A patient taking intravenous bisphosphonates (zoledronic acid) for metastatic cancer requires extraction of three teeth. What is the MOST appropriate next step?

Correct answer: A. Refer to an oral and maxillofacial surgeon for management

• A. CORRECT. Patients on IV bisphosphonates (especially zoledronic acid) for oncologic indications have the HIGHEST risk of medication-related osteonecrosis of the jaw (MRONJ). Multiple extractions in this setting require specialist management by an oral and maxillofacial surgeon who can coordinate with the oncologist, assess the risk-benefit, and perform the procedure with appropriate surgical and pharmacological management.
• B. Indefinite delay may not be in the patient's best interest if the teeth are causing infection or pain — the decision must be individualized, not categorically deferred.
• C. Proceeding with extractions in an IV bisphosphonate patient without specialist consultation risks MRONJ — exposed, non-healing bone that is difficult to treat. Even 'atraumatic' extraction causes surgical trauma.
• D. Chlorhexidine rinse and deferral may be appropriate for low-risk patients on oral bisphosphonates, but IV oncologic bisphosphonate patients need specialist referral, not observation.