Osteoporosis Medications: Bisphosphonates and Jaw Necrosis Risks

When you’re prescribed a medication to protect your bones from breaking, the last thing you expect is a rare but serious risk to your jaw. Yet for some people taking bisphosphonates for osteoporosis, that’s exactly what happens. The condition, called medication-related osteonecrosis of the jaw (MRONJ), isn’t common-but when it occurs, it’s painful, hard to treat, and often preventable.

MRONJ means bone in the jaw becomes exposed and doesn’t heal. It can start after a tooth extraction, gum surgery, or even a routine dental cleaning. The bone stays visible for more than eight weeks, sometimes with pain, swelling, or infection. It sounds scary, and it is-but the odds are incredibly low. For someone taking oral bisphosphonates like alendronate (Fosamax) for osteoporosis, the risk is about 0.7 in 100,000 people per year. That’s less than one case in a million. Compare that to the fact that osteoporosis causes over 2 million fractures in the U.S. every year. The math isn’t even close: the benefit of preventing a broken hip or spine far outweighs the risk of jaw necrosis.

Not all bisphosphonates are the same. The most common ones taken by mouth-alendronate, risedronate, ibandronate-are much safer than the intravenous versions used in cancer treatment. Zoledronic acid (Reclast), given as an annual IV infusion for osteoporosis, carries a higher risk than daily or weekly pills. Why? Because IV doses are stronger, and the drug stays in your bones longer. In fact, bisphosphonates can linger in your skeleton for over 10 years. That’s why even people who stopped taking these drugs years ago can still develop MRONJ.

The jaw is uniquely vulnerable. Unlike other bones, the jawbone is constantly exposed to bacteria from your mouth. It also remodels itself 10 times faster than your thigh bone. That means it’s always repairing, always healing. Bisphosphonates shut down the cells responsible for that repair-osteoclasts. Without them, small injuries from brushing, flossing, or dental work can’t heal. Add in gum disease or an infected tooth, and the risk climbs. That’s why dentists stress: get your teeth checked before starting bisphosphonates. Fix cavities, treat gum disease, pull teeth if needed-all before the medication begins.

Denosumab (Prolia), another osteoporosis drug, works differently than bisphosphonates but carries a similar or even higher risk of jaw necrosis. Studies show it’s 1.7 to 2.5 times more likely to cause MRONJ than oral bisphosphonates. That’s surprising, since it’s newer and often seen as safer. But its mechanism-blocking a protein that activates bone-eating cells-is just as powerful at halting healing. If you’re on denosumab, the same rules apply: keep your mouth healthy, tell your dentist you’re on it, and don’t delay needed dental work.

What about stopping the drug to lower the risk? This is where things get complicated. A major 2024 study in Nature Communications found that if you stop IV zoledronic acid for more than a year, your risk of jaw necrosis drops by 82%. Sounds great, right? But here’s the catch: stopping the drug increases your risk of breaking a bone by 28%. That’s not a trade-off most people can afford. For someone with severe osteoporosis, a broken hip can mean losing independence-or even your life. So doctors don’t recommend stopping bisphosphonates just to avoid jaw problems unless you’ve been on them for many years and your fracture risk has dropped.

Dentists are learning how to handle this. The American Association of Oral and Maxillofacial Surgeons says MRONJ has three stages. Stage 1 is just exposed bone with no pain or infection. Stage 2 adds swelling and pus. Stage 3 means the bone is broken or there’s a hole connecting the mouth to the skin. Most cases in osteoporosis patients are stage 1 or 2. Treatment usually means antibiotics, mouth rinses, and gentle cleaning-not surgery unless absolutely necessary. Aggressive surgery often makes things worse. The goal isn’t to remove all the dead bone-it’s to control infection and let the body heal around it.

Real stories show how confusing this can be. One woman on a patient forum said she developed exposed bone after a cleaning, and it took 18 months of antibiotics and surgery to heal. Another person, on the same forum, said they’d been on Fosamax for 22 years, had multiple extractions and implants, and never had a problem. There’s no pattern. Genetics, dental hygiene, how long you’ve been on the drug, and whether you had existing gum disease all matter. That’s why blanket rules don’t work.

Many patients are terrified. A 2023 survey found 87% of osteoporosis patients worry about jaw necrosis before any dental work. But only 2.3% ever actually develop it. Meanwhile, dentists are getting nervous too. Some refuse to pull teeth or do implants on patients taking bisphosphonates, even when the risk is minimal. That’s a problem. Avoiding needed dental care leads to infections, pain, and tooth loss-all of which can be worse than MRONJ.

So what should you do? First, don’t stop your osteoporosis medication because you’re scared. The fractures you’re preventing are life-changing. Second, see your dentist before starting bisphosphonates. Get a full exam, X-rays, and a cleaning. Fix any problems now. Third, keep up with your dental care. Brush twice a day, floss daily, and see your dentist every six months. Tell them you’re on a bisphosphonate or denosumab. Fourth, if you need major dental work, talk to both your doctor and dentist. They can coordinate. For some people on long-term IV therapy, a short drug holiday might be considered-but only if your fracture risk is low.

There’s no magic bullet. Bisphosphonates are the most proven, effective osteoporosis drugs we have. They’ve cut hip fracture risk by half in clinical trials. They’ve helped millions live longer, more active lives. The risk of jaw necrosis is real, but it’s not a reason to avoid treatment. It’s a reason to be smart about it.

Looking ahead, doctors are working on better ways to predict who’s at risk. Some are testing urine markers to see how fast your bones are breaking down. Others are studying genetic factors. In the next few years, we may be able to say: “You’re low risk-keep taking your pill.” Or: “You’re high risk-let’s switch to a different drug.” Until then, the best advice is simple: protect your mouth, protect your bones, and never let fear stop you from living well.

What are the most common bisphosphonates used for osteoporosis?

The three most commonly prescribed oral bisphosphonates are:

• Alendronate (Fosamax): Taken weekly. First approved for osteoporosis in 1995. Most widely used.
• Risedronate (Actonel): Taken weekly or daily. Often preferred for people with stomach sensitivity.
• Ibandronate (Boniva): Taken monthly or as a quarterly IV infusion.

For intravenous use, zoledronic acid (Reclast) is given once a year. It’s stronger and carries a higher risk of MRONJ than oral forms.

Is MRONJ more common in cancer patients?

Yes-dramatically. Cancer patients receiving high-dose IV bisphosphonates or denosumab for bone metastases have a much higher risk. Studies show 3% to 16% of these patients develop MRONJ, depending on the drug and treatment duration. That’s hundreds of times higher than the risk in osteoporosis patients. The doses are much higher, the treatment lasts longer, and many of these patients also have poor nutrition, radiation therapy, or chemotherapy-all of which weaken healing.

Can I still get dental implants if I’m on bisphosphonates?

It’s possible, but it’s not straightforward. For people on oral bisphosphonates for osteoporosis, implants can be done safely if your jawbone is healthy and you’ve had good dental care. Many oral surgeons will proceed with caution, using gentle techniques and antibiotics. But if you’re on IV bisphosphonates or have been on oral therapy for more than 3-5 years, most experts recommend avoiding implants unless absolutely necessary. The risk of implant failure and MRONJ rises with longer drug exposure.

What’s the difference between MRONJ and regular jaw infection?

MRONJ isn’t just an infection-it’s a failure of the bone to heal. In a normal infection, the body fights off bacteria and repairs damaged tissue. With MRONJ, the bisphosphonate has shut down the bone’s ability to rebuild. So even after the infection clears, the bone stays exposed. It doesn’t heal over. That’s why antibiotics alone don’t cure it. The bone needs time, gentle care, and sometimes surgery to remove dead fragments.

How do I know if I’m at higher risk for MRONJ?

You’re at higher risk if:

• You’ve been on bisphosphonates for more than 3-5 years
• You’re taking IV bisphosphonates (like Reclast)
• You have gum disease, tooth decay, or loose teeth
• You smoke or have diabetes
• You’ve had a tooth extraction or dental surgery after starting the medication
• You’re on denosumab (Prolia)

If you have none of these, your risk is extremely low.

Should I stop my bisphosphonate before a dental procedure?

For oral bisphosphonates, no. Stopping won’t lower your risk significantly because the drug stays in your bones for years. For IV bisphosphonates, a drug holiday of 3-6 months may be considered-but only if your fracture risk is low and your doctor agrees. Never stop without talking to your doctor. The risk of a fracture from stopping is higher than the risk of MRONJ from keeping it.

What’s the bottom line?

Don’t let fear of jaw necrosis keep you from treating your osteoporosis. The chance of developing MRONJ is tiny. The chance of breaking a hip or spine without treatment is huge. The best way to protect yourself is simple: take your medication as prescribed, see your dentist regularly, fix dental problems early, and never skip your checkups. If you’re worried, talk to your doctor and dentist together. They can make a plan that keeps your bones strong and your mouth healthy.