Is withdrawal of antiresorptive agents necessary before and after tooth extraction? A systematic review

Objectives: The need for prevention and management of medication-related osteonecrosis of the jaw (MRONJ) has increased with the growing number of patients using antiresorptive agents. The scope of this systematic review (SR) was to determine whether the withdrawal of antiresorptive agents is necessary for tooth extractions in patients receiving each of the antiresorptive medications. Materials and methods: The searches were performed using the MEDLINE databases. We selected SRs, randomized controlled trials (RCTs), prospective and retrospective non-randomized clinical (observational) studies, and case reports/case series in this order of preference. Results: We included one SR, one RCT, five observational studies, and three case reports. Meta-analyses were not conducted because the RCT had an extremely small sample size and the observational studies had different definitions of intervention and comparison that could not be integrated across studies. In this SR, no studies showed a benefit (i.e., a reduction in the incidence of osteonecrosis of the jaw) of short-term withdrawal of antiresorptive agents for tooth extraction. Additionally, no studies examined the harm (i.e., an increase in femoral and vertebral fractures and skeletal-related events during bone metastasis) of withdrawal for tooth extraction. Conclusions: We were unable to determine whether withdrawal before and after tooth extraction is necessary with a high certainty of evidence. Future systematic reviews including RCTs with larger samples are expected to provide such evidence. Clinical relevance: This systematic review provides evidence-based information for multidisciplinary collaborations related to patients receiving antiresorptive agents.