Osteoporosis and Dental Work

So much good information in this thread -- thanks @gently and others. @gently, do you have any information on whether Fosamax or Reclast is "safer" -- meaning less likely to cause ONJ??? I haven't been able to find much info, and my doc (a specialist at Cleveland Clinic) is recommending Reclast once I stop Tymlos. According to her, both stay in your bones, so one is not better than the other. I was thinking Fosamax would be better because you could stop taking it if you needed invasive dental work.

I am 65. I took Reclast for 3 yrs - twice a year for the first two at only 1/5 the dose, then once at half the dose. My endo was very careful with me due to the side effects I get from medications and the Reclast.
My last dose of Reclast was May 2025. In July 2025 I had a root canal that failed so ended up with an apicoectomy in August.
I was referred to an oral surgeon as imaging showed a tooth that needed extraction. He is a surgeon who doesn’t like to touch people who’ve been on Reclast. He advised waiting “ as long as possible” for the extraction. It was finally removed in February 2026.

The area around the other tooth treated with root canals remained painful to touch for months and I had been feeling unwell with fluctuating fevers during this time. More than once I asked the surgeon if waiting to intervene could harm my bones but he said it’s better to wait due to my Reclast history. I finally convinced the oral surgeon to do a cbct and it showed infection remained and had eaten a lot of the bone there. The tooth was extracted in March 2026.

I’ve been off Reclast during this time to get the work done and to wait to receive implants, which he said he would do after I healed enough, so we waited 5 months. Now the surgeon says he always felt I wasn’t a good candidate for implants due to the Reclast and since it’s tooth 11 and 12 ( near the front) the bone there is naturally thinner ( in all people) and he’d be forced to implant at a bad angle that would make the tooth stick out.
He doesn’t want to do a bone graft, but would if I insist.

At this point I feel it’s not good to ask a doctor to do something they’re not comfortable with and I wish I had gone for a second opinion last year. Waiting to do the work created much more damage ( that area which is 4 months post extraction needs more time to fill in, and still remains somewhat touch sensitive on the exterior of my face )

Given the fact that my dosage of Reclast was mainly 1/5 of a dose and only once at 1/2 a dose my instincts are that the odds of osteocronosis should be lower. I am going to look for an oral surgeon who’s comfortable treating me. How does one find someone like this- hopefully without paying for multiple consults? ( some are $200- $300 to consult plus a new cbct if I can’t get the one just done - many practices say they can’t read the cbct from other drs as they have different readers.

@sebutler Following...! I have many questions & concerns. Diagnosed with severe osteoporosis (-4.10 left femer)
It has been suggested I begin Evenity, I am having a tooth pulled next week.
I am reading as much as I can and slowly heading towards the Evenity, with much fear! I need bilateral hip surgery due to osteoarthritis, and don't dare move forward with that until my bones are stronger. I am in so much pain that exercise is out of the question..I need a hug!

I think you should have the implant, I'm not sure you should take Prolia. The trouble with Prolia is that it prevents your bones from remodeling. Eventually your bones become avascular. So the bones are brittle because they haven't been renewed and then they become even more brittle. Many oral surgeons won't do surgery for patients on Prolia. Prolia weakens the immune system which makes you more susceptible to the ever-present germs in your mouth. Often we get antibiotics. But on Prolia there isn't the vascular system to take the antibiotic to a bone infection. All the bone can do is decay. There is a risk of osteonecrosis of the jaw with the use of Prolia.
Some never experience this and since you are just beginning Prolia, you might escape unharmed. But there is the risk of osteonecrosis with Evenity. So you might be set-up for harm. You might talk to you endocrinologist about pausing a month and starting Prolia at the end of September. It is safer if you've already had the root canal on that tooth. You probably know that once you start Prolia, it is difficult to stop the medication.

@gently

Tooth decay doesn’t mean someone has Osteonecrosis, right? How is osteonecrosis diagnosed? Bone scans? Would it show up on standard dental X-rays? I am at the beginning of weekly Fosamax and have had pain in a tooth that my dentist filled six months ago. I want to switch to an injection instead of the Fosamax because I have trouble remembering to take it and always drink water before I get up in the morning. My PCP isn’t helpful. The tooth needs a crown so does it matter if I do the crown before switching to an injection? I know my medication is very different from Prolia. But is dental work concerning for all osteoporosis meds?

@gently

Tooth decay doesn’t mean someone has Osteonecrosis, right? How is osteonecrosis diagnosed? Bone scans? Would it show up on standard dental X-rays? I am at the beginning of weekly Fosamax and have had pain in a tooth that my dentist filled six months ago. I want to switch to an injection instead of the Fosamax because I have trouble remembering to take it and always drink water before I get up in the morning. My PCP isn’t helpful. The tooth needs a crown so does it matter if I do the crown before switching to an injection? I know my medication is very different from Prolia. But is dental work concerning for all osteoporosis meds?

I am 65. I took Reclast for 3 yrs - twice a year for the first two at only 1/5 the dose, then once at half the dose. My endo was very careful with me due to the side effects I get from medications and the Reclast.
My last dose of Reclast was May 2025. In July 2025 I had a root canal that failed so ended up with an apicoectomy in August.
I was referred to an oral surgeon as imaging showed a tooth that needed extraction. He is a surgeon who doesn’t like to touch people who’ve been on Reclast. He advised waiting “ as long as possible” for the extraction. It was finally removed in February 2026.

The area around the other tooth treated with root canals remained painful to touch for months and I had been feeling unwell with fluctuating fevers during this time. More than once I asked the surgeon if waiting to intervene could harm my bones but he said it’s better to wait due to my Reclast history. I finally convinced the oral surgeon to do a cbct and it showed infection remained and had eaten a lot of the bone there. The tooth was extracted in March 2026.

I’ve been off Reclast during this time to get the work done and to wait to receive implants, which he said he would do after I healed enough, so we waited 5 months. Now the surgeon says he always felt I wasn’t a good candidate for implants due to the Reclast and since it’s tooth 11 and 12 ( near the front) the bone there is naturally thinner ( in all people) and he’d be forced to implant at a bad angle that would make the tooth stick out.
He doesn’t want to do a bone graft, but would if I insist.

At this point I feel it’s not good to ask a doctor to do something they’re not comfortable with and I wish I had gone for a second opinion last year. Waiting to do the work created much more damage ( that area which is 4 months post extraction needs more time to fill in, and still remains somewhat touch sensitive on the exterior of my face )

Given the fact that my dosage of Reclast was mainly 1/5 of a dose and only once at 1/2 a dose my instincts are that the odds of osteocronosis should be lower. I am going to look for an oral surgeon who’s comfortable treating me. How does one find someone like this- hopefully without paying for multiple consults? ( some are $200- $300 to consult plus a new cbct if I can’t get the one just done - many practices say they can’t read the cbct from other drs as they have different readers.

@dmr4ever, Tymlos and Forteo are the only medications that don't pose a risk for the jawbone. In fact, either can be prescribed as adjunct medication for ONJ. The risk is small and usually you have to be on the antiresorptives for a long time to be at risk. If the injection is a bisphosphonate, then it would be better to wait.
Six months is a long time to for the tooth to hurt after a filling. But you are getting a crown. It may be that the decay was too close to the root, or maybe the tooth has cracked. If you are having a root canal that's where infection can enter the bone. How long will you wait. Are you like me just not wanting to go in or are you waiting for insurance or other windfall.
Osteonecrosis doesn't show up on dental x rays until there is substantial damage to the jaw. It is most often diagnosed through a visual exam exhibiting exposed bone or area of the gum that just won't heal.
Decay in the tooth absolutely does not indicate osteonecrosis.
If you haven't been on Fosamax for long, you shouldn't worry. If you are thinking about Reclast, I'd suggest waiting for the bone to heal.