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, bis-phosphonates
are likely to reduce the numbers of deaths associated with
this and other fractures due to osteoporosis.
These benefits outweigh the risk of side effects of bis-
phosphonates, which are minimal. Osteo-Necrosis of the
jaw (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 BRONJ is
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
oral 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.
Stopping 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
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.
Note: Intravenous or IV means that a medication is injected directly into the vein
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 BRONJ.
|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 March 2017
BRONJ has been classified as follows:
|Oral Health Management of Patients Prescribed Bisphosphonates - Summary
Guidance (Scottish Dental Clinical Effectiveness Programme 2011. Advice for
Patients Prescribed Bisphosphonates)
|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
(SDCEP Oral Health Management of Patients Prescribed Anti-resorptive or
Anti-angiogenic Drugs Dental Clinical Guidance (Draft) - 2016)