MRONJ risk of adjuvant bisphosphonates in early stage breast cancer

Key Points

  • Highlights that bisphosphonates continue to be the most common drug implicated in medication-related osteonecrosis of the jaw.

  • Shows that an additional use of bisphosphonates has been indicated and now a further 20,000 women may be prescribed the medication and be exposed to the risk of jaw necrosis.

  • Suggests the burden of additional dental assessment for these patients will fall upon GDPs.

  • Introduces a new communication idea of the dental alert card which provides a warning to dentists for 'at risk' patients.


Medication-related osteonecrosis of the jaw (MRONJ) has most commonly been associated with bisphosphonates. The routine uses of these drugs are now well established predominantly in metastatic cancer with bone involvement, multiple myeloma, hypercalcaemia, osteoporosis and Paget's disease. Recently, however, the use of bisphosphonates in early breast cancer has shown a reduction in breast cancer recurrence and breast cancer deaths. This new indication for their use approximates to a further 20,000 women per year in the UK being prescribed bisphosphonates. In this article, we consider the dental impact of this new use of bisphosphonates, report on the rates of MRONJ seen in early breast cancer bisphosphonate trials and discuss strategies aimed at minimising the risk of bisphosphonate-exposed patients developing MRONJ.

Key Points


Giving bisphosphonates (BPs) to postmenopausal women with intermediate to high risk early breast cancer is beneficial in reducing breast cancer recurrence and mortality

In the UK, approximately 20,000 women a year may benefit from adjuvant BPs as part of their early breast cancer treatment

Oral clodronate and i.v. zoledronic acid appear to be equally effective in reducing breast cancer recurrence and mortality in the adjuvant setting

In early breast cancer studies, oral clodronate was associated with a lower risk of MRONJ IV than zoledronic acid

In the adjuvant setting, the risk of MRONJ from BPs is small relative to the larger risk of breast cancer recurrence and mortality

All patients offered adjuvant BPs (oral or IV) should be informed of the associated risk of MRONJ

Patients treated with adjuvant BP should undergo the same pre-BP dental assessment and MRONJ preventative measures (eg regular dental checks, avoiding extractions) as patients treated with BPs in other settings

The risk of MRONJ may continue long after completion of adjuvant BP treatment due to the long half-life of BPs in bone (estimated >ten years) and so dental precautions should be continued (especially after zoledronic acid)

As MRONJ risk increases with duration of BP exposure, adjuvant treatment should be stopped once the period of known benefit is complete (3–5 years)

Dental health professionals should be aware of this new use of BPs when obtaining patient drug histories

A patient-held Dental Alert Card may help dental health professionals identify patients at risk of MRONJ

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Figure 1: Dental Alert Card.


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Patel, V., Mansi, J., Ghosh, S. et al. MRONJ risk of adjuvant bisphosphonates in early stage breast cancer. Br Dent J 224, 74–79 (2018).

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