Bisphosphonate-associated osteonecrosis of the jaws (BP-ONJ) is a well-known side effect in patients receiving bisphosphonates (BP) due to e.g. osteoporosis, multiple myeloma or malignant diseases with metastases to the bone; prevalences range between 0.1% for patients with primary osteoporosis to 1% in patients with secondary osteoporosis and up to about 20% for special high risk subpopulations of patients with a malignant disease and further predisposing factors. In addition to general risk factors such as the primary disease implicating the antiresorptive therapy, the antiresorptive therapy itself, concomitant diseases and medications and other influencing systemic factors usually a further factor triggering the development of BP-ONJ can be identified such as periodontal disease, extractions, denture pressure sores, or implant insertion. Usually BP-ONJ occurs in patients of higher ages (69 years ±10 years) due to the primary disease causing the BP therapy so that it is not unusual that these patients seek the dentist for oral rehabilitation where implant therapy and bone augmentation for optimal implant positioning might be considered to substitute lost teeth.

There are guidelines describing BP treatment as a contraindication for implant therapy in patients with an oncologic primary disease that say implant insertion should be avoided. On the other hand, there are studies describing the safety of dental implant surgery in patients with oral BP and osteoporosis with no occurring BP-ONJ cases. However, there are cases of successful implant insertion in patients with malignant primary diseases and cases of BP-ONJ in patients with osteoporosis. Reviews mention that there are only very few retrospective studies with moderate strength of evidence addressing this topic so that no final recommendation can be given. Oral and intravenous BP are not seen as absolute contraindications for dental implant therapy and that dental implants can osseointegrate successfully. It is recommended to do a risk assessment and to inform the patient about the potential risk of BP-ONJ development.

A similar scenario is well known in patients with radiation of the jaws. Initially, radiation therapy was seen as a contraindication for implant insertion because of osteoradionecrosis. In Germany meanwhile, implants are covered by the health insurance by law in some of these patients (§28 SGB V Sozialgesetzbuch). Due to xerostomia sufficient fixation of a denture is rather complicated, and implants can improve the situation and might reduce the incidence of osteoradionecrosis by avoiding pressure denture sores that could result in exposed bone and eventually osteoradionecrosis.

This development could be transferred to patients with antiresorptive treatment (bisphosphonates, denosumab) since implants might reduce the incidence of BP-ONJ due to the lack of denture pressure sores in these patients. As well, denture pressure sores have been described by many authors as the triggering factor for BP-ONJ.

The German guidelines on bisphosphonate- and medication-associated osteonecrosis of the jaws state that there might be a limitation in the indication of implant insertion in these patients, but the implant-based oral rehabilitation was not a part of these guidelines. To address this deficit in the literature, the rationale of this literature review was to find out which patients with antiresorptive therapy (BP, denosumab) benefit from dental implants without being exposed to an unreasonable high risk of osteonecrosis development.