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British Journal of Oral and Maxillofacial Surgery 47 (2009) 598–601

A survey of consultant members of the British Association of

Oral and Maxillofacial Surgeons regarding
bisphosphonate-induced osteonecrosis of the jaws
S.N. Rogers a,b,∗ , J. Hung a , A.J. Barber a , D. Lowe a,b
a Regional Maxillofacial Unit, University Hospital Aintree, Longmoor Lane, Liverpool L9 7LN, UK
b Evidence-Based Practice Research Centre (EPRC), Faculty of Health, Edge Hill University, St Helens Road, Ormskirk L39 4QP, UK

Accepted 27 July 2009

Available online 12 September 2009

Abstract

The aims of this survey of consultants in the British Association of Oral and Maxillofacial Surgeons were threefold. Firstly, to estimate the
number of patients screened for oral health before starting intravenous bisphosphonate medication, secondly, to indicate the use of antibiotics
in patients on bisphosphonates who need routine extraction of a lower first molar tooth, and finally to estimate the number of new and currently
managed cases of bisphosphonate-induced osteonecrosis of the jaw (BONJ) in the last year, and approximately how many of those currently
being managed had healed.
A questionnaire was mailed to 322 consultants working at 154 hospitals in the summer of 2008. There were responses from 184 consultants
(57%) and from 111 hospitals (72%). Screening patients before starting intravenous bisphosphonates was uncommon (15%). Almost all
consultants would prescribe antibiotics for molar extraction and in about two-thirds this was both before and after extraction. Relatively few
would stop bisphosphonates. Nearly two-thirds of consultants had seen new cases of BONJ from intravenous treatment in the last year, and a
quarter had seen three or more. A similar proportion had patients on intravenous bisphosphonates under review for BONJ, and it was estimated
that in a fifth of patients the lesion had healed.
This survey indicates current practice among oral and maxillofacial surgeons in the UK. A national project for the registration of new
patients will provide a stronger evidence base with respect to incidence, risk factors, and management of BONJ.
© 2009 Published by Elsevier Ltd on behalf of The British Association of Oral and Maxillofacial Surgeons.

Keywords: Bisphosphonates; Bisphosphonate-induced osteonecrosis of the jaws; Survey; British Association of Oral and Maxillofacial Surgeons

Introduction indications include treatment for Paget disease, ankylos-

Bisphosphonates are some of the most commonly prescribed
drugs in the world,1,2 and are prescribed for patients with
osteoporosis,3 and for bone metastasis such as that in prostate
cancer,4 multiple myeloma,5–7 and breast cancer.8 Other
∗ Corresponding author at: Regional Maxillofacial Unit, University Hos-
pital Aintree, Longmoor Lane, Liverpool L9 7LN, UK.
Tel.: +44 0151 529 5287; fax: +44 0151 529 5288.
E-mail addresses: snrogers@doctors.co.uk (S.N. Rogers),
janitrix@gmail.com (J. Hung), andrewbarber2@nhs.net (A.J. Barber),
astraglobeltd@btconnect.com (D. Lowe).
ing spondylitis, and even bone diseases in children such as
osteogenesis imperfecta.9 The side effect of bisphosphonate-
induced osteonecrosis of the jaw (BONJ) in medical care
was reported by Marx in 2003.10 Since then there have
been numerous case reports, patient series, and review
statements.11–14
The incidence of BONJ is not clear and varies between
reports, but it is much higher in patients on intravenous prepa-
rations. Incidence from cumulative exposure in patients on
long-term oral bisphosphonates is yet to be fully realised.
Hoff et al.15 recently published a report of a large series of

0266-4356/$ – see front matter © 2009 Published by Elsevier Ltd on behalf of The British Association of Oral and Maxillofacial Surgeons.
doi:10.1016/j.bjoms.2009.07.020
 S.N. Rogers et al. / British Journal of Oral and Maxillofacial Surgery 47 (2009) 598–601
patients on intravenous treatment in which 16 of 1338 with
breast cancer (1%), and 13 of 548 with multiple myeloma
(2%) developed osteonecrosis of the jaw (ONJ). The inci-
dence of BONJ in osteoporotic patients has been reported
to be in the region of 1 in 2260–8470 (0.04–0.01%).16
Sedghizadeh et al.17 recently published an estimate by the
University of Southern California that about 4% of their
patient population had BONJ secondary to oral treatment
with alendronate sodium. There is very little data on patients
in the UK.
Risk factors for BONJ are becoming recognised and broad
guidelines for the oral and dental management of patients on
bisphosphonates have been developed, such as those by the
Canadian Association of Oral and Maxillofacial Surgeons,18
and the American Association of Oral and Maxillofacial
Surgeons.19 These multidisciplinary guidelines were devel-
oped for medical and dental practitioners as well as for oral
pathologists and related specialists. They suggest that all
oncology patients should have a thorough dental examina-
tion that includes radiographs before initiation of intravenous
treatment with bisphosphonates. Patients with osteoporosis
on oral or intravenous bisphosphonates do not require a dental
examination before initiating treatment if they have appro-
priate dental care and good oral hygiene. Malden et al.20
proposed an algorithm for low and high-risk patients who
require extractions. Although suggested, there is a lack of
evidence for stopping bisphosphonates before invasive den-
tal procedures.18,21 There are several treatment guidelines for
the management of BONJ, but the evidence base is weak.21–23
In 2007 a survey of oral and maxillofacial surgeons in
Australia was published.16 A hundred and fifty-eight cases
of BONJ were identified primarily in patients with bone
malignancy (72%), and the main trigger was dental extrac-
tion (73%). Other factors were untreated periodontal disease,
mucosal trauma, or ill-fitting dentures. Immunocompromised
patients seem to have the highest risk. The reported num-
ber of cases varied between different Australian states with
the highest incidence being reported in states with the best
integrated health systems.
In view of the absence of a survey of opinion amongst oral
and maxillofacial consultants, and the paucity of data with
respect to the screening of patients commencing bisphos-
phonate treatment, prescription of antibiotics for extractions,
and the incidence of BONJ in the UK, a national survey was
undertaken. Consultants were asked to estimate numbers of
patients in the previous 3 months that they had screened for
oral health before starting intravenous bisphosphonate medi-
cation, and to describe their usual management of patients on
bisphosphonates who required routine extraction of a lower
first molar tooth. They were also asked if their hospital or
unit had a protocol for managing such patients for minor
oral surgery, and whether such management varied accord-
ing to certain factors. Finally they were asked to estimate
numbers of new and currently managed cases of BONJ in
the last year, and how many of those currently managed had
healed.
599
Methods
A questionnaire was mailed in June 2008 to all consultants
(excluding SAS grades) on the May 2007 mailing list (white
book) of the British Association of Oral and Maxillofacial
Surgeons (BAOMS) at each hospital where they worked. A
postage-paid reply envelope was included. Members of the
BAOMS who work at more than one hospital were asked
to complete the questionnaire only once unless they had a
different practice in another hospital. Reminders were sent
after 3 weeks to consultants who did not respond.
Results
A total of 443 questionnaires were sent to 322 consultants
at 154 hospitals. Responses were received from 184 of 322
consultants (57%) (7 responded from two different hospitals),
and from 111 of 154 hospitals (72%). Fourteen blank returns
were omitted, which left 177 responses for analysis. Missing
data is reflected by variations in denominator.
In the previous 3 months 26 of 177 consultants (15%)
had screened at least one patient before starting intravenous
bisphosphonates. Responses to the question “What would
normally be done if a patient taking oral or intravenous bis-
phosphonates required “routine” extraction of a lower first
molar tooth?” are shown in Tables 1 and 2.
Forty-seven of 163 (29%) had protocols in their hospital or
unit for the management of patients taking oral or intravenous
bisphosphonates who need minor operations. Management of
such patients depended on duration of medication for 55 of
156 (35%), on requirements for surgical extraction for 65 of
154 (42%), for coexisting diseases such as diabetes and use
of steroids for 62 of 154 (40%), on patients being elderly for
38 of 155 (25%), and on the presence of infection for 77 of
151 (51%).
A hundred and twenty-four of 168 consultants (74%) had
seen new cases of BONJ from oral bisphosphonates in the last
year, and 40 of 168 (24%) had seen at least four. A hundred
and eleven of 164 (68%) were currently managing patients
with BONJ from oral bisphosphonates, and 38 of 164 (23%)
were managing at least five. The total was 486, of which 190
(39%) were stated to be, or were estimated to be healed.
In the last year 103 of 162 (64%) had seen new cases
of BONJ from intravenous bisphosphonates, and 43 of 162
(27%) had seen at least three. Ninety-six of 155 (62%) were
currently managing BONJ cases from intravenous bisphos-
phonates, and 35 of 155 (23%) were managing at least four.
The total was 449, of which 90 (20%) were stated to be, or
were estimated to be healed.
Discussion
This survey gives an insight into the views of consultant
oral and maxillofacial surgeons with respect to the screening
600 S.N. Rogers et al. / British Journal of Oral and Maxillofacial Surgery 47 (2009) 598–601

Table 1 of patients on intravenous bisphosphonates, use of antibi-

Results of questionnaire to the question “What would normally be done otics for lower molar extractions, and the number of cases of
if a patient taking oral or intravenous bisphosphonates required “routine”
extraction of a lower first molar tooth? Data are number (%).
BONJ. Nearly three-quarters of units responded. Although
it is acknowledged that postal surveys have limitations, this
Patients taking bisphosphonates
raises some interesting points.
Orally Intravenously Few consultants screened patients before starting intra-
Normally do you stop bisphosphonate medication preoperatively? venous bisphosphonates. The guidelines for starting patients
Yes 29/175 (17) 62/161 (39) on this treatment are that they should have a dental assess-
If yes, for how many months? ment and be rendered dentally fit.23 The fact that consultant
Less than 1 month 5/29 (17) 9/62 (15)
1–2 months 7/29 (24) 20/62 (32)
oral and maxillofacial surgeons are not really involved in
3–4 months 13/29 (45) 13/62 (21) screening should be seen as appropriate use of their time and
More than 4 months 3/29 (10) 5/62 (8) expertise, but it raises the question of how many patients are
Not stated 1/29 (3) 15/62 (24) actually being screened and by whom. Some patients will not
If yes, when do you suggest the bisphosphonates are restarted? be referred by the clinician, and a proportion will have a regu-
Immediately 2/29 (7) 4/62 (6) lar dental practitioner. Further studies are needed to evaluate
Only when socket has healed 16/29 (55) 39/62 (63) the screening pathway for this high-risk group. In a recent
Other (see Table 2) 6/29 (21) 8/62 (13)
survey of general dental practitioners with respect to osteo-
Not stated 5/29 (17) 11/62 (18)
radionecrosis, McLeod et al.24 reported that only 35% asked
Do you prescribe antibiotics for the extraction? specifically about head and neck cancer or radiotherapy as
Yes 147/170 (86) 143/157 (91)
If yes, when?
part of the medical history. If this relatively low awareness of
Before extraction only 13/147 (9) 6/143 (4) the patient’s history was seen for bisphosphonates it would
After extraction only 40/147 (27) 30/143 (21) imply that potentially there are many patients who are not
Before and after extraction 85/147 (58) 95/143 (66) recognised to be at risk from cumulative oral exposure or
Not stated 9/147 (6) 12/143 (8) intravenous treatment.
If yes, which antibiotic(s) Most consultants used antibiotics for the extraction of
Amoxicillin alone 43/147 (29) 38/143 (27) a lower molar tooth. The type of antibiotics being pre-
Metronidazole alone 14/147 (10) 10/143 (7)
scribed varied greatly in duration and frequency of dose.
Co-amoxiclav (Augmentin) alone 45/147 (31) 45/143 (31)
Amoxicillin and metronidazole 4/147 (3) 4/143 (3) Chlorhexidine mouthwash was commonly used as an adjunc-
Other alone 20/147 (14) 22/143 (15) tive measure. Clinical management was also influenced by
Other combinations 13/147 (9) 14/143 (10) factors such as existing infection (51%), coexisting disease
Not stated 8/147 (5) 10/143 (7) (40%), age (25%), duration of treatment with bisphospho-
Do you use a chlorhexidene mouthwash for the extraction? nates (35%), and the need for surgical extraction (42%).
Yes 117/170 (69) 116/159 (73) Evidence for use of prophylactic antibiotics is weak. There is
If yes, when? a need for greater understanding of the risk factors of BONJ
Before extraction only 21/117 (18) 16/116 (14)
After extraction only 21/117 (18) 17/116 (15)
as this should allow better selection of patients who might
Before and after extraction 72/117 (62) 76/116 (66) benefit from antibiotic prophylaxis.
Not stated 3/117 (3) 7/116 (6) This survey did not attempt to address which patients
Do you ask for a restorative dentist’s opinion? should be treated specifically by oral and maxillofacial
Yes 53/153 (35) 60/155 (39) surgeons, and it would not be appropriate to make any defi-
nite recommendations from the evidence presented because
Table 2 patients on intravenous bisphosphonates have a considerably
Breakdown of responses marked as “other” in reply to the question “When higher risk of BONJ, and it is suggested that they are seen
do you suggest the bisphosphonates are restarted?”.
by clinical teams familiar with the problems in management
Patients taking bisphosphonates associated with them.
Orally Intravenously The survey showed a lack of consistency with respect to
6 weeks postoperatively 1 1 the stopping of bisphosphonates before extractions. About
2–3 months postoperatively 4 3 39% of consultants would stop intravenous use, and 17%
Assessing urgent clinical 1 – would stop oral medications. This difference in practice
need reflects a deficit in understanding the risks of developing
On recommendation of – 1
physician
BONJ and the lack of robust evidence for guidelines.
Leave up to oncologist – 1 During the last year three quarters of consultants had seen
As late as possible in liaison – 1 new cases of BONJ in patients taking oral medication and
with haematology or two-thirds had seen new cases in those on intravenous medi-
oncology, or other specialty cation. Data on actual numbers and rates of healing from the
Leave up to prescriber or – 1
oncologist
survey is limited, but it does support the premise that BONJ
is a growing clinical problem.
 S.N. Rogers et al. / British Journal of Oral and Maxillofacial Surgery 47 (2009) 598–601
This survey gives an indication of current practice but
highlights the urgent need for a better estimation of the
national incidence of BONJ in the UK, more robust data
on potential risk factors, and a clearer understanding of out-
come (rates of healing). A new 2-year national registration of
patients with BONJ who were referred to oral and maxillo-
facial departments and dental hospitals in England, Wales,
Scotland and Northern Ireland will start in Summer 2009.
With good compliance nationally from members of the Asso-
ciation, this study will address many of the uncertainties.
Acknowledgement
We thank Christopher Evans, Audit Facilitator, Regional
Maxillofacial Unit, University Hospital Aintree for help in
sending out the questionnaires.
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