Sir, I read with interest the conclusion of the two-year study (BDJ 2012; 213: 594) that the incidence of bisphosphonate-related osteonecrosis (BRONJ) is rare.

During the period covered by the study I saw, in my single-handed general practice, two patients who fulfilled the criteria for a diagnosis of BRONJ.

The first patient was a 63-year-old female with a history of breast cancer and bony metastases. She was receiving intravenous bisphosphonate therapy, Zoledronic acid, 4 mg monthly, together with a cocktail of other medication. Following extraction of a mandibular molar under intravenous antibiotics she developed a bony sequestrum but following a further procedure to remove necrotic bone made a good recovery.

The second patient was a 68-year-old female with a long history of rheumatoid arthritis. Following extraction of a mandibular molar the extraction site failed to heal. Although she had revealed she was taking prednisolone and methotrexate she omitted to reveal she was also on Alendronic acid 5 mg weekly. It was only following referral to hospital that further investigation revealed oral bisphosphonate therapy. Following removal of necrotic bone and curettage the patient made a good recovery and further extractions have been carried out with intravenous antibiotic cover that have proved uneventful. The Alendronic acid has now been discontinued.

These two cases highlight the need in general practice to identify those patients at risk from BRONJ. One, correctly identified, received appropriate hospital treatment. The other, however, failed to reveal the extent of her medication, perhaps not understanding the relevance. With the widespread prescription of bisphosphonates patients need to be fully informed by their medical practitioners of the possible risk of BRONJ. In addition, we as dentists must ensure that patients understand the need to reveal all their medication when asked.

1. London