Bisphosphonate-associated osteonecrosis of the jaw

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Bisphosphonate-associated osteonecrosis of the jaw
Classification and external resources
MeSH D059266

Bisphosphonate-associated osteonecrosis of the jaw (often abbreviated as BON, BONJ, or BON of the jaw), also called bisphosphonate-related osteonecrosis of the jaw (BRONJ) (pronounced /brɒndʒ/) or bisphosphonate-induced osteonecrosis of the jaw (BIONJ), is osteonecrosis of the jaw in a person with a history of bisphosphonate use who undergoes subsequent dental surgery. It may lead to surgical complication in the form of impaired wound healing following oral and maxillofacial surgery, periodontal surgery, or endodontic therapy.[1]

A correlation between history of bisphosphonate use and osteonecrosis of the jaw after later surgery was detected in the oral medicine fields for several years before the exact nature of the relationship (etiology, pathogenesis) could begin to be understood, and it is still not entirely clear, although it has been nicknamed "bis-phossy jaw"[2] based on its similarity with phossy jaw. There is no known prevention for bisphosphonate-associated osteonecrosis of the jaw.[3] Avoiding the use of bisphosphonates is not a viable prevention on a general-population basis because the drugs have more benefit throughout the population (preventing osteoporotic fractures and treating bone cancers) than harm (BRONJ).


Osteonecrosis, or localized death of bone tissue, of the jaws is a rare potential complication in cancer patients receiving treatments including radiation, chemotherapy, or in patients with tumors or infectious embolic events. In 2003,[4][5] reports surfaced of the increased risk of osteonecrosis in patients receiving these therapies concomitant with intravenous bisphosphonate.[6] Matrix metalloproteinase 2 may be a candidate gene for bisphosphonate-associated osteonecrosis of the jaws, since it is the only gene known to be associated with both bone abnormalities and atrial fibrillation, another side effect of bisphosphonates.[7]

In response to the growing base of literature on this association, the United States Food and Drug Administration issued a broad drug class warning of this complication for all bisphosphonates in 2005.[8]

Signs and symptoms[edit]


Although the methods of action are not yet completely understood, it is hypothesized that bisphosphonate-associated osteonecrosis of the jaw is related to a defect in jaw bone physiologic remodeling or wound healing. The strong inhibition of osteoclast function precipitated by bisphosphonate therapy can lead to inhibition of normal bone turnover. Because bisphosphonates are preferentially deposited in bone with high turnover rates, it is possible that the levels of bisphosphonate within the jaw are selectively elevated. To date, there has been no reported cases of bisphosphonate-associated complications within bones outside the craniofacial skeleton.[8]


A diagnosis of bisphosphonate-associated osteonecrosis of the jaw relies on three criteria:[3]

  1. the patient possesses an area of exposed bone in the jaw persisting for more than 8 weeks,
  2. the patient must present with no history of radiation therapy to the head and neck,
  3. the patient must be taking or have taken bisphosphonate medication.

According to the updated 2009 BRONJ Position Paper published by the American Association of Oral and Maxillofacial Surgeons, both the potency of and the length of exposure to bisphosphonates are linked to the risk of developing bisphosphonate-associated osteonecrosis of the jaw.[10]

Bisphosphonates: intravenous vs. oral[edit]

Cases of BRONJ have also been associated with the use of the following two intravenous and three oral bisphosphonates, respectively: Zometa (zoledronic acid) and Aredia (pamidronate) & Fosamax (alendronate), Actonel (risedronate) and Boniva (ibandronate).[11]


The overwhelming majority of BRONJ diagnoses, however, were associated with intravenous administration of bisphosphonates (94%). Only the remaining 6% of cases arose in patients taking bisphosphonates orally.[3]

Although the total United States prescriptions for oral bisphosphonates exceeded 30 million in 2006, less than 10% of BON cases were associated with patients taking oral bisphosphonate drugs.[12] Studies have estimated that BRONJ occurs in roughly 20% of patients taking intravenous zoledronic acid for cancer therapy and in between 0-0.04% of patients taking orally administered bisphosphonates.[13]

Owing to prolonged embedding of bisphosphonate drugs in the bone tissues, the risk for BRONJ is high even after stopping the administration of the medication for several years.[14]

Treatment and outcomes[edit]

Treatment usually involves antimicrobial mouth washes and oral antibiotics to help the immune system fight the attendant infection, and it also often involves local resection of the necrotic bone lesion. Many patients with BRONJ have successful outcomes after treatment, meaning that the local osteonecrosis is stopped, the infection is cleared, and the mucosa heals and once again covers the bone.

See also[edit]

External links[edit]


  1. ^ Nase JB, Suzuki JB (August 2006). "Osteonecrosis of the jaw and oral bisphosphonate treatment". J Am Dent Assoc 137 (8): 1115–9; quiz 1169–70. doi:10.14219/jada.archive.2006.0350. PMID 16873327. 
  2. ^ Mario Abu-Id et al. "'Bis-phossy jaws' – High and low risk factors for bisphosphonate-induced osteonecrosis of the jaw". Department of Oral and Maxillofacial Surgery and Plastic Surgery, Asklepios Klinik Nord, Hamburg, Germany. Journal of Cranio-Maxillofacial Surgery. 04/2008; 36(2):95-103. DOI: 10.1016/j.jcms.2007.06.008
  3. ^ a b c Osteoporosis medications and your dental health pamphlet #W418, American Dental Association/National Osteoporosis Foundation, 2008
  4. ^ Marx RE (September 2003). "Pamidronate (Aredia) and zoledronate (Zometa) induced avascular necrosis of the jaws: a growing epidemic". J. Oral Maxillofac. Surg. 61 (9): 1115–7. doi:10.1016/S0278-2391(03)00720-1. PMID 12966493. 
  5. ^ Migliorati CA (November 2003). "Bisphosphanates and oral cavity avascular bone necrosis". J. Clin. Oncol. 21 (22): 4253–4. doi:10.1200/JCO.2003.99.132. PMID 14615459. 
  6. ^ Appendix 11: Expert Panel Recommendation for the Prevention, Diagnosis and Treatment of Osteonecrosis of the Jaw
  7. ^ Lehrer S, Montazem A, Ramanathan L; et al. (January 2009). "Bisphosphonate-induced osteonecrosis of the jaws, bone markers, and a hypothesized candidate gene". J. Oral Maxillofac. Surg. 67 (1): 159–61. doi:10.1016/j.joms.2008.09.015. PMID 19070762. 
  8. ^ a b Ruggiero SL (March 2008). "Bisphosphonate-related Osteonecrosis of the Jaws". Compendium of Continuing Education in Dentistry 29 (2): 97–105. 
  9. ^ Zadik Y, Benoliel R, Fleissig Y, Casap N. (February 2012). "Painful trigeminal neuropathy induced by oral bisphosphonate-related osteonecrosis of the jaw: a new etiology for the numb-chin syndrome". Quintessence Int. 43 (2): 97–104. PMID 22257870. 
  10. ^ Medical News Today AAOMS Updates BRONJ Position Paper, January 23, 2009
  11. ^ American Dental Association Osteonecrosis of the Jaw
  12. ^ Grbic JT, Landesberg R, Lin SQ; et al. (January 2008). "Incidence of osteonecrosis of the jaw in women with postmenopausal osteoporosis in the health outcomes and reduced incidence with zoledronic acid once yearly pivotal fracture trial". J Am Dent Assoc 139 (1): 32–40. doi:10.14219/jada.archive.2008.0017. PMID 18167382. 
  13. ^ Cartsos VM, Zhu S, Zavras AI (January 2008). "Bisphosphonate use and the risk of adverse jaw outcomes: a medical claims study of 714,217 people". J Am Dent Assoc 139 (1): 23–30. doi:10.14219/jada.archive.2008.0016. PMID 18167381. 
  14. ^ Zadik Y, Abu-Tair J, Yarom N, Zaharia B, Elad S. (September 2012). "The importance of a thorough medical and pharmacological history before dental implant placement.". Aust Dent J 57 (3): 388–392. doi:10.1111/j.1834-7819.2012.01717.x. PMID 22924366.