Endodontic therapy and Medication-related osteonecrosis of the jaw onset: a scoping review and expert opinion-based qualitative meta-synthesis

Introduction: Medication-related osteonecrosis of the Jaw (MRONJ) is a serious side effect of bone-modifying agents (BMAs), including bisphosphonates, denosumab, and antiangiogenic drugs. Some dental procedures are recognized as local risk factors for MRONJ. Given the lack of specific guidelines for root canal therapy in patients treated with BMA, this scoping review aimed to investigate the risk of MRONJ associated with failed root canal therapy. Subsequently, a meta-synthesis of expert opinions was performed to identify existing recommendations and pitfalls of root canal therapy in patients at risk of MRONJ. Methods: A review search was conducted in PubMed, Scopus, and Web of Science to answer the PIO question: Is root canal therapy failure associated with an increased risk of developing MRONJ? Subsequently, a meta-synthesis was conducted to analyze guidelines, recommendations, and expert opinions regarding root canal therapy in BMA-treated patients. Results: Five studies were included. All studies were case reports and case series, except one case-control study. Twenty-three patients who developed MRONJ after root canal therapy failure were analyzed. Also, a case- control study including 65 patients receiving BMAs and 46 patients never treated with BMAs was evaluated. In the last one only 4.8% of patients under BMAs developed MRONJ. The most common BMA used was zoledronate. A total of 223 teeth underwent root canal therapy. Conclusions: This study highlights the potential risks of root canal therapy failure in BMA-treated patients, emphasizing the need to evaluate treatment appropriateness and risk-benefit ratio carefully.