Sir, in a recent BDJ article1 the authors' argument for improving awareness of the risks of anti-resorptive medication is compelling: the population is ageing and the number of patients living with and beyond cancer is increasing. Thus the number of patients at risk of medication-related osteonecrosis of the jaw (MRONJ) will also increase. The argument is timely too, as recent developments will have a significant impact on the population at risk of MRONJ. In the light of a number of high-quality clinical trials of the use of anti-resorptive medications in breast cancer the National Institute for Health and Care Excellence (NICE) have recently revised guidance on the use of bisphosphonates in early and locally advanced breast cancer.2 More recently a European Panel of experts issued a consensus recommendation on the use of bisphosphonates in women with early disease.3 Previously the use of the high potency bisphosphonates clodronate and zoledronate was reserved for patients with established bone metastases – for management of pain and prevention of pathological fracture. The 2016 statement included recommendations that the use of these highly effective anti-resorptive medications be used in both pre- and post-menopausal women and, crucially, for the prevention of cancer treatment induced bone loss (CBITL) as well as prevention of bone metastases. It is particularly noteworthy that the recommendations mean a significant number of patients will receive anti-resorptive medication concomitantly with systemic chemotherapy.

This sea change of indications for anti-resorptives will produce a large number of young patients who are at relatively high risk of developing MRONJ. Dr Tanna and co-authors correctly assert that education of primary care practitioners is important for effective management of patients who have taken anti-resorptive medications. We would like to suggest that communication and coordination between specialist oncology services, patients and primary care dentists is also of paramount importance in order to minimise adverse effects on this group of patients.