Metformin, interferons, zoledronate and lisinopril — three extractions

Correct answer: D. Bisphosphonate (zoledronate) use

• A. 132/92 is stage 1 hypertension — treatment can proceed, with monitoring. It is not the dominant concern here.
• B. HbA1c of 8 indicates suboptimal but not extreme control; healing may be somewhat impaired, but this does not outweigh IV bisphosphonate exposure.
• C. Dry socket is a real but self-limiting complication managed with irrigation and a sedative dressing; it does not carry the morbidity of osteonecrosis.
• D. Correct. ZOLEDRONATE is a high-potency INTRAVENOUS nitrogen-containing bisphosphonate. IV administration carries a far higher risk of MRONJ than oral bisphosphonates, and extraction is the single greatest local risk factor. This concern outweighs the other findings.

Note: Zoledronate is used both for osteoporosis (annual low dose) and for METASTATIC BONE DISEASE / myeloma (frequent high dose). Interferon in the medication list hints at an oncologic or MS indication — worth asking why the drug was prescribed, since it changes the MRONJ risk category.

Correct answer: B. Refer to a specialist

• A. Limiting extractions to non-restorable teeth is sound MRONJ risk reduction in principle, but the decision and the surgery are best made in a specialist setting for this risk profile.
• B. Correct per the source key. Multiple extractions in a patient on IV bisphosphonate therapy with additional systemic comorbidity is appropriately referred to an oral and maxillofacial surgeon, ideally with consultation of the prescribing physician regarding the indication and duration of therapy.
• C. Antibiotic prophylaxis alone does not prevent MRONJ and does not address the underlying risk.
• D. Indefinite deferral leaves active disease untreated, which itself can precipitate osteonecrosis.