Anti-resorptive medications and periodontitis: critical appraisal, clinical management and ONJ risk

Purpose: This manuscript critically appraised the literature on, and analyzed the clinical scenario of, osteo-metabolic patients affected by periodontitis. Methods: A brief narrative review of literature was performed. The link between periodontitis and osteoporosis, the impact of anti-resorptive (AR) medications on the treatment of periodontitis, and the risk of medication-related osteonecrosis of the jaws (MRONJ) in different clinical scenarios were discussed. Results: Data suggest a bidirectional link between periodontitis and osteoporosis. Patients affected by osteoporosis showed higher risk of periodontitis and periodontitis-induced tissue destruction. Even though treatment with AR medications has been hypothesized to reduce inflammatory periodontal bone resorption, it may not be suggested as an adjunctive intervention in the treatment of periodontitis. Four clinical scenarios were identified: patients waiting for AR treatment, patients treated with bisphosphonates for less than three years, patients treated with bisphosphonates for more than three years, and patients treated with denosumab. The risk of osteonecrosis in each of these cases is described and practical clinical recommendations are provided. Briefly, both non-surgical and surgical treatment of periodontitis may be beneficial for these patients. Conclusions: Periodontitis treatment may be safe and predictable in patients treated with AR medications, keeping the MRONJ risk very low over time. KEY WORDS: Anti-resorptive medications, bisphosphonate, periodontitis, MRONJ.