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-associated 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-associated

  • 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 BONJ?

  • 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 BONJ of the mandible in a patient treated with
intravenous bisphosphonate therapy
What should I do to minimize the risk of BONJ?

  • 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 BONJ be treated?

There is no cure for BONJ 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 cease

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

Alendronate (Fosamax, Fosamax plus, Alendro) and Risedronate
Actonel, Actonel Combi) 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 BONJ 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
osteoporosis generally far outweigh the risk of developing BONJ.

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

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
Exposed necrotic bone in the anterior left maxilla related to use of
Stage I Bisphosphonate-related Osteo-Necrosis of the Jaw (BONJ)
of the right
mylohyoid ridge area
Last Updated 30th November 2010