Antiresorptive drugs: hygienists see these patients far more often than surgeons do

Bisphosphonates and denosumab are among the most widely prescribed drugs in the adult population, and a considerable share of patients on them sit in the hygiene chair without anyone having asked.

They matter because they reduce bone turnover. In the jaws remodelling is particularly high, and in that region the interference translates into a risk of osteonecrosis not seen elsewhere.

The orders of magnitude differ greatly between the two populations. In patients treated for osteoporosis, typically orally and at low doses, risk is low; in oncology patients receiving high intravenous doses it is appreciably higher.

The most frequently documented trigger is a procedure that exposes bone, and dental extraction heads the list.

From this follows the most important practical consequence: prevention consists of not reaching the point of extraction. Which is, literally, a description of what hygiene does.

The ideal moment would be before therapy starts, with dental clearance, removal of unsalvageable teeth and complete healing of the sites. Where coordination with the prescribing physician is possible, this is the single most useful intervention.

In the hygiene appointment, ongoing therapy is not a contraindication. Scaling and root planing are non-surgical procedures, they should be carried out, and suspending them out of caution exposes the patient to the greater risk, namely ending up at extraction.

What changes is the attention required: atraumatic instrumentation on soft tissue, avoiding mucosal lacerations, and checking prosthetic pressure points.

Ill-fitting removable dentures deserve a separate mention, being a concrete and frequently overlooked risk factor: chronic pressure sores can expose bone at a point under repeated load.

The signs to recognise are exposed bone persisting for weeks, pain unexplained by any dental cause, mobility appearing without reason, non-healing fistulas, and altered sensation of the lower lip.

Patients almost never connect the symptoms to the drug, and often do not mention it in the history. Six-monthly administrations in particular are not perceived as ongoing therapy, so the question must be put explicitly and in plain terms, asking also about injections given once or twice a year.

As for suspending the drug, the decision is a medical one and does not belong to the dental practice. The benefit of interrupting it is debated, and the two classes do not behave alike: bisphosphonates accumulate in bone and their effect persists long after withdrawal, whereas the effect of denosumab wears off over a shorter period.

In summary: risk is low in osteoporotic patients and high in intravenous oncology patients, extraction is the main trigger, the hygiene appointment should go ahead rather than be suspended, ill-fitting dentures are an underestimated risk factor, and suspending the drug is the prescribing physician's decision.