Patients should be evaluated by a dentist prior to initiation of antiresorptive or antiangiogenic therapy according to the guidelines below. All invasive dental procedures that involve manipulation of bone should be completed at least 4-8 weeks (or longer if clinically feasible) prior to initiation of therapy. • Update (within one year) radiographs sufficient to rule out dental disease (e.g., caries and periodontal disease) and evaluate previously endodontically treated teeth and third molars • Dental treatment plan the patient • Extract teeth that are non-restorable or with poor long-term prognosis (including root tips) • Complete all restorative dentistry, endodontic therapy, and periodontal therapy as appropriate depending on the clinical circumstances • Place the patient on regular follow-up schedule

Frequently Asked Questions (FAQs)
● Which dental procedures are safe to perform in patients at risk for or with MRONJ? Any procedure that does not involve manipulation of the bone may be safely performed. These generally include delivering local anesthesia, scaling and prophylaxis, placing restorations including crowns and fixed prostheses, fabricating dentures and conventional root canal therapy. ● Which dental procedures should be avoided in patients at risk for or with MRONJ? Any invasive elective procedure that involves manipulating the bone should be avoided if possible but if performed, should be followed by two weeks of antibiotic coverage as noted above. This includes periodontal surgery (e.g., crown-lengthening and bone grafting), endodontic surgery (e.g., apicoectomy), and placement of dental implants (see section below). In addition, orthodontic treatment outcomes may be negatively affected in patients with a history of bisphosphonate use. ● Should patients at risk for, or with MRONJ be prescribed antibiotics prior to dental treatment? There is no need to prescribe antibiotics for dental prophylaxis, routine caries control or other noninvasive procedures. However, antibiotic therapy is indicated for any dental procedure involving manipulation of the bone (e.g., extraction) and should be administered for two weeks following the dental procedure or until the overlying mucosa has healed. ● Is a drug holiday indicated for patients at risk for, or with MRONJ prior to invasive dental procedures? There is insufficient evidence to support a drug holiday prior to invasive dental procedures. Some experts suggest possible benefit of a two-month drug holiday in patients who have taken oral bisphosphonates for more than four years. Ultimately the patient’s need for antiresorptive therapy should supersede drug holiday considerations and the decision should be made by the oncology team or other physician. At this time, there is no consensus regarding a drug holiday for patients on denosumab. Similarly, no recommendation pertaining to a drug holiday can be made for antiangiogenic agents due to lack of data. In these cases, best clinical judgment should be used taking into consideration the patient’s disease status and consultation with the oncology team. – ● Can patients at risk for, or with MRONJ, receive dental implants? Although the incidence of dental implant failure is unknown in cancer patients with exposure to antiresorptive and antiangiogenic agents, implant placement is generally not recommended, especially in patients with established MRONJ. Dental implants may be placed with caution in patients with osteoporosis at risk for MRONJ because MRONJ occurs infrequently in these patients. Patients should be carefully counseled and radiographs of the patients should be examined for evidence of bone changes as noted above. ● Should patients at risk for, or with MRONJ receive any adjunctive therapies prior to invasive dental procedures? There is insufficient high-quality evidence to support or refute the use of adjunctive therapies such as hyperbaric oxygen, pentoxifylline and tocopherol, low-level laser, ozone, teriparatide, bone morphogenic proteins and platelet-rich plasma prior to dental procedures.