|Medications & 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 Syndrome')?
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 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
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 ONJ?
- 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 BONJ of the mandible in a patient treated with
intravenous bisphosphonate therapy
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 cease bis-phosphonates.
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
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 Bisphosphonates
|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:
|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 Bisphosphonates)