Cody M. Dazen
| Cody M. Dazen |
Introduction
Antiresorptive therapies, such as bisphosphonates and denosumab, are a class of drugs commonly used to treat osseous diseases and cancer-related conditions (1). A major side effect of antiresorptive therapy is medication-related osteonecrosis of the jaw (MRONJ), which can develop following trauma to the maxillofacial region while prescribed these drugs. It has been well-documented in literature that dental extractions increase the risk for MRONJ in adults taking IV bisphosphonates by 14.8% (1,2). Antiresorptives have recently become a favorable treatment modality among the pediatric population (3). The occurrence of MRONJ in the children, however, is still unknown (1). Though MRONJ occurrence in the pediatric population is unknown, dental providers should not ignore this possible incidence following dental extraction. Whenever possible, patients should be evaluated for necessary and prophylactic extractions prior to receiving antiresorptives.
Methods
A common extraction of the permanent dentition is of the third molars. Typically, the optimal time to extract these teeth are once the roots are one-third to two-thirds developed (typically during the late teens) (4). Premature extraction of third molars might necessitate the need to remove excess bone to access the tooth buds, and delayed extraction may lead to an increased risk of side effects (4). Regardless, third molar extractions in a patient prescribed antiresorptives may lead to MRONJ. This forms the question: should third molars be extracted prior to the initiation of these medications even if they are not ideally developed?
Results
Patients on antiresorptives needing dental extractions have limited treatment options. One option for patients taking antiresorptives is a drug holiday, which involves the patient undergoing cessation of the medication for a certain period of time prior to treatment. There is conflicting support for drug holidays. They may be ineffective entirely due to the long half-life of IV antiresorptives and further possibility of complicating the patient’s systemic disease (5). The most ideal treatment option to prevent MRONJ entirely is to perform all dental extractions prior to the patient beginning antiresorptive therapy. This guideline should be specifically enforced on the antiresorptive-pediatric population when considering the need for potential future third molar extractions.
Conclusion
Many experts have recommended that extractions of teeth and other dental procedures should be performed prior to even beginning antiresorptive therapy to avoid the complication of MRONJ entirely (1). As aforementioned, there is no significant increased risk of side effects when prematurely extracting third molars other than the potential need to remove excess bone. The authors recommend dental providers to highly consider prophylactic extraction of third molars prior to pediatric patients beginning antiresorptive therapy. We believe that the pros exponentially outweigh the cons of these prophylactic extractions. Dental providers and their medical colleagues must work hand-in-hand to properly communicate about both the initiation of antiresorptive therapy and the need to remove these third molars in their mutual patients.