Why worry about bisphosphonate-related osteonecrosis of the jaw? A guide to diagnosis, initial management, and referral of patients

Bisphosphonate-related osteonecrosis of the jaw (BRONJ) is a chronic condition of the oral cavity resulting in mucosal ulceration and exposure of underlying necrotic bone, and the ensuing secondary complications. As a relatively newly recognised condition, the epidemiology of BRONJ is poorly described. In a 2012 position statement by the UK Faculty of General Dental Practice, an estimated incidence of 10 patients per year per million population was stated.1 This would indeed classify it as a rare condition, with a GP expecting to see only a handful of cases in their career. However, with increased numbers of patients on bisphosphonate (BP) therapy, all GPs should be aware of the risk factors for BRONJ and the pre-assessment advice they give to patients commencing BP therapy. BPs inhibit the action of osteoclast cells, decreasing bone turnover and increasing bone density.2 The mechanism by which BPs cause osteonecrosis is not proven but is probably due to a combination of decreased bone remodelling, poor wound healing, and an antiangiogenic effect leading to ischaemic changes and subsequent necrosis in response to a local traumatic insult.2 The main indications for the use of BPs are for the treatment of post-menopausal osteoporosis, steroid-induced osteoporosis, Paget’s disease, and the complications of metastatic bone lesions and multiple myeloma, namely, hypercalcaemia and bony pain. It is outside the scope of this article to discuss BP …