Dear Sir,

We followed the discussion that arose from Chan et al’s article on medication-related osteonecrosis of the jaw (MRONJ) with great interest and would like to applaud the timely publication of papers regarding this under-reported medical complication.(1-3)

Some oral complications of medical therapy take some time to appear. We have worked in hospital dentistry for more than two decades, and it saddens us that dentists have to bear the brunt of the complications following routine dental procedures when there is a slight change in patients’ underlying medical conditions. With the frequent introduction of new drugs, we also have to constantly keep ourselves updated via the Internet.

In the case of MRONJ, we can expect the possible advent of this problem from the moment antiresorptive therapy is prescribed to osteoporotic women. Hence, we strongly agree that patients should be informed of the possible consequences of antiresorptive therapy from the beginning. As shared decision-making is a practice that more clinicians are adopting, it is inadvisable to leave the decision to start antiresorptive therapy solely in the hands of clinicians. As dentists, we should rethink our treatment plan when patients tell us that they are taking ‘bone-strengthening pills’ without knowing what they are.

Toh and Dutton’s(2) comment that Chan et al’s recommendation(1) “may frighten and deter some patients from taking the medications that they need” is a common misconception that we observe among medical practitioners and specialists. Perhaps the lack of exposure to dental care for special needs patients among medical practitioners and specialists contributed to this misconception, as this is considered a new area of dentistry in Malaysia and several other countries in the world. To make matters worse, some of our dental colleagues who graduated before the millennium remain ignorant about antiresorptive therapy and its complication. The low level of dental awareness among many Asian populations is not helping either, as patients seek dental care only when symptoms arise, resulting in compromised treatment for those on antiresorptive therapy.

Most of Chow’s case reports from Hong Kong were of fragile elderly patients with multiple chronic diseases.(4) Such underlying conditions may further compromise patients’ ability to heal following dental surgery. We have seen patients who developed MRONJ spontaneously or even after dental scaling, so this complication is very real. As such, we strongly urge all medical colleagues treating patients with chronic disease or on long-term medication such as antiresorptive therapy to consistently remind their patients about the importance of dental maintenance. After all, prevention is still better than cure.

Yours sincerely,

Editor’s note: The authors, Chan et al, have declined to respond to the above letter.

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.
Toh CL, Dutton A. Comment on: Medication-related osteonecrosis of the jaw in osteoporotic patients:prevention and management. Singapore Med J. 2018;59:287.
Chan BH, Yee R, Puvanendran R, Ang SB. Authors' reply: Medication-related osteonecrosis of the jaw in osteoporotic patients: prevention and management. Singapore Med J. 2018;59:288.
Chow TK. Oral bisphosphonate-related osteonecrosis of the jaws: report of six Hong Kong Chinese patients and review of the literature. Hong Kong Dent J. 2012;9:33-8.