• No.

Is medical consult advised?  

• No, assuming patient/client is already under medical care for osteoporosis, has no complicating oral features, and is not taking an antiresorptive bone drug (ARD; e.g., a bisphosphonate, denosumab, or romosozumab¹).
• Yes, for the patient/client taking a bisphosphonate (orally, by injection, or intravenously) or other ARD (such as denosumab or romosozumab by subcutaneous injection). (Refer to Medication-Related Osteonecrosis of the Jaw (MRONJ) Fact Sheet for more information.) 

• No, in osteoporotic patients/clients without MRONJ (which is the vast majority of persons with osteoporosis).

Is medical consult advised? 

• See above.

Is medical clearance required? 

• No, in the absence of MRONJ.

Is antibiotic prophylaxis required?  

• No, for patients/clients who are not taking antiresorptive drugs.
• No, for most low-risk patients/clients² who are taking ARDs and do not have MRONJ. (Refer to MRONJ Fact Sheet for more formation.)

Is postponing treatment advised?

• No, for patients/clients who are not taking antiresorptive drugs.
• No, for most low-risk patients/clients (see footnote 2) who are taking ARDs and do not have MRONJ.
• Potentially, if injectable/intravenous bisphosphonate drugs or other antiresorptive drugs are being used. (Refer to MRONJ Fact Sheet for more information.)  Informed by medical/dental consultation, routine scaling is usually indicated during bisphosphonate (or other antiresorptive) therapy to optimize oral health and reduce risk of MRONJ development.

• Low estrogen levels, which commonly occur in post-menopausal women, are associated with osteoporosis and decreased alveolar bone density. The risk of tooth loss is particularly high in osteoporotic women who smoke. Estrogen replacement therapy (ERT) may be beneficial in decreasing tooth loss in women with osteoporosis, as well as in reducing gingival inflammation and attachment loss.³
• Dental x-rays can distinguish patients/clients with low bone density from those with normal bone density. Patients/clients suspected to have osteoporosis on radiographic examination (and previously undiagnosed) should be referred for medical evaluation. 
• The majority of osteoporotic fractures result from low trauma (i.e., falls from standing height or lower). Fractures of the wrist are most common, followed by fractures of the upper arm. Wrist fractures tend to occur at a younger age than spine and hip fractures. Such fractures, especially in one’s dominant arm, may interfere with brushing and flossing ability.
• The dental hygienist should be alert for signs/symptoms of medication-related osteonecrosis of the jaw (MRONJ) in patients/clients treated with bisphosphonates or other antiresorptive drugs (see below). Some invasive dental procedures should be minimized for patients/clients treated with injectable bisphosphonates, although routine scaling is often indicated during bisphosphonate therapy to optimize oral health and reduce risk of MRONJ development.

• Osteoporosis is associated with alveolar bone loss and an elevated risk of periodontal disease. Osteoporotic women, in particular, are at increased risk of alveolar bone resorption, attachment loss, tooth loss, and edentulousness.
• Dental concerns that may indicate low bone density include loose teeth, receding gums or gums detaching from teeth, and loose or ill-fitting dentures.
• Bisphosphonate drugs (used to treat osteoporosis, in addition to Paget’s disease, multiple myeloma, and hypercalcemia of malignancy) and other antiresorptive drugs (e.g., denosumab, used to treat osteoporosis amongst other indications, and romosozumab, used to treat osteoporosis) can infrequently lead to medication-related osteonecrosis of the jaw (MRONJ).⁴ MRONJ can occur with the oral administration of bisphosphonates (which is typically the administration route for osteoporosis patients/clients, and includes risedronate and alendronate), but is rare. MRONJ is a more common complication of injectable bisphosphonates (such as pamidronate and zoledronic acid), which are used in patients/clients with primary bone cancer or skeletal metastases. In the early stages of MRONJ, no radiographic abnormalities can be seen and patients/clients are usually asymptomatic. However, patients/clients may develop severe pain due to necrotic bone becoming secondarily infected. A common initial complaint is the sudden presence of intraoral discomfort and roughness that may progress to involve the soft oral tissues surrounding the area of necrotic bone. Often progressive, MRONJ may lead to areas of bony exposure and dehiscence, as well as extraoral fistula formation.

• Osteoporosis is a skeletal disorder of low bone density caused by decreased bone formation and increased bone resorption.⁵ Spine, hip, wrist, and shoulder fractures associated with osteoporosis are a significant cause of disability, mortality, healthcare utilization, and healthcare costs.
• More than 2.3 million Canadians live with osteoporosis, with the disease being most common in persons 50 years of age and older.
• Signs/symptoms (which arise late in the clinical course of the disease following a typically long asymptomatic period) include:
  • bone pain or tenderness
  • fractures with no or little trauma (i.e., fragility fractures)
  • height loss over time
  • kyphosis⁶, and
  • low back and/or neck pain from vertebral fractures. 
• Osteoporosis is more likely to develop if one does not reach optimal peak bone mass during one’s bone-building years. Women and men begin to lose bone in their mid-30s.
• Persons at elevated risk for osteoporosis include those who are:
  • female
  • Caucasian (white) or Asian
  • post-menopausal women⁷
  • older adults
  • small in body size (thin)
  • eating a diet low in calcium
  • eating a diet low in Vitamin D or experiencing little sun exposure
  • physically inactive
  • drinking alcohol excessively
  • smoking
  • taking certain medications/treatments (e.g., glucocorticoids, antiseizure drugs⁸, excessive thyroid hormone, proton pump inhibitors⁹, antidepressants¹⁰, diabetes drugs¹¹, and androgen deprivation therapy)
  • living with at-risk diseases/disorders (e.g., anorexia nervosa, celiac disease, and cystic fibrosis).
• At least 1 in 3 women and 1 in 5 men will break a bone due to osteoporosis in their lifetime. 22% of women and 33% of men who suffer a hip fracture will die within one year.

• College of Dental Hygienists of Ontario
  https://cdho.org/advisories/osteoporosis-and-osteonecrosis/
  https://cdho.org/factsheets/medication-related-osteonecrosis-of-the-jaw
• Lim SY. Romosozumab for the treatment of osteoporosis in women: Efficacy, safety, and cardiovascular risk. Womens Health (Lond). 2022 Jan-Dec;18:17455057221125577. doi: 10.1177/17455057221125577. PMID: 36154750; PMCID: PMC9511529. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9511529/
• Government of Canada
  https://www.canada.ca/en/public-health/services/chronic-diseases/osteoporosis/what-impact-osteoporosis-what-canadians-doing-maintain-healthy-bones.html
• Osteoporosis Canada 
  https://osteoporosis.ca
• National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health
  https://www.niams.nih.gov/health-topics/bone-health-and-osteoporosis
  https://www.niams.nih.gov/health-topics/osteoporosis
  https://www.niams.nih.gov/health-topics/surgeon-generals-report-bone-health-and-osteoporosis-what-it-means-you
• American Dental Association
  https://www.ada.org/en/resources/research/science-and-research-institute/oral-health-topics/osteoporosis-medications
• Mayo Clinic https://www.mayoclinic.org/drugs-supplements/denosumab-subcutaneous-route/description/drg-20074315
• Little JW, Falace DA, Miller CS and Rhodus NL. Dental Management of the Medically Compromised Patient (9^th edition). St. Louis: Elsevier; 2018.
• Bowen DM (ed.) and Pieren JA (ed.).  Darby and Walsh Dental Hygiene: Theory and Practice (5^th edition).  St. Louis:  Elsevier; 2020.
• Ibsen OAC and Peters SM. Oral Pathology For The Dental Hygienist (8^th edition). St. Louis: Elsevier; 2023.
• Prajer RG and Grosso G. DH Notes − Dental Hygienist’s Chairside Pocket Guide. Philadelphia: F.A. Davis Company; 2011.

¹ Unlike bisphosphonates and denosumab, romosozumab has both antiresorptive and bone-formation properties.
² Patients/clients at lower risk of developing MRONJ include those taking low potency oral bisphosphonate formulations (typical in treatment of osteoporosis) rather than high potency intravenous formulations, those who are in a state of good oral health, and those who do not have cancer.
³ Treatment of osteoporosis includes lifestyle modification and medications based on disease severity.
⁴ 1 in 10,000 persons with osteoporosis who are treated with at-risk medications develops MRONJ (in contrast with up to 10% of persons whose drug indication is cancer-related).
⁵ Osteoporosis is diagnosed via bone densitometry, usually accomplished by dual energy x-ray absorptiometry (DEXA) or, less commonly, by a special CT scan. Bone mineral density (BMD) is measured.
⁶ Kyphosis is curving of the spine that causes a bowing or rounding of the back, which results in hunchback or slouching posture.
⁷ Post-menopausal osteoporosis is the most common type of osteoporosis.
⁸ in particular, carbamazepine, phenytoin, primidone, and valproic acid
⁹ used to reduce stomach acid in conditions such as gastroesophageal reflux disease (GERD)
¹⁰ in particular, selective serotonin reuptake inhibitors (SSRIs)
¹¹ in particular, thiazolidinediones, which are used to treat type 2 diabetes

* Includes oral hygiene instruction, fitting a mouth guard, taking an impression, etc.
** Ontario Regulation 501/07 made under the Dental Hygiene Act, 1991. Invasive dental hygiene procedures are scaling teeth and root planing, including curetting surrounding tissue.