Bis-Phosphonates & Osteo-Necrosis of the Jaw
('Dead Jaw Syndrome')

Update, December 2012

British Dental Journal 213, 594 (2012)

Published online: 21 December 2012

The findings of a 2-year national, new patient registration of patients with
avascular necrosis of the jaws including Bisphosphonate-Related Necrosis
BRONJ) referred to Oral Surgery, Oral Medicine, Oral & Maxillofacial
Departments & Dental Hospitals in England, Wales, Scotland and Northern Ireland
have been published.

Bis-phosphonate-Related Osteonecrosis of the Jaw (BRONJ) is rare.

A 2 year national study based on patient case records has concluded that
incidence of Bisphosphonate-Related Osteonecrosis of the Jaw (BRONJ) can
be considered as rare

This study, a collaboration between the
Faculty of General Dental Practice (UK)
(FGDP [UK]) and the
British Association of Oral & Maxillofacial Surgeons
BAOMS), was designed to capture all new referrals of patients with avascular
necrosis of the jaw
, including BRONJ, to Oral & Maxillofacial departments &
dental hospitals in England, Wales, Scotland and Northern Ireland, from June 2009
to May 2011.

One of the 2 clinical leads for the study was Professor Simon Rogers for
who commented: “
Although the data need to be interpreted with caution, the report
would suggest that there are around 600 cases of
BRONJ each year in the UK,
and around 400 of these are related to oral bis-phosphonates.  Considering how
commonly bis-phosphonates are prescribed for conditions such as osteoporosis,
these results should serve to reassure the public given the relative small number
of cases of
BRONJ each year.  Further data and research is required”.

The 2 year study is the first of its kind.  It allows patients & healthcare
professionals to get a better understanding of the likely rates of
BRONJ.  From the
study, it was estimated that in the UK (England, Wales, Scotland and Northern
Ireland), there were approximately 620 (508 - 793) cases / year.  Although caution
needs to be applied to the interpretation of rates in post-menopausal women with
osteoporosis treated with an oral bisphosphonate, the rate was estimated at
between 1 in 1,260 to 1 in 4,420 per year.  Thus,
BRONJ can be considered as a
rare or very rare condition depending on the patient group studied.


  • Accepting that there has been a degree of under-reporting of new cases
    nationally, the best estimate of incidence is that BRONJ occurs in 10 patients
    per year per million population.  For women, the estimated rate is 14 per
    million per year and for men, 6 per million per year.  In women aged 70 - 79
    years, the rate is in excess of 50 patients per million per year.  As the elderly
    population and associated bis-phosphonate prescribing increases, it is
    expected that the number of BRONJ cases presenting each year will increase
    over time assuming that other risk factors remain constant.  These estimates
    of incidence if applied to the current UK population of 62 million people, would
    indicate a total of 620 (508 - 793) BRONJ cases a year.

  • It was estimated that the incidence of BRONJ in a population of post-
    menopausal woman with osteoporosis and treated with an oral
    bisphosphonate developing BRONJ as being somewhere between 1 in 1,262
    & 1 in 4,419 per year.  Interpretation needs to be very cautious given the
    number of assumptions involved but if the logic is appropriate then this risk can
    therefore be regarded at worst as ‘rare’ (occurring ≥ 1/10,000 to < 1/1,000).  
    The risk of developing BRONJ has to be balanced against the risk and
    subsequent outcome following fracture neck of femur and vertebral fractures.  
    The incidence of BRONJ for patients receiving bis-phosphonates for cancer is
    likely to be higher but too few data are available to make an estimate.

  • Two-thirds of cases (69%) were female and the overall mean age was 69
    years.  In 56% of cases, the route of administration was oral (34%), IV (7%)
    both oral and IV and unknown for 2%.  This high percentage of cases with oral
    administration probably reflects the predominance community prescribing of
    oral bis-phosphonates.

  • In patients who had received oral treatment, the majority (71%) had taken
    alendronic acid.  In patients, who had received IV treatment, the majority
    (61%) were given zoledronic acid.

  • In 73% of patients, the precipitating event was a dental extraction.  Pain
    (74%), discharge (46%) & swelling (43%) were the main symptoms stated.  In
    8% of cases, the presentation was said to be asymptomatic.

  • The site of BRONJ was more often the mandible (lower jaw) than the maxilla
    (upper jaw) in a ratio of 2:1.  Sites were predominantly in the molar region and
    evenly spread between right & left.

  • The number of BRONJ cases will increase in the years to come.

The full report can be viewed at
Faculty of General Dental Practice (UK).
Last Updated 23rd January 2013