Impact of denosumab therapy on periapical healing following root canal treatment: a 10-year retrospective case-control study

Abstract Introduction Denosumab is a potent RANKL inhibitor used for osteoporosis, yet its impact on root canal treatment (RCT) outcomes remains less understood compared to bisphosphonates. This study evaluated the periapical healing outcomes of RCT in patients receiving denosumab and identified clinical variables influencing treatment success. Methods This retrospective case-control study included 20 patients with osteoporosis receiving denosumab who underwent RCT at a major tertiary hospital between July 2014 and June 2024 (group D), along with 20 age- and sex-matched systemically healthy controls (group C). Among 116 denosumab-treated patients screened, 20 met the strict selection criteria and were enrolled as the study group. Periapical healing was assessed using the Periapical Index (PAI) at a minimum follow-up of 3 months after treatment. Various clinical and radiographic factors, including initial PAI scores and sealer extrusion, were analyzed using logistic regression to determine their impact on healing rates. Results The median follow-up period was 534 (287–956) days for group D and 421 (235–1045) days for group C. The overall periapical healing rates were 75.0.% in the denosumab group and 90.0% in the healthy control group ( P = 0.407). Multivariable logistic regression analysis did not identify any statistically significant predictors of healing outcomes. However, higher initial PAI scores (OR = 7.610, P = 0.088) and sealer extrusion (OR = 3.70, P = 0.185) were associated with less favorable outcomes in the multivariable model. Sealer extrusion was significantly associated with healing outcomes in univariate analysis ( P = 0.034). Conclusions Within the limitations of this study, there was no statistically significant difference in the proportion of healed cases between patients receiving denosumab therapy and healthy controls. These findings suggest that non-surgical root canal treatment may remain a viable tooth-preserving treatment option for patients receiving denosumab therapy. Careful apical control and long-term follow-up may be particularly important in patients presenting with large pre-existing periapical lesions and sealer extrusion.