A patient taking bisphosphonates who also had head and neck radiotherapy and chemotherapy 8 years ago presents with severe pain and infection in a tooth judged non-restorable. What is the best next step?

Correct answer: C. Contact the physician and oncologist to obtain the radiation dose and field before deciding on extraction

• A. Drug holidays have limited and contested evidence, apply mainly to oral bisphosphonates, and do nothing whatever about the radiation risk. A 3-month delay is also unacceptable with active infection.
• B. Immediate extraction without knowing the radiation field risks precipitating osteoradionecrosis in irradiated bone — a far worse problem than the presenting one.
• C. CORRECT. This patient carries a DOUBLE risk — medication-related osteonecrosis from the bisphosphonate AND osteoradionecrosis from prior radiotherapy. The decision hinges on information you do not yet have: the total radiation DOSE, whether the jaw in question was within the FIELD, and the bisphosphonate route and duration. Doses above roughly 60 Gy to the mandible carry substantial ORN risk and may require hyperbaric oxygen or a different surgical approach. Consultation comes first; the acute infection is managed in the meantime with antibiotics and drainage.
• D. Antibiotics alone for 6 months leaves the source of infection in place and courts spread.

Note: Managing the acute problem and gathering the information are not in conflict: start antibiotics and drainage now, obtain the oncology records in parallel, and plan definitive treatment once the risk is characterised.