The impact of bisphosphonates on oral health: lessons from the past and opportunities for the future

Osteonecrosis of the jaw (ONJ), a challenging medical condition seen primarily among intravenous bisphosphonate (BP) users, is characterized by exposed necrotic bone that persists for more than eight weeks. While rare among people with osteoporosis treated with oral BPs, ONJ has captured the public's attention and caused significant distress. For many, the risk-benefit scale has conceptually changed, tipping steeply toward risk, while for others the benefit of increased bone mass still outweighs the possibility of ONJ. While more than seven years have passed since the first cases were published, the scientific and medical communities are not yet ready to address with certainty the issue of causal inference, nor do they have any concrete recommendations for risk assessment or management of ONJ. Equally important, the dental literature has been skewed by the perceived risk associated with prolonged use of BPs and has neglected to explore how the antiosteoclastic activity of BPs may be utilized to improve dental outcomes. This article reviews critically the current state of knowledge about the impact of bisphosphonates on oral health. Using the principles of epidemiology, the article identifies scientific gains, research challenges, and future research opportunities on the topic.