Endodontic treatment and management of patients under antiresorptive treatment: a scoping review on MRONJ risk.

Abstract

Objectives: To summarize the current scientific evidence on the implications of root canal treatment (RCT) in patients receiving antiresorptive therapy and to outline best practices for managing such cases to prevent MRONJ.

Materials and methods: A search strategy across PubMed, Web of Science and Scopus was performed. Clinical studies and reports on RCTs in patients on antiresorptive therapy were screened by two independent reviewers. Data on patient factors (sex, age, disease, treatment, outcome) and tooth-related aspects (procedure, diagnosis, anesthesia, irrigation, obturation, antibiotics) were extracted.

Results: Of the 514 studies identified, 15 articles (133 patients) met inclusion criteria. One prospective study included 65 patients and 96 RCTs; the remaining patients were reported in case reports or series and in two retrospective studies. Endodontic protocols varied largely across studies. The most common indications for RCT were pulpitis (n = 62) and periapical lesions with acute endodontic diseases (n = 119). All patients were undergoing antiresorptive therapy with oral or intravenous bisphosphonates for the management of osteoporosis or oncologic conditions. RCT was performed in all cases using conventional protocols that included local anesthesia (in some cases without vasoconstrictors), mechanical instrumentation, chemical irrigation (most commonly with sodium hypochlorite) and root canal obturation. Five studies reported antibiotic use. The cases of MRONJ (n = 7, 5.3%; mean treatment duration was 49 months) appeared only in oncological patients.

Conclusions: RCT appears to be a safe procedure for patients receiving bisphosphonates. Cases in which RCT appeared to act as a trigger for MRONJ are rare and ambiguous and seem primarily associated with procedural errors or high-risk patients. Although some recommendations for endodontic practice to prevent MRONJ have been proposed, there is a clear need for further research in this area.

Clinical relevance: Dentists can safely perform RCT in patients undergoing bisphosphonate therapy. Some clinical recommendations based on the available literature are provided.