BETWEEN OSSEOINTEGRATION AND OSTEONECROSIS: DENTAL IMPLANT DECISION-MAKING IN PATIENTS EXPOSED TO ANTIRESORPTIVE THERAPY

Abstract

Objective: To examine clinical decision-making regarding dental implant therapy in patients currently receiving or previously exposed to antiresorptive medications, with emphasis on differences between osteoporosis-dose and oncologic-dose therapy, osseointegration, implant survival, medication-related osteonecrosis of the jaw (MRONJ), and individualized risk stratification. Methods: A narrative review of the literature was conducted using PubMed/MEDLINE and Scopus, supplemented by targeted searches of clinical guidelines, consensus statements, position papers, and reference lists. The updated searches were performed on September 5, 2026. The principal search strategy combined terms related to dental implants, antiresorptive medications, osteoporosis, MRONJ, and osteonecrosis. Additional targeted searches addressed denosumab and oncologic-dose therapy. Evidence was prioritized according to methodological hierarchy, with clinical guidelines and consensus statements considered alongside systematic reviews, meta-analyses, and relevant primary studies. Results: The clinical implications of antiresorptive therapy differ substantially according to treatment indication, dose, cumulative exposure, drug class, systemic risk factors, oral conditions, and surgical complexity. In patients treated for osteoporosis, current evidence does not support considering antiresorptive therapy alone an absolute contraindication to dental implant placement. However, the certainty of evidence remains low or very low, and a low absolute risk of MRONJ should not be interpreted as absence of risk. In contrast, elective implant placement should generally be avoided during active oncologic-dose bone-modifying therapy. Bisphosphonates remain clinically relevant after discontinuation because of their prolonged skeletal retention, whereas denosumab requires particular attention to dosing intervals, treatment interruption, rebound bone turnover, and the limited implant-specific evidence available. Implant survival should also be distinguished from late implant-related MRONJ, including complications arising around previously osseointegrated implants. Conclusion: Dental implant therapy may be considered in appropriately selected patients receiving antiresorptive therapy for osteoporosis, following individualized risk assessment, informed consent, control of periodontal and peri-implant inflammation, and long-term maintenance. This approach should not be extrapolated to patients receiving active oncologic-dose therapy, in whom elective implant placement should ordinarily be avoided. Decisions regarding modification or interruption of antiresorptive treatment should be coordinated with the prescribing physician and should consider the indication, regimen, cumulative exposure, sequential therapy, systemic risk factors, and planned surgical procedure.