Intended for healthcare professionals

Practice Practice Pointer

Preventing medication-related osteonecrosis of the jaw

BMJ 2019; 365 doi: (Published 08 May 2019) Cite this as: BMJ 2019;365:l1733
  1. Lara Zebic, dental core trainee (oral surgery)1,
  2. Vinod Patel, consultant (oral surgery)2
  1. 1Oral Surgery Department, Birmingham Dental Hospital, Birmingham B5 7EG, UK
  2. 2Oral Surgery Department, Guy’s Dental Hospital, London SE1 9RT, UK
  1. Correspondence to: L Zebic Lara.zebic3{at}

What you need to know

  • Osteonecrosis of the jaw is a rare but serious adverse effect associated with anti-resorptive and anti-angiogenic therapies used in cancers and osteoporosis

  • Patients with cancer receiving intravenous infusion of these therapies or using a combination of therapies are at a higher risk

  • Fewer than 1 in 1000 individuals taking oral bisphosphonates for osteoporosis will develop osteonecrosis of jaw

  • Inform patients of the risks before starting treatment and offer referral to dental services for screening and remedial treatment

  • Ask patients who are receiving treatment to report jaw pain or awareness of exposed bone and promptly refer suspected cases to dental or oral maxillofacial services in secondary care

Osteonecrosis of the jaw is a severe adverse effect reported with certain drugs commonly used in the treatment of cancers and osteoporosis. Although rare, it can severely impair quality of life.1 The number and type of drugs associated with osteonecrosis of the jaw continue to increase, as do their indications. With greater life expectancy and more people living with cancer as a chronic disease, the pool of those “at risk” is increasing.

Management can be costly, invasive, and difficult.2 Clinicians can play a pivotal role in prevention of medication-related osteonecrosis of the jaw by informing patients of the risks when they prescribe these drugs and discussing ways to minimise the risk. In this article we describe the risks associated with different therapies and provide guidance on prevention for non-specialists.

Data sources and selection

We have drawn on the recommendations from the American Association of Oral and Maxillofacial Surgeons and the Scottish Dental Clinical Effectiveness Programme, with relevant citations identified from their content. We supplemented this with literature from our personal archive of references which includes randomised controlled trials, prospective and retrospective studies as well as case reports. In discussing the risk of medication-related osteonecrosis of the …

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