Should Wisdom Teeth Be Removed Before Starting Denosumab Treatment?

Q: Should Wisdom Teeth Be Removed Before Starting Denosumab Treatment?

Hello： If your wisdom tooth is only partially erupted and is partially covered by bone or gum tissue, that area can easily accumulate debris, leading to bacterial infection. <br>Therefore, the dentist recommends that you have the wisdom tooth extracted. <br>Bisphosphonate medicat

Is it necessary to have wisdom teeth extracted before using denosumab?

I am a patient with a giant cell tumor of bone, and I had surgery on February 3rd.
I am planning to start denosumab to reduce the recurrence rate.
One of the side effects of denosumab is osteonecrosis of the jaw, and I haven't had an oral examination in a long time.
Therefore, I decided to see a dentist.
After an X-ray, it was found that I have four wisdom teeth, one of which appears to be horizontally impacted.
However, the dentist only reviewed the X-ray and did not examine my mouth.
He referred me to another oral surgeon for the extraction of my wisdom teeth, suggesting that if I wanted to have them removed quickly, he could extract all four at once.
However, theoretically, it should not be necessary to extract all four at the same time, right? Wouldn't it be sufficient to just remove the horizontally impacted one?
Today, on February 23rd, I had a follow-up appointment with the surgeon who treated my giant cell tumor.
He mentioned that there is no urgent need to start denosumab immediately and that it can be delayed a bit.
I would like to ask, if I see a dentist for extraction next week (between February 28th and March 6th), how long after the extraction can I start the denosumab treatment? If I do not extract the wisdom teeth, after completing the denosumab treatment (which the doctor said might last 1-2 years, depending on my condition, with injections once a month), will there be any permanent effects on future oral treatments? For example, will there be a significantly increased risk of osteonecrosis of the jaw? Is there any relevant literature to support this?

Ming, 20~29 year old female. Ask Date: 2021/02/23

Dr. Lin Jiayong reply Dentistry

Hello: If your wisdom tooth is only partially erupted and is partially covered by bone or gum tissue, that area can easily accumulate debris, leading to bacterial infection.
Therefore, the dentist recommends that you have the wisdom tooth extracted.
Bisphosphonate medications can delay bone metabolism, so if an impacted wisdom tooth area becomes infected, there is a high likelihood of it progressing to osteomyelitis of the jaw.
If left untreated, the worst-case scenario could lead to jaw necrosis, and subsequent debridement surgery would have a poor prognosis.
If you plan to receive a bone graft, it is advisable to have the affected tooth extracted as soon as possible.
You should wait for the extraction site to heal (the alveolar ridge to fill in, with no exposed alveolar bone in the oral cavity) before undergoing the bone graft.
After stopping the medication, you should wait at least six months, have blood tests to check relevant values, and confirm that bone metabolism has returned to normal before proceeding with any oral surgery.
Sincerely, Lin Chia-Yung, Department of Dentistry, Taichung Hospital, Ministry of Health and Welfare.

Reply Date: 2021/02/23

More Info

When considering the removal of wisdom teeth before starting denosumab treatment, there are several important factors to take into account, especially given your history of giant cell tumor of bone and the potential side effects associated with denosumab, such as osteonecrosis of the jaw (ONJ).

Firstly, it is crucial to understand that denosumab is a medication that inhibits bone resorption by targeting RANKL, a key factor in the formation and function of osteoclasts. While it is effective in reducing the risk of recurrence of certain bone tumors, it also carries a risk of ONJ, particularly in patients who have dental issues or undergo dental procedures during treatment. Therefore, addressing any dental problems, including impacted wisdom teeth, before starting denosumab is generally advisable.

Regarding your specific situation, if you have four wisdom teeth, and one is horizontally impacted, it is reasonable to consider removing that tooth, especially if it poses a risk of infection or complications. However, the decision to extract all four wisdom teeth at once should be made based on a thorough clinical evaluation by an oral surgeon or dentist. Factors such as the position of the teeth, your overall dental health, and the potential for complications should guide this decision. It is not uncommon for dentists to recommend the removal of all wisdom teeth if they are likely to cause problems in the future, but this should be balanced against the risks of surgery and recovery time.

If you plan to have your wisdom teeth extracted between February 28 and March 6, it is essential to allow adequate healing time before starting denosumab. Typically, the healing process after tooth extraction can take anywhere from a few days to a couple of weeks, depending on the complexity of the extraction and your individual healing response. It is generally recommended to wait at least two weeks after dental extractions before starting denosumab, but this timeline can vary. You should consult with both your oral surgeon and the physician managing your denosumab treatment to establish a safe timeline.

If you choose not to have your wisdom teeth removed before starting denosumab, it is important to be aware of the potential risks. The use of denosumab can increase the risk of ONJ, particularly if there are existing dental issues. If you experience any dental problems during or after treatment with denosumab, the risk of complications may be heightened. Literature suggests that patients on denosumab who have dental procedures or existing dental disease may have an increased risk of developing ONJ, which can lead to significant complications.

In summary, it is advisable to have a thorough dental evaluation and consider the removal of problematic wisdom teeth before starting denosumab. If you proceed with extraction, ensure you allow sufficient healing time before beginning treatment. Always communicate openly with your healthcare providers about your dental health and treatment plans to minimize risks and ensure the best outcomes for your overall health.

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