- Vitamin D's role in oral and systemic health: How vitamin D deficiency affects bone metabolism, immune function, and implant success, emphasizing the clinical relevance of screening and supplementation in dental care.
- Implications of antiresorptive therapies in dentistry: The session examined how medications like bisphosphonates and Denosumab, commonly used to treat osteoporosis and cancer-related bone conditions, can increase the risk of osteonecrosis of the jaw and complicate dental procedures.
- Prevention, diagnostics, and interdisciplinary collaboration: Emphasis was placed on early detection, patient education, chairside vitamin D testing, and proactive treatment planning to reduce complications and improve outcomes in implantology and periodontology.
This is the summary of a workshop on the specific topic held during the conference “Schnittstellen der Parodontologie“ (Interfaces in Periodontology), conference of the “Deutsche Gesellschaft für Parodontologie” (German Society for Periodontology) marking the organization’s 100th anniversary, September 19-21, 2024, at the World Conference Center Bonn, Germany. Main program under the scientific direction of Prof. Dr. Dr. Søren Jepsen and Prof. Dr. Henrik Dommisch with seven interfaces in seven sessions.
Vitamin D in oral health and implantology
Prof. Dr. Dr. Knut A. Grötz (Oral and Maxillofacial Surgery Specialist, Wiesbaden) and Dr. Philipp Bilobrk (Oral Surgery Specialist, Berlin) led a hands-on workshop focusing on the relevance of vitamin D levels and supplementation for oral health and implantology. Prof. Grötz also discussed how antiresorptive medications—specifically bisphosphonates and Denosumab—should be considered when planning periodontal and implant treatments. Participants performed the botissCARE Rapi-D™ rapid test (Straumann Group) to instantly measure their own vitamin D levels, gaining practical insight into how such chairside testing can be integrated into daily practice. “In Germany, 25% of the population suffers from severe vitamin D deficiency, with this figure rising to 50% between February and March,” Prof. Grötz noted, surprising the audience. He emphasized that deficiency is defined as serum levels below 12 ng/ml (30 nmol/l), while levels below 30 ng/ml (75 nmol/l) are already considered suboptimal.
Supporting osseointegration
“Vitamin D is an essential prohormone that promotes calcium and phosphate absorption and is crucial for bone mineralization,” said Prof. Grötz. This fat-soluble vitamin supports bone health, the periodontium, muscle function, and immune health. It lowers the risk of periodontal disease, promotes implant osseointegration, and helps prevent osteoporosis. Studies confirm that sufficient vitamin D levels lead to significantly improved osseointegration of dental implants. One study by Kwiatek et al. showed higher secondary implant stability at three and six months with higher vitamin D levels, along with improved peri-implant bone levels six and twelve weeks after implantation. Vitamin D also enhances bone formation when combined with xenografts in alveolar ridge augmentation procedures. Prof. Grötz cited clinical and radiographic research to support this. Vitamin D plays a key metabolic role, aiding in protein synthesis, gene regulation, cell growth, and maintaining healthy oral mucosa.
Improved cancer prognosis
Studies show a connection between vitamin D status and chronic diseases such as hypertension, type 2 diabetes, cardiovascular disease, and certain cancers. Prof. Grötz emphasized that adequate 25(OH)-vitamin D serum concentrations correlate with better outcomes in breast and colorectal cancer. Research presented as a "pre-guideline" during the workshop suggests a possible link between vitamin D insufficiency and the development or progression of OPMDs (oral potentially malignant disorders). Those over 70 and individuals supplementing prior to a cancer diagnosis appear to benefit most. While the overall meta-analysis did not show a statistically significant reduction in cancer mortality, a subgroup analysis found that daily supplementation (as opposed to bolus doses) reduced cancer mortality by 12% and increased survival by 11%.
Ensuring adequate vitamin D intake
The body mainly synthesizes vitamin D through the skin via UV-B radiation—not UVA—from sunlight. This requires sufficient outdoor time, yet from October to April, there is no significant vitamin D production in Germany. Diet contributes little, and modern indoor lifestyles increase the risk of deficiency. Given its physiological importance, determining a patient’s vitamin D status can be critical for successful implant or periodontal procedures. Traditionally done in labs, Prof. Grötz criticized the delays and costs associated with lab testing. In contrast, chairside rapid tests like the botissCARE Rapi-D™ offer fast, flexible, and reliable results. Routine testing isn’t necessary for every patient, but is advised for high-risk cases or suspected deficiency. In bone-regenerative procedures, testing and supplementation can occur simultaneously. In winter, daily supplementation of 20 µg (800 IU) is recommended.
Figures 1–9 illustrate the practical workshop applications and rapid test usage, emphasizing the value of on-site vitamin D testing in clinical settings, as well as the AGSMO form's role in individualized risk assessment and showing how local soft tissue inflammation can trigger AR-ONJ.
Bisphosphonates and Denosumab in dental practice
The workshop’s second part addressed antiresorptive medications, again led by Prof. Grötz and Dr. Bilobrk (Charité). While osteoradionecrosis was described as early as 1906, bisphosphonate-associated jaw necrosis (BRONJ) is a more recent diagnosis, first noted around 20 years ago. It has significantly impacted dental and maxillofacial care. Two primary antiresorptive drug types are involved: bisphosphonates and Denosumab (Prolia and XGeva). These are used in oncology (bone metastases) and osteoporosis treatment. The condition is now referred to as AR-ONJ (antiresorptive agent-related osteonecrosis of the jaw). These medications inhibit osteoclast differentiation and function, reducing bone remodeling. Long-term, high-dose treatments may make bone more brittle and susceptible to necrosis. Prof. Grötz warned that while bisphosphonates reduce bone loss, they also suppress the bone's natural defense against infection. Clinical images demonstrated that inflammatory conditions in the soft tissue—from gingivitis, periodontitis, impacted teeth, or pressure sores from dentures—can trigger AR-ONJ. Surgery-related inflammation, like post-extraction wounds or oral mucosal trauma, can also lead to osteonecrosis. Multiple studies indicate a direct link between periodontal disease and jaw necrosis development.
“Pressure sores from dentures are a key factor in AR-ONJ development,” emphasized the presenters. Since pain is not always a symptom, dentists must remain vigilant. The hallmark of AR-ONJ is exposed bone, visible either by inspection or probing. Other symptoms include loose teeth, halitosis, fistulas, swelling, and numbness in the lower lip.
Prophylaxis and patient communication
AR-ONJ can seriously impact oral health quality of life. Preventive measures before and during antiresorptive treatment are essential. According to Prof. Grötz, even a single dose of such medication may increase risk, although it's typically dose and time-dependent. Risk factors include periodontitis, peri-implantitis, extractions, and denture-related trauma. Patients must be thoroughly informed about these risks. An individual risk assessment should be made, using tools like the AGSMO form, endorsed in the S3 guidelines since 2007. This form is available for free download at www.onkosupport.de. Dr. Bilobrk noted that the oral cavity is often a “terra incognita” for general practitioners, and the AGSMO form fosters better interdisciplinary collaboration.
Oral sanitation before bisphosphonate therapy
Dentists should perform thorough diagnostics, prosthetic adjustments, and address oral infections before initiating antiresorptive therapy. Teeth that are damaged but salvageable should not be removed prophylactically. Likewise, impacted teeth and asymptomatic apical lesions do not automatically require surgery. Patients with AR-ONJ typically have fewer teeth and greater attachment loss, both in quantity and severity, compared to healthy controls. Thus, a comprehensive periodontal treatment should precede antiresorptive therapy, mirroring the approach for implants.
Implants, communication, and monitoring
When conditions allow, implants can restore chewing function and reduce the risk of necrosis caused by denture pressure points. However, all procedures must be minimally invasive, atraumatic, and accompanied by antibiotic prophylaxis. Patients must be clearly informed about potential complications and commit to frequent recall visits. “Jaw necrosis is a crisis,” summarized Prof. Grötz. “But every crisis is also a chance. Addressing these topics is a huge opportunity to integrate dental, oral, and maxillofacial medicine more deeply into overall healthcare. Our goal is to strengthen interdisciplinary understanding, discuss new findings, and raise awareness of critical connections.”
Key takeaways
- Vitamin D's role in oral and systemic health: The workshop explored how vitamin D deficiency affects bone metabolism, immune function, and implant success, emphasizing the clinical relevance of screening and supplementation in dental care.
- Implications of antiresorptive therapies in dentistry: The session examined how medications like bisphosphonates and Denosumab, commonly used to treat osteoporosis and cancer-related bone conditions, can increase the risk of osteonecrosis of the jaw and complicate dental procedures.
- Prevention, diagnostics, and interdisciplinary collaboration: Emphasis was placed on early detection, patient education, chairside vitamin D testing, and proactive treatment planning to reduce complications and improve outcomes in implantology and periodontology.