If you take a bone-strengthening medication like Fosamax, Reclast, or Prolia — or a similar drug for cancer — you may have heard about a rare jaw complication called osteonecrosis. Here's what it means for your dental care, and why saving a tooth with a root canal is usually the safer path than pulling it.
These drugs slow bone turnover or blood-vessel growth, which is helpful for your bones or your cancer care but can slow how the jaw heals after bone surgery. Bring a full list of what you take to your visit.
Examples: Alendronate (Fosamax), risedronate (Actonel), ibandronate (Boniva)
Taken as a weekly or monthly pill for osteoporosis or osteopenia. Risk of jaw complications is low but not zero, and rises with the number of years on the medication.
Examples: Zoledronic acid (Reclast for osteoporosis; Zometa for cancer), pamidronate (Aredia)
Given by infusion. The high-dose cancer forms carry a meaningfully higher jaw risk than the once-a-year osteoporosis dose.
Examples: Denosumab (Prolia for osteoporosis; Xgeva for cancer)
An injection every 6 months (Prolia) or more often (Xgeva). Unlike bisphosphonates it clears the body over months, which changes how treatment is timed.
Examples: Bevacizumab (Avastin), sunitinib (Sutent), and related agents
Used in cancer care; can add to jaw risk, especially when combined with an antiresorptive.
Medication-related osteonecrosis of the jaw (MRONJ) is overwhelmingly triggered by procedures that expose or injure the jawbone — above all, tooth extractions and oral surgery. A non-surgical root canal treats the infection through the crown of the tooth and leaves the tooth and its surrounding bone in place. By saving the tooth, it removes the reason to extract — which is exactly the event these medications make riskier.
The 2022 AAOMS position paper and the AAE's 2026 guideline agree that preserving a tooth with root canal treatment is preferable to extraction in patients on antiresorptive therapy whenever the tooth is restorable. Per AAOMS and AAE, the risk of MRONJ specifically from endodontic (root canal) treatment is not established, whereas the risk from extraction is well documented.
Apical surgery (apicoectomy) does involve the jawbone, so for patients on these medications we weigh it more carefully, coordinate with your physician, and usually prefer non-surgical treatment or retreatment first. Most cases never need surgery.
This page is general education, not medical advice for your specific situation. Never start, stop, or change a medication without talking to the physician who prescribed it.
Yes. For patients on osteoporosis medications, a root canal is generally considered a safer choice than pulling the tooth, because tooth extraction — not root canal treatment — is the main trigger for medication-related osteonecrosis of the jaw (MRONJ). Saving the tooth avoids that surgical trauma. Always tell us which medication you take and for how long, so we can plan accordingly.
MRONJ stands for medication-related osteonecrosis of the jaw. It's a rare condition in which an area of jawbone fails to heal and becomes exposed, usually after a procedure that injures the bone — most often a tooth extraction. Certain bone and cancer medications reduce the bone's ability to heal, which is why they raise the risk. It is uncommon, especially at the low doses used for osteoporosis, and the risk is managed by avoiding unnecessary bone surgery and keeping up with dental care.
Do not stop or change any medication on your own. Whether a brief pause (a "drug holiday") makes sense depends on your specific drug, dose, and medical history — and it's a decision for your physician, not your dentist. For a non-surgical root canal, stopping the medication is usually not necessary at all, because the procedure doesn't involve bone surgery. We're happy to talk with your doctor if a coordinated plan is needed.
The main ones are antiresorptive drugs — bisphosphonates such as alendronate (Fosamax), risedronate (Actonel), ibandronate (Boniva), and zoledronic acid (Reclast/Zometa), and denosumab (Prolia/Xgeva) — plus certain antiangiogenic cancer drugs. IV and cancer-dose forms carry more risk than the low doses used for osteoporosis. Bring a full list of your medications to your visit.
Yes — this is strongly recommended. There is good evidence that having any needed dental work done, and getting your mouth healthy, before starting antiresorptive therapy lowers the chance of problems later. If you have a tooth that may eventually need a root canal or extraction, it's far better to address it beforehand. Ask your physician to coordinate a dental check-up before your first dose.
In almost all cases, yes — provided the tooth is restorable. Because extraction is the leading trigger for MRONJ and root canal treatment is not, saving the natural tooth is the more conservative, lower-risk path for patients on these medications. That's the position of both the American Association of Endodontists and the American Association of Oral and Maxillofacial Surgeons.
Bring your medication list and we'll walk you through the safest way to save the tooth. We coordinate with your physician whenever it helps.