Is a Fosamax drug holiday necessary before dental implants?

Implant placement in patients with osteoporosis undergoing antiresorptive therapy

The risk of MRONJ after dental implant placement is considered to be comparable to the risk of MRONJ associated with tooth extraction ( 8 ). Based on current recommendations, the placement of dental implants should be avoided in patients receiving intravenous antiresorptive or antiangiogenic therapy, whereas treatment with oral antiresorptive drugs is not considered an explicit contraindication for the procedure ( 48 ). However, caution is advised in view of conflicting data regarding implant failure and the risk for MRONJ development in patients with osteoporosis. A study with 235 women with osteoporosis receiving oral bisphosphonates who underwent dental implant placement and concomitant application of plasma rich in growth factor reported no cases of MRONJ and a survival implant rate of 98.7% ( 49 ). Successful dental implant installation has also been reported in patients using alendronate for 3 years who received antibiotic prophylaxis for 7 days before the procedure, with favorable osseointegration observed in 98% of the patients ( 50 ).

Prevention and treatment of oral adverse effects of antiresorptive medications for osteoporosis – A position paper of the Brazilian Society of Endocrinology and Metabolism (SBEM), Brazilian Society of Stomatology and Oral Pathology (Sobep), and Brazilian Association for Bone Evaluation and Osteometabolism (Abrasso). Madeira M, Rocha AC, Moreira CA, Aguiar ÁMM, Maeda SS, Cardoso AS, de Moura Castro CH, D'Alva CB, Silva BCC, Ferraz-de-Souza B, Lazaretti-Castro M, Bandeira F, Torres SR. Creative Commons Attribution 4.0 International (https://creativecommons.org/licenses/by/4.0/).

Drug holiday for MRONJ prevention

Based on the residual effects of bisphosphonates after long-term therapy, patients at low fracture risk after 5 years of alendronate or 3 years of zoledronic acid can undergo a drug holiday with periodic reassessment. This recommendation aims to minimize safety concerns ( 27 ). However, a retrospective population study in a Korean database showed a higher prevalence of MRONJ in the first 3 years after bisphosphonate suspension ( 28 ). Although patients with and without cancer were studied, no correlation between dosing frequency or time since bisphosphonate discontinuation and the occurrence of MRONJ was observed in either group ( 28 ). The risk of developing MRONJ is small compared with the antifracture benefits of bisphosphonates in individuals with moderate to high fracture risk using these drugs ( 29 ). So far, no evidence-based study has demonstrated efficacy of bisphosphonate drug holiday in preventing MRONJ. Denosumab has no sustained antiresorptive effect. Hence, drug holiday is not recommended with this medication, mainly due to recent concerns about a rapid increase in the risk of vertebral fractures following denosumab discontinuation ( 30 ).

Prevention and treatment of oral adverse effects of antiresorptive medications for osteoporosis – A position paper of the Brazilian Society of Endocrinology and Metabolism (SBEM), Brazilian Society of Stomatology and Oral Pathology (Sobep), and Brazilian Association for Bone Evaluation and Osteometabolism (Abrasso). Madeira M, Rocha AC, Moreira CA, Aguiar ÁMM, Maeda SS, Cardoso AS, de Moura Castro CH, D'Alva CB, Silva BCC, Ferraz-de-Souza B, Lazaretti-Castro M, Bandeira F, Torres SR. Creative Commons Attribution 4.0 International (https://creativecommons.org/licenses/by/4.0/).

Review

Prevention strategies: Current expert recommendations support a comprehensive pre-treatment dental evaluation before initiating antiresorptive or antiangiogenic therapy, including elimination of active dental disease and optimization of oral hygiene [46-48]. Patient education regarding oral hygiene maintenance is strongly encouraged. Invasive dental procedures, including extractions and implant placement, should be avoided during therapy whenever possible; when extraction is unavoidable, conservative surgical technique with primary wound closure is recommended. Drug-holiday strategies remain controversial. The current expert recommendation notes that, in selected patients receiving osteoporosis-dose oral bisphosphonates for more than four years, or more than four years with concomitant systemic risk factors, temporary discontinuation for approximately two months before and three months after invasive dental procedures may be considered in consultation with the prescribing physician, although supporting evidence remains limited [47].

The Oral Cavity as a Window to Systemic Disease: Diagnostic Clues and Pre-treatment Dental Management for Interdisciplinary Trainees. Copyright © 2026, Sarbeland et al. Creative Commons Attribution 4.0 International (https://creativecommons.org/licenses/by/4.0/).

4. Discussion

Before implant placement, inflammatory or infectious conditions should be managed through tooth extraction or periodontal treatment to obtain intact bone integrity. Patients who had complications after extraction should be excluded from dental implantation. Only patients with insignificant problems can undergo this surgery. The control of inflammation should be the first step, and wound-healing-compromising diseases and medications should be considered for osteoporotic patients. This may suggest that the risk profiles for ONJ occurrence between the selective insertion of dental implants and other dentoalveolar surgery associated with infectious conditions are different [58] and that dental implants may reduce the risk by requiring dental care for implant placement and maintenance. In addition, the selective use of dental implants may prevent mucosal sores caused by denture pressure, and this may account for the lower risk ratios of dental implants.

Dental Implant Survival and Risk of Medication-Related Osteonecrosis in the Jaws in Patients Undergoing Antiresorptive Therapy: A Systematic Review. © 2025 by the authors. Creative Commons Attribution 4.0 International (https://creativecommons.org/licenses/by/4.0/).

Drug holiday for MRONJ prevention

Only one study has aimed to evaluate the effect of interrupting oral bisphosphonates before invasive dental procedures for the prevention or treatment of MRONJ ( 31 ). In this study, 1,175 patients underwent 2,458 surgical procedures. Some patients underwent the procedure after 2 or 3 months of bisphosphonate withdrawal, and no significant difference in the frequency of MRONJ occurred between patients who did or did not discontinue the medication before tooth extraction. There is no evidence supporting the suspension of antiresorptive therapy for osteoporosis before dental procedures for preventing MRONJ ( 31 ). Position papers from several professional societies and task forces do not include a recommendation for routine discontinuation of bisphosphonate therapy for osteoporosis before invasive dental procedures ( 15 , 16 , 24 , 27 ). Additionally, a multicenter retrospective study has shown that the suspension of bisphosphonates has no benefit on the outcome of patients with osteoporosis who developed MRONJ ( 32 ).

Prevention and treatment of oral adverse effects of antiresorptive medications for osteoporosis – A position paper of the Brazilian Society of Endocrinology and Metabolism (SBEM), Brazilian Society of Stomatology and Oral Pathology (Sobep), and Brazilian Association for Bone Evaluation and Osteometabolism (Abrasso). Madeira M, Rocha AC, Moreira CA, Aguiar ÁMM, Maeda SS, Cardoso AS, de Moura Castro CH, D'Alva CB, Silva BCC, Ferraz-de-Souza B, Lazaretti-Castro M, Bandeira F, Torres SR. Creative Commons Attribution 4.0 International (https://creativecommons.org/licenses/by/4.0/).

5. Conclusions

The available data suggest that dental implants may not be linked to a higher risk of osteonecrosis of the jaw (ONJ) in patients taking low-dose bone-modifying agents. The prevalence of ONJ related to osteoporosis treatment was found to be very low. Dental implants did not pose a risk, while a significantly higher risk of ONJ was associated with dental extraction in patients receiving antiresorptive therapy. The long-term survival of implants in osteoporotic patients taking oral antiresorptive medication was similar to that of a healthy population and significantly higher than in untreated controls. However, there are still insufficient data on implants in patients taking “high-dose bone modifying agents”, with few cases and short follow-up periods. Despite these encouraging findings, more prospective studies are needed to further investigate this topic. The guidelines for dental practitioners need to be updated periodically based on recent evidence, and they should recommend consultations and collaboration with physicians.

Dental Implant Survival and Risk of Medication-Related Osteonecrosis in the Jaws in Patients Undergoing Antiresorptive Therapy: A Systematic Review. © 2025 by the authors. Creative Commons Attribution 4.0 International (https://creativecommons.org/licenses/by/4.0/).

Implant placement in patients with osteoporosis undergoing antiresorptive therapy

Despite the low risk of MRONJ with oral bisphosphonates, only a few studies have accurately defined the risk of developing MRONJ in the presence of dental implants. Approximately 20% and 80% of the patients who developed MRONJ in the vicinity of dental implants have osteoporosis and oncologic disease, respectively ( 51 ). Although the risk of MRONJ is significantly higher in patients using intravenous bisphosphonates, an association between peri-implantitis and the etiology of MRONJ can also be observed in patients who use oral bisphosphonates ( 48 , 51 ). The use of minimally invasive techniques and soft tissue bone coverage have been described as factors that considerably reduce the incidence of complications after dental implant treatment ( 50 ). Measures such as avoiding bone augmentations and administration of antimicrobial prophylaxis are also recommended in these patients ( 52 ).

Prevention and treatment of oral adverse effects of antiresorptive medications for osteoporosis – A position paper of the Brazilian Society of Endocrinology and Metabolism (SBEM), Brazilian Society of Stomatology and Oral Pathology (Sobep), and Brazilian Association for Bone Evaluation and Osteometabolism (Abrasso). Madeira M, Rocha AC, Moreira CA, Aguiar ÁMM, Maeda SS, Cardoso AS, de Moura Castro CH, D'Alva CB, Silva BCC, Ferraz-de-Souza B, Lazaretti-Castro M, Bandeira F, Torres SR. Creative Commons Attribution 4.0 International (https://creativecommons.org/licenses/by/4.0/).