Bis-Phosphonates &
Osteo-Necrosis of the Jaw
('Dead Jaw Syndrome')
Bis-Phosphonate medications are widely used in the
treatment of bone diseases including
osteoporosis and
Paget’s disease and in some cancers.  They are used in
low oral doses to treat
osteoporosis and to prevent

They are used in high
IV (intravenous) doses in cancer to
prevent complications when it spreads to bone.  They have
been used for over 10 years.

Bis-Phosphonates reduce the risk of fractures (broken
bones) by about 50%.  As up to 30% of patients can die in
the first 12 months after a hip fracture,
are likely to reduce the numbers of deaths associated with
this and other fractures due to

These benefits outweigh the risk of side effects of
, which are minimal.  Osteo-Necrosis of the
(ONJ) is a very rare side-effect of bis-phosphonates.

However, you should be aware of this rare but potentially
serious association of
bis-phosphonate treatment and take
appropriate measures to help prevent it.

What is Osteo-Necrosis of the Jaw ('Dead Jaw

Osteo-Necrosis means death of bone.  Osteo-Necrosis of
the Jaw
(ONJ) is defined as an area of exposed bone (not
covered by gum) in the jaw region that does not heal within
8 weeks of identification.  The exact cause of
currently unknown.

What is the risk of developing this complication?

The risk of developing Bis-phosphonate-Related ONJ
ranges between 1/10,000 to 1/100,000 for patients taking
bis-phosphonate for treatment of osteoporosis or
Paget’s disease.  The risk is much higher, ranging between
1% and 10%, for patients with cancers on high IV doses.

What are the risk factors for Bis-phosphonate-Related

  • Use of high-dose IV bis-phosphonate
  • Longer duration of treatment with bis-phosphonate
  • Steroid use (Prednisolone, Dexamethasone etc.)
  • Alcohol abuse and tobacco use
  • People suffering from cancer
  • Poor dental hygiene and those who undergo a dental
    procedure such as dental extraction
  • Diabetes mellitus

What are the symptoms of BRONJ?

  • Severe jaw pain
  • Numbness of the jaw
  • Swelling and infection of the jaw region
  • Loosening of teeth and exposed bone

These symptoms may occur spontaneously or more often,
following tooth extraction.
Extensive stage III BRONJ of the mandible in a patient treated with intravenous
What should I do to minimize the risk of BRONJ?

Inform your dentist that you are taking bis-phosphonates especially if you plan to
have a dental procedure
  • Maintain good oral hygiene, attend regular dental visits and report any oral
    problems to your dentist.
  • If you are planning to take bis-phosphonates for cancer, you should have a
    dental evaluation prior to starting the medication and then every 6 to 12
    months or as directed by your dentist.
  • Discuss possible side-effects with your GP

Can BRONJ be treated?

There is no cure for BRONJ to date.

bis-phosphonates may not alter the progression of the disease.  You
should therefore discuss with your doctor whether or not it is appropriate for you to

What are the common bis-phosphonates used in treatment of osteoporosis &

Alendronate (Fosamax, Fosamax plus, Alendro) and Risedronate (Actonel, Actonel
) are most often used for osteoporosis treatment in oral form.  Pamidronate
Aredia, Pamisol) and Zolendronic Acid (Zometa) are given by IV dose in cancer.

Intravenous or IV means that a medication is injected directly into the vein

Important Points

The main risk group for BRONJ are patients on IV doses who have CANCER —
NOT patients on oral doses for osteoporosis.

The overall benefits of oral
bis-phosphonates in preventing complications (including
death) from minimal trauma fractures due to
osteoporosis generally far outweigh
the risk of developing
Exposed necrotic bone in the anterior left maxilla related to use of
Stage I Bisphosphonate-Related Osteo-Necrosis of the Jaw (BRONJ)
of the right
mylohyoid ridge area
Last Updated 25th October 2017
BRONJ has been classified as follows:
Update, December 2012
Oral Health Management of Patients Prescribed Bisphosphonates - Summary
(Scottish Dental Clinical Effectiveness Programme 2011.  Advice for
Patients Prescribed Bisphosphonates)
Useful Websites:

Bandolier - Evidence-Based Healthcare

Journal of the American Dental Association

American Dental Association

Journal of the Royal College of Surgeons of Edinburgh and Ireland

Dentistry Today.com

Useful Articles:

J Am Dent Assoc 2005.  Managing the Care of Patients with Bisphosphonate-
Associated Osteonecrosis - An American Academy of Oral Medicine Position Paper

Dental Update 2006 - BONJ - A Guide for the GDP

Journal of American Dental Association 2006 - American Dental Association Report
- Dental Management of Patients receiving oral bisphosphonate therapy

British Dental Journal 2007 - Bisphosphonate osteonecrosis of the jaws; an
increasing problem for the dental practitioner

Dental Update 2008 - Recent Recommendations on BONJ

Journal of Rheumatology 2008 - Guidelines for bisphosphonate-associated
osteonecrosis of the jaw

American Academy of Oral Medicine 2008. Patient Information Sheet.  
Bisphosphonate Therapy & the Oral Cavity

British Dental Journal 2009 - Dental extractions and bisphosphonates - the
assessment, consent and management, a proposed algorithm

J Oral Maxillofac Surg 2009.  Bisphosphonates - What the Dentist Needs to Know.  
Practical Considerations.

J Oral Maxillofac Surg 2009.  American Association of Oral & Maxillofacial
Surgeons Position Paper on BONJ.  Update.

British Medical Journal 2009 - Battle over Fosamax bursts into court

British Medical Journal 2010 - Osteonecrosis of the Jaw and Bisphosphonates -
Low Doses for Osteoporosis seem to be safe

Oral Surgery 2010. Reviewing the efficacy of changing prophylactic measures for
the prevention of Bisphosphonate Related Osteonecrosis of the Jaws (BRONJ) in
the management of oral surgery patients

J Oral Maxillofac Surg 2010.  Occurrence of Bisphosphonate-Related
Osteonecrosis of the Jaw After Surgical Tooth Extraction

JOMS 2010.  Dental extractions in patients receiving Bisphosphonate therapy

J Oral Maxillofac Surg 2011.  Nationwide Survey for Bisphosphonate-Related
Osteonecrosis of the Jaws in Japan

BJOMS 2011. Leading Article.  Bisphosphonate Osteonecrosis of the Jaw - A
Literature Review of UK Policies versus International Policies on the Management
of Bisphosphonate Osteonecrosis of the Jaw

Dental Update 2011.  A Current Update on Osteonecrosis of the Jaw &

BJOMS 2011.  Leading Article.  Bisphosphonate Osteonecrosis of the Jaw — A
Literature Review of UK policies vs. International Policies on Bisphosphonates,
Risk Factors & Prevention

BJOMS 2011.  Treatment of BONJ - Presentation of a Protocol & an
Observational Longitudinal Study of an Italian Series of Cases

BJOMS 2011.  Short communication.  Non-surgical management of stage 3
biphosphonate-related oro-antral fistula

Dental Update 2011.  Practical Considerations for Treatment of Patients taking
Bisphosphonate Medications - An Update

JADA 2011.  For The Dental Patient...Osteoporosis Medications & your Dental

Scottish Dental Clinical Effectiveness Programme.  Oral Health Management of
Patients Prescribed Bisphosphonates Dental Clinical Guidance

Scottish Dental Clinical Effectiveness Programme 2011.  Advice for Patients
Prescribed Bisphosphonates

The Surgeon, J RCS Edinburgh & Ireland 2012. Review. Bisphosphonate
Osteonecrosis of the Jaw.  A Historical & Contemporary Review

BDJ 2012.  Letter to Editor.  Bisphosphonate Considerations

BDJ 2012.  Bisphosphonate-Related Osteonecrosis of the Jaw is Rare

FGDP (UK).  December 2012.  National study on Avascular Necrosis of the Jaws
including Bisphosphonate-Related Necrosis

JOMS 2013.  Tooth Extractions in Intravenous Bisphosphonate-Treated Patients -
A Refined Protocol

JOMS 2013.  Osteonecrosis of the Jaw Onset Times are based on the Route of
Bisphosphonate Therapy

Dent Update 2013. The Characteristics of Bisphosphonate Patients Developing
BRONJ Attending an OMFS Department

Dent Update 2013. The Risk of BRONJ in Children. A Case Report & Literature

BDJ 2014.  Legal liability in bisphosphonate-related osteonecrosis of the jaw

Dent Update 2015. Case Report. Beware the Silver Nitrate Stick. A Risk Factor for

NHS England 2015.  Dental Management of Patients Prescribed Bisphosphonates -
Clinical Guidance.

Dent Update 2016.  Relevance of Bisphosphonate Therapy in Osteoporosis &
Cancer − No Cause for Alarm

Scottish Dental Clinical Effectiveness Programme (SDCEP) 2017.  Oral Health
Management of Patients at Risk of Medication-related Osteonecrosis of the Jaw -
Dental Clinical Guidance
Dental Advice for Patients Prescribed a Bisphosphonate Drug (Scottish Dental
Clinical Effectiveness Programme 2011.  Advice for Patients Prescribed
Managing a Dental Patient Taking Anti-Resorptive or Anti-Angigenic Drugs
Anti-angiogenic Drugs Dental Clinical Guidance (Draft) - 2016)Anti-angiogenic
Drugs Dental Clinical Guidance (Draft) - 2016)