Endodontics · patient case question
Given that the tooth is non-vital and the patient is on denosumab, what is the most appropriate treatment?
Patient case: Intracoronal attachment prosthesis in a patient on denosumab
Patient: Female, 72 years old
Chief complaint: “Something feels loose on this side and the tooth has changed colour.”
History: Osteoporosis treated with denosumab, six-monthly injections for the past four years. No other systemic disease.
Findings: Intracoronal (precision) attachment retaining a removable partial denture. The abutment tooth shows extensive vertical bone loss, greater than the radiograph shown suggests. The tooth does not respond to pulp testing.
Show answer and explanation
Correct answer: D. Root canal treatment to retain the tooth
- A. Observation leaves an infected non-vital tooth in place, and periapical infection is itself an MRONJ risk factor. Antibiotics do not treat a necrotic pulp.
- B. Extraction plus immediate implant placement is the highest-risk option available: it combines the extraction with additional osseous surgery in a patient whose bone cannot remodel normally.
- C. Extraction with primary closure reduces MRONJ risk relative to leaving bone exposed, but it is still surgery that a root canal would avoid.
- D. CORRECT. Denosumab is a RANK ligand inhibitor that suppresses osteoclast function and carries a genuine risk of MEDICATION-RELATED OSTEONECROSIS OF THE JAW. Any dentoalveolar surgery raises that risk substantially. The governing principle in antiresorptive patients is to AVOID EXTRACTION where a tooth can be retained, so a non-vital tooth is root-canal treated rather than removed, even where the periodontal prognosis is guarded. Where a tooth is genuinely unrestorable, decoronation with root canal treatment of the retained root is preferred to extraction.
Note: Denosumab differs importantly from bisphosphonates: it is NOT incorporated into bone, so its effect wanes within about six months of the last dose. That makes a planned treatment window in the later part of the dosing interval feasible — a discussion to have with the prescribing physician.