of the waning drug effect. This review also synthesises practical recommendations for routine dental care, pretreatment evaluation, risk stratification and management of established MRONJ. A clinical decision-making flowchart is proposed to assist dental practitioners in evaluating treatment needs, assessing patient risk and planning interventions with minimal disruption to systemic therapy. Taken together, understanding the unique characteristics of denosumab-associated MRONJ is essential for reducing morbidity and improving patient outcomes. Strengthening collaboration between dental practitioners and medical prescribers, along with early identification of vulnerable patients, remains the cornerstone of prevention.