Dear Sir,

We read the article titled ‘Medication-related osteonecrosis of the jaw (MRONJ) in osteoporotic patients: prevention and management’ by Chan et al(1) with great interest. The authors agreed that osteoporosis is a serious medical condition that requires treatment and suggested that the condition is both underdiagnosed and undertreated. Patients who are diagnosed with osteoporosis should be given appropriate counselling regarding the risks of treatment, which should be balanced against their fracture risk.

We believe that the recommendation by the authors to send all patients for dental clearance may frighten and deter some patients from taking the medications that they need to prevent a fracture and even premature death as a result of the fracture. The American Association of Oral and Maxillofacial Surgeons (AAOMS) position paper quoted by the authors referenced a Kaiser Permanente survey of patients taking bisphosphonates for osteoporosis, which reported a 0.1% incidence of MRONJ among these patients.(2) The same position paper quoted an incidence of 0.00038% (< 1 case per 100,000 exposed) based on another report. The AAOMS paper also concluded that “The risk for ONJ (osteonecrosis of the jaw) among patients treated with either zolendronate or denosumab approximates the risk for ONJ of patients enrolled in placebo groups”.

A Canadian paper found that over a three-year period, the cumulative incidence for bisphosphonates-associated ONJ for osteoporosis was 0.001% (1.04 per 100,000).(3) The Canadian practice guidelines specifically recommended against routine dental examination for osteoporosis patients with no dental problems.(4) Everyone should maintain good oral hygiene and see their dentist regularly, and referral for dental clearance should only be necessary for high-risk patients.

Yours sincerely,

Chan BH, Yee R, Puvanendran R, Ang SB.Medication-related osteonecrosis of the jaw in osteoporotic patients: prevention and management. Singapore Med J. 2018;59:70-5.
American Association of Oral and Maxillofacial Surgeons Position Paper: Medication-Related Osteonecrosis of the Jaw—2014 Update [online]. Available at: Accessed April 18 2018.
Khan AA, Rios LP, Sándor GK, et al. Bisphosphonate-associated osteonecrosis of the jaw in Ontario: a survey of oral and maxillofacial surgeons. J Rheumatol. 2011;38:1396-402.
Khan AA, Sándor GK, Dore E, et al. Canadian Association of Oral and Maxillofacial SurgeonsCanadian consensus practice guidelines for bisphosphonate associated osteonecrosis of the jaw. J Rheumatol. 2008;35:1391-7.