Dear Sir,

We would like to thank Toh and Dutton for their comment(1) regarding the recommendation suggested in our article(2) to refer all osteoporotic patients starting antiresorptive therapy for dental clearance.

To clarify, the term ‘dental clearance’ means a comprehensive and thorough dental examination, with the provision of preventive and necessary dental treatment for patients starting therapy for osteoporosis. This should be carried out even for patients who routinely attend dental visits, as the oral condition is dynamic, and changes to oral health may sometimes go unnoticed. The dental examination is meant to establish the patient’s existing oral condition prior to starting therapy, as well as to treat active or potential inflammation/infection, which may predispose the patient to developing medicine-related osteonecrosis of the jaw (MRONJ) in the future.(3) Patients who are examined and deemed to be dentally fit, and practise good preventive habits, should continue to receive routine dental care. These recommendations are supported by the American Association of Oral and Maxillofacial Surgeons’ position paper, the Scottish Dental Clinical Effectiveness Programme guideline and the Canadian practice guideline.(4-6)

The Canadian guideline mentioned in the letter did not recommend against routine dental examination for osteoporosis patients with no dental problems, but rather suggested that patients who have been practising appropriate preventive dental care and report no acute dental problems only require routine dental care.(6) The paper also suggested that “if appropriate dental care has not taken place, or if there is an acute dental problem, this should be addressed prior to initiating a bisphosphonate”.(6)

One must be aware that certain acute dental conditions and states of chronic dental inflammation are often painless, and changes to oral health may go unnoticed by the patient. Without a thorough examination, patients on antiresorptive therapy may eventually be faced with a decision to weigh the risk of developing MRONJ against the need for invasive dental treatment.

Yours sincerely,
References
Toh CL, Dutton A.Comment on: Medication-related osteonecrosis of the jaw in osteoporotic patients: prevention and management. Singapore Med J. 2018;59:287.
Chan BH, Yee R, Puvanendran R, Ang SB.Medication-related osteonecrosis of the jaw in osteoporotic patients: prevention and management. Singapore Med J. 2018;59:70-5.
McGowan K, McGowan T, Ivanovski S.Risk factors for medication-related osteonecrosis of the jaws: a systematic review. Oral Dis. 2018;24:527-36.
American Association of Oral and Maxillofacial Surgeons Position Paper: Medication-Related Osteonecrosis of the Jaw—2014 Update [online]. Available at: https://www.aaoms.org/docs/govt_affairs/advocacy_white_papers/mronj_position_paper.pdf. Accessed April 18 2018.
Scottish Dental Clinical Effectiveness Programme Oral Health Management of Patients at Risk of Medication-related Osteonecrosis of the Jaw: Dental Clinical Guidance [online]. Available at http://www.sdcep.org.uk/wp-content/uploads/2017/04/SDCEP-Oral-Health-Management-of-Patients-at-Risk-of-MRONJ-Guidance-full.pdf. Accessed April 23 2018.
Khan AA, Sándor GK, Dore E, et al. Canadian Association of Oral and Maxillofacial SurgeonsCanadian consensus practice guidelines for bisphosphonate associated osteonecrosis of the jaw. J Rheumatol. 2008;35:1391-7.