A patient who has been receiving intravenous zoledronic acid (Zometa) for 5 years requires dental extractions and a complete denture. What is the most appropriate management?

Intravenous bisphosphonates (particularly zoledronic acid/Zometa) carry a significantly higher risk of medication-related osteonecrosis of the jaw (MRONJ) compared to oral bisphosphonates, with risk increasing with duration of therapy. After 5 years of IV zoledronic acid, this patient is considered high risk for MRONJ. Multiple extractions significantly increase this risk. Per AAOMS 2022 guidelines, high-risk patients requiring extensive extractions should be referred to an oral and maxillofacial surgeon or specialist with MRONJ experience for comprehensive risk stratification, pre-surgical planning, and post-operative monitoring. Discontinuation of bisphosphonate therapy ('drug holiday') does not rapidly reduce risk due to their long skeletal half-life.