A 66-year-old male with osteoporosis is taking Denosumab (Prolia). He presents with a chief complaint of pain in tooth #30 when biting. Radiographic examination reveals deep caries on tooth #30 extending to the alveolar crest. Which treatment is most appropriate?

Correct answer: A. Excavate caries and build up with composite

• A. CORRECT. In patients on antiresorptive medications like Denosumab, the goal is to avoid any surgical procedure that could trigger MRONJ. The most conservative option — excavating the caries and placing a composite build-up — avoids surgery entirely while addressing the immediate pathology. This is the safest approach in this patient.
• B. Coronectomy still involves surgical osseous intervention, which carries MRONJ risk in patients on Denosumab and should be avoided.
• C. Crown lengthening is a surgical procedure involving bone removal. In a patient on Denosumab (an antiresorptive/RANKL inhibitor), surgical bone manipulation significantly increases the risk of MRONJ (Medication-Related Osteonecrosis of the Jaw), making this option high-risk.
• D. Extraction is contraindicated in patients on Denosumab due to the high risk of MRONJ following tooth removal. Even though the caries is extensive, extraction should be avoided whenever possible.