SAPHO Medicines: Pause Before Dental Work or Surgery?

There is no universal rule for whether you should pause your SAPHO syndrome medications before dental work or surgery. The decision requires a personalized, drug-specific plan. Automatically stopping all medications is not recommended and can cause severe disease flares ^[1]. You will need your rheumatologist, surgeon, dentist, and anesthesiologist to coordinate a written plan before any procedure.

If you have an urgent surgical emergency or an active dental infection, do not delay care to wait for a medication “washout” period. Instead, give the treating team your complete medication list, including the exact time of your last dose, so they can manage any risks immediately.

The Balancing Act: Infection vs. Flare

When planning for a procedure, your care team weighs two main risks:

1. Infection and Healing: Some medications suppress the immune system, increasing the risk of post-surgical infections or delayed wound healing.
2. Disease Flare: SAPHO syndrome naturally has a relapsing-remitting course. Holding treatments for too long increases your risk of a severe flare of skin issues or bone inflammation (osteitis) ^[1]. Because no single treatment universally controls all SAPHO manifestations, keeping your disease stable is a priority ^[2].

DMARDs and Biologics: A Drug-Specific Approach

Not all immune-modulating drugs are handled the same way.

• Conventional DMARDs (disease-modifying antirheumatic drugs, like methotrexate or sulfasalazine) can often be continued through many surgeries without being stopped ^[3].
• Biologics and Targeted Drugs (such as TNF inhibitors) are more likely to be paused. For major elective surgeries like joint replacement, guidelines recommend scheduling the surgery at the very end of your “dosing cycle” (when the drug level in your body is lowest) ^[4][3].

However, guidelines for joint replacements do not universally apply to all other surgeries or routine dental fillings ^[5]. Your rheumatologist must evaluate the exact procedure to decide whether to continue or hold your dose.

Restarting: If a drug is paused, it should not be restarted on a rigid timetable. Doctors typically wait to restart these medications until they can confirm your wound is healing properly and there are no signs of active infection (such as fever, worsening redness, or drainage) ^[6].

Bisphosphonates, Dental Work, and Jaw Health

Many people with SAPHO syndrome take bisphosphonates to treat bone pain and inflammation ^[7]. A major concern with these drugs during dental procedures—especially extractions or implants—is MRONJ (medication-related osteonecrosis of the jaw), a rare condition where the jawbone fails to heal properly ^[8].

If you need dental work while taking bisphosphonates, keep these facts in mind:

• Risk varies: Your risk for MRONJ depends heavily on the specific drug, whether it is given by IV or pill, your dose, and how long you have taken it.
• Do not delay necessary care: While unnecessary extractions should be avoided, you should not leave an active dental infection or a non-restorable tooth untreated. Discuss tooth-preserving options with your dentist, but proceed with necessary treatments ^[9][10].
• “Drug holidays” are not proven: Evidence does not show that routinely stopping bisphosphonates shortly before dental work prevents MRONJ ^[11].
• Blood tests are not universal clearance: A serum CTX test (which measures bone turnover) is not a reliable predictor of MRONJ risk and should not be used as a strict clearance test for surgery ^[12].

NSAIDs, Blood Thinners, and Corticosteroids

• NSAIDs: Nonsteroidal anti-inflammatory drugs (NSAIDs) are a primary SAPHO treatment. Bleeding risk varies depending on the specific NSAID and procedure ^[13]. Your doctor may pause them if you have chronic kidney disease (where NSAIDs can trigger acute kidney injury) or if you have severe heart disease ^[14][15].
• Blood Thinners and Aspirin: Do not confuse standard NSAIDs with prescribed low-dose aspirin or prescription blood thinners (anticoagulants). Taking NSAIDs alongside blood thinners heavily increases your bleeding risk ^[16][17]. Never stop prescribed aspirin or blood thinners without direct instructions from the prescribing doctor.
• Corticosteroids: If you take daily steroids (like prednisone), never stop them abruptly before surgery. Stopping suddenly can cause a life-threatening condition called adrenal crisis ^[18]. Most patients continue their usual daily dose through surgery, but the anesthesia team must know your exact dose to plan safely ^[19].

Building Your Perioperative Plan

Make sure every member of your care team has your current medication list and a brief summary of your SAPHO history.

• Identify the procedure: Is it a routine filling, an extraction, or major surgery?
• Get it in writing: Ensure you have a written plan that explicitly states which drugs to stop, when to stop them, and the clinical criteria for restarting them.
• Know the warning signs: Ask your surgeon what symptoms (such as fever, spreading facial swelling, a nonhealing extraction site, or wound drainage) require immediate medical attention.