Dental checks before starting bone-strengthening drugs

This page is for people starting, or already taking, bone-strengthening drugs as part of cancer care. It explains why a dental checkup comes first and what to watch for.

It feels like a detour. You are about to start a drug that protects your bones. Suddenly someone is asking about your teeth.

The link is a condition called osteonecrosis of the jaw, or ONJ. NCI describes it as the breakdown of bone tissue in the mouth.

NCI also lists the medicines tied to it. Bisphosphonates are one. They are given to some patients whose cancer has spread to the bones. Denosumab is another. It is a monoclonal antibody used for bone problems.

NCI adds that angiogenesis inhibitors (drugs that block the growth of new blood vessels) may also cause ONJ. Those drugs include bevacizumab, sunitinib, and sorafenib. NCI says the risk goes up when angiogenesis inhibitors and bisphosphonates are used together.

Once you know that, the dental referral stops looking like red tape.

The advice is preventive. And prevention only works before the drug starts.

NCI's wording is worth reading closely. Patients with bone metastases (cancer that has spread to the bone) may lower their risk of ONJ by getting screened and treated for dental problems before bisphosphonate or denosumab therapy starts.

MedlinePlus says the same thing from the drug side. For denosumab, a dentist should examine your teeth first. The dentist should also do any needed treatment. That includes cleaning, or fixing dentures that do not fit. All of it comes before you start to receive the injection.

Get the dental work done first. That one point about order is what this whole article is about.

NCI notes that ONJ is not common. It lists several things that raise the chance:

• Getting bisphosphonates or denosumab by injection rather than by mouth
• Tooth extraction
• Dentures that fit poorly
• A diagnosis of multiple myeloma
• Using angiogenesis inhibitors and bisphosphonates together
• Long-term bisphosphonate or denosumab therapy

The extraction point explains a lot. Dentists get cautious once treatment has begun. Work that would be routine at any other time now carries extra weight. That is why it is better done in advance.

Many people read about this after their first dose. That is not a disaster. It is also not, on its own, a reason to stop the medicine. Ask your care team before making any change.

It does mean dental care should now be coordinated, not casual. MedlinePlus advises keeping up good oral hygiene. It also says to check with your doctor before any dental treatment during denosumab therapy.

So tell your dentist exactly which cancer drug you take. And tell your oncology team before any dental procedure is booked.

MedlinePlus says to brush your teeth and clean your mouth properly while you receive denosumab. NCI says ONJ care focuses on infection control and oral hygiene. Ask your dentist and care team what mouth care is right for you.

When ONJ does happen, NCI lists the treatments. They include antibiotics, medicated rinses, pain management, and surgery to remove infected bone. So this is a condition that can be managed. It is not untreatable.

• Call your care team right away if you can see bare bone in your mouth, if your gums are painful or swollen, if a tooth has come loose on its own, if your jaw feels numb or heavy, or if your jaw is not healing. MedlinePlus lists these as warning signs of ONJ with denosumab.
• Call your care team within a day or two if mouth soreness or a lasting bad taste has not settled.
• Book a dental appointment, and tell your cancer team first, if you need any tooth removed or other dental work while you are on one of these drugs.

Tell both your dentist and your cancer team. Do not pick one over the other. Early attention is the part you control.