Sir, I wish to endorse wholeheartedly the views of Varley, Kanatas and Carter (An impossible position; BDJ 2012; 212: 153–154) in their wish to improve access of appropriate care for those patients on bisphosphonates. I would like to add to this 'impossible position' from my perspective for those patients who are on or about to commence high dose intravenous/oral bisphosphonates as part of their oncology care for their multiple myeloma or for their metastatic bony lesions from breast, prostate or renal carcinoma.

Where I work as a consultant in special care dentistry (SCD), the SCD and oncology teams have worked very hard and closely to be proactive in the care of this cohort of patients. We now have a streamlined/fast-tracked referral system which endeavours to see these patients as an absolute priority before commencing their bisphosphonate treatment, as they are at an even higher risk of developing bisphosphonate related osteonecrosis of the jaws (BRONJ) following exodontias, or, spontaneously.

Although they are being referred from an oncology consultant to a SCD consultant, and 50% of the time are seen in a hospital location, there is a catch. I am employed as a consultant in primary care and as such these patients are subject to the normal NHS patient charges as they would be on the high street (other than normal exemption). For many of these patients these charges come at a time when they are not receiving their usual salary, when they are already having to come to terms with their diagnosis, difficult treatment and prognosis, on top of the extra finance of multiple hospital visits, car parking charges and ever increasing cost of fuel, often in our area up to a hundred miles for a round trip to access a regional centre care.

To make additional decisions around the possible loss of a number of teeth, or in some cases a posterior dental clearance, to reduce the risk of BRONJ and cope with the treatment can be one decision too many with which to cope. A significant amount of time is usually required to give appropriate holistic and pastoral support for their decision making. Then to add to this that they need to pay for the 'privilege' of receiving this care, I think is of concern. I am not suggesting that dental treatment should be free for life as the constraints on funding for NHS care are of course significant for the foreseeable future. However, free dental care for their time of most need would seem appropriate in my eyes.

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