Risk of medication-related osteonecrosis of the jaws (MRONJ) in osteoporotic patients treated with antiresorptive drug therapy and dental implants

Abstract

Pereira Santos RM, Ottaviani G, Di Lenarda R, Biasotto M, Rupel K. MRONJ Risk Related to Dental Implants in Osteoporosis Treated with Denosumab: A Systematic Review. Oral Dis. 2026 Jan 8. https://doi.org/10.1111/odi.70181 . A literature search using a combination of MeSH terms and specific keywords like osteoporosis, dental implants, jaws, osteoradionecrosis, MRONJ, Denosumab, and Bisphosphonates was conducted using Boolean operators in PubMed and Scopus, until October 2025, following PRISMA guidelines and a predefined PICO framework. Randomized clinical trials, retrospective studies, and case series (reporting a minimum of 4 patients) were included according to the following research question: “What will be the impact of dental implant in osteoporotic patients undergoing treatment with DEN on MRONJ development, considering both implant surgery-triggered osteonecrosis (ISTO) and implant presence-triggered osteonecrosis (IPTO). Only human studies published in English and evaluating osteoporotic patients treated with antiresorptive therapy (ART), including Bisphosphonates (BP’s) and/ or Denosumab (DEN), and dental implants were considered eligible. Relevant data, such as type of ART, dose and duration of therapy, timing of implant placement to differentiate between implant surgery-triggered osteonecrosis (ISTO) and implant presence-triggered osteonecrosis (IPTO), and stage of MRONJ, were extracted independently by two reviewers. The quality assessment of included studies was reported using appropriate tools according to the study design. Ten studies met the inclusion criteria, comprising one randomized controlled trial, two retrospective studies, one case–control study, and six case series, involving a total of 1823 implants placed in 8220 patients. Most patients were postmenopausal females (mean age = 71.45 years). Four studies reported implants placed prior to initiation of ART, whereas three studies analysed the implants positioned after therapy initiation. Implants were identified as a trigger for MRONJ in 8 studies, with 24 implants associated with MRONJ. Patients developed MRONJ after receiving several doses of DEN (two to nine); however, data related to dose and duration of monotherapy or after transitioning from BP’s were inconclusive. The risk of bias ranged from moderate to high. Large variations in the study design, dose, and duration of ART, type of therapy (DEN alone or following transition from BP’s), and follow-up periods produced highly heterogeneous data, restricting comparability. Current evidence suggests that MRONJ related to dental implants in osteoporotic patients treated with DEN is uncommon but clinically relevant, particularly in patients with prior bisphosphonate exposure or peri-implant inflammation. Most of the studies reported MRONJ associated with implants already in position, followed by antiresorptive therapy (IPTO). However, the results should be interpreted with caution, as there is a lack of homogeneous evidence regarding the impact of ART, especially Denosumab monotherapy, on the risk of MRONJ and implant failure in osteoporotic individuals. Well-designed prospective studies with standardized reporting of implant timing, antiresorptive exposure, and peri-implant conditions are needed to help in evidence-based clinical decision-making.