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Mecanismos de ação dos bifosfonatos versus denosumab e seus riscos pós-extração dentária: revisão de escopo
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A terapêutica antirreabsortiva com bifosfonatos (BPs) e denosumab (Dmab) tem sido amplamente utilizada no tratamento da osteoporose e de metástases ósseas, porém está associada ao desenvolvimento de osteonecrose dos maxilares relacionada a medicamentos (MRONJ), especialmente após extrações dentárias. O objetivo desta revisão de escopo foi comparar os mecanismos de ação dos BPs e do Dmab e avaliar seu impacto na cicatrização óssea e no risco de MRONJ após as extrações dentárias. Para tal, a pesquisa bibliográfica foi realizada nas seguintes bases de dados: PubMed, Scopus, Web of Science e Cochrane Library, o período temporal dos trabalhos publicados foi restringido de 2015 a 2025. A triagem dos artigos foi realizada segundo as diretrizes PRISMA-ScR, dos 269 artigos identificados, 19 atenderam aos critérios de elegibilidade. Apesar das diferenças farmacológicas entre os BPs e o Dmab, ambos estão associados ao risco de desenvolvimento de MRONJ após extrações dentárias, com maior incidência em pacientes tratados por via injetável e naqueles sob Dmab com histórico prévio de BPs ou submetidos à múltiplas exodontias. As pausas terapêuticas demonstraram eficácia limitada não sendo autossuficientes como medidas preventivas. Por outro lado, as estratégias preventivas como a profilaxia antibiótica, técnicas cirúrgicas minimamente invasivas, fechamento primário de ferida e o controlo rigoroso de infeções orais, mostraram-se mais eficazes na redução da incidência de MRONJ. Contudo, a maioria da evidência identificada provém de estudos retrospetivos, estudos de coorte de pequeno porte, ensaios clínicos piloto e relatos de caso, o que limita a generalização dos achados. Torna-se, portanto, imprescindível a realização de novas pesquisas com maior robustez metodológica, especialmente ensaios clínicos randomizados com amostras representativas, padronização dos desfechos e acompanhamento longitudinal, a fim de consolidar diretrizes clínicas mais seguras e individualizadas para a gestão de pacientes submetidos a terapias antirreabsortivas.
Antiresorptive therapy with bisphosphonates (BP) and denosumab (Dmab) has been widely used in the treatment of osteoporosis and bone metastases; however, it is associated with the development of medication-related osteonecrosis of the jaw (MRONJ), especially following tooth extractions. The aim of this scoping review was to compare the mechanisms of action of BP and Dmab, and to assess their impact on bone healing and the risk of MRONJ after dental extractions. To achieve this, a literature search was conducted in the following databases: PubMed, Scopus, Web of Science, and Cochrane Library, and the publication period was limited to works published between 2015 and 2025. Article screening was performed according to the PRISMA-ScR guidelines. Of the 269 articles identified, 19 met the eligibility criteria. Despite pharmacological differences between BP and Dmab, both are associated with the risk of developing MRONJ after dental extractions, with a higher incidence in patients treated via injectable routes and in those on Dmab with a prior history of BP use or who underwent multiple extractions. Therapeutic drug holidays showed limited effectiveness and were not sufficient as standalone preventive measures. On the other hand, preventive strategies such as antibiotic prophylaxis, minimally invasive surgical techniques, primary wound closure, and strict control of oral infections proved more effective in reducing the incidence of MRONJ. However, most of the identified evidence comes from retrospective studies, small cohort studies, pilot clinical trials, and case reports, which limits the generalizability of the findings. Therefore, there is a pressing need for new research with greater methodological robustness, especially randomized clinical trials with representative samples, standardized outcomes, and longitudinal follow-up, in order to establish safer and more individualized clinical guidelines for managing patients undergoing antiresorptive therapies.
Antiresorptive therapy with bisphosphonates (BP) and denosumab (Dmab) has been widely used in the treatment of osteoporosis and bone metastases; however, it is associated with the development of medication-related osteonecrosis of the jaw (MRONJ), especially following tooth extractions. The aim of this scoping review was to compare the mechanisms of action of BP and Dmab, and to assess their impact on bone healing and the risk of MRONJ after dental extractions. To achieve this, a literature search was conducted in the following databases: PubMed, Scopus, Web of Science, and Cochrane Library, and the publication period was limited to works published between 2015 and 2025. Article screening was performed according to the PRISMA-ScR guidelines. Of the 269 articles identified, 19 met the eligibility criteria. Despite pharmacological differences between BP and Dmab, both are associated with the risk of developing MRONJ after dental extractions, with a higher incidence in patients treated via injectable routes and in those on Dmab with a prior history of BP use or who underwent multiple extractions. Therapeutic drug holidays showed limited effectiveness and were not sufficient as standalone preventive measures. On the other hand, preventive strategies such as antibiotic prophylaxis, minimally invasive surgical techniques, primary wound closure, and strict control of oral infections proved more effective in reducing the incidence of MRONJ. However, most of the identified evidence comes from retrospective studies, small cohort studies, pilot clinical trials, and case reports, which limits the generalizability of the findings. Therefore, there is a pressing need for new research with greater methodological robustness, especially randomized clinical trials with representative samples, standardized outcomes, and longitudinal follow-up, in order to establish safer and more individualized clinical guidelines for managing patients undergoing antiresorptive therapies.
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Bifosfonatos Denosumab Mecanismos de ação Extração dentária Osteonecrose dos maxilares relacionada a medicamentos Cicatrização óssea Bisphosphonates Mechanisms of action Tooth extraction Medication-related osteonecrosis of the jaw Bone healing