# Dental assessment before bone-modifying agents and jaw osteonecrosis prevention

Source: https://onco.cc/protocols/dental-assessment-before-bone-modifying-agents/  
OnCo record `dental-assessment-before-bone-modifying-agents` (Protocol). Data CC BY-NC 4.0, attribute "Data from OnCo (onco.cc)"; commercial use needs a licence.

## TL;DR

Medicines that strengthen bone in cancer, such as zoledronic acid and denosumab, can rarely cause a patch of jawbone to break down, usually after a tooth is taken out. Before you start, see a dentist so any problem teeth can be treated first, keep your mouth very clean, and tell your dentist about the medicine. Report any jaw pain, loose teeth or exposed bone in the mouth.

## Summary

MRONJ is exposed bone, or bone that can be probed through a fistula, in the jaw for more than 8 weeks in someone who has had a bone-modifying agent (BMA) or angiogenic inhibitor, with no radiotherapy or metastasis to the jaw (MASCC/ISOO/ASCO 2019). In cancer the doses are much higher than in osteoporosis (denosumab 120 mg monthly against 60 mg every 6 months), so the risk is greater: the Korean 2025 statement cites an incidence with zoledronate of 1.6 to 4 per cent in the first 2 years, rising after that, and finds that pretreatment dental care cut MRONJ by 77.3 per cent in one meta-analysis of people on high-dose bisphosphonates.

MASCC/ISOO/ASCO recommend a comprehensive dental assessment when a BMA is started, discussion of modifiable risk factors, and avoiding elective dentoalveolar surgery during treatment; whether to stop the BMA before necessary surgery is uncertain. The Korean statement makes dental evaluation mandatory before high-dose therapy for cancer, ideally before it begins, with extraction of teeth that cannot be saved, treatment of gum and root infections, adjustment of ill-fitting dentures and education on oral hygiene and warning signs. NICE NG101 asks that the risk of jaw osteonecrosis be discussed before adjuvant bisphosphonates in breast cancer. Established MRONJ is staged by an experienced clinician and treated conservatively first (MASCC/ISOO/ASCO), whereas the Korean statement favours earlier surgery.

## Fields

- Kind: Protocol
- Last checked: 2026-11-11
- Also known as: MRONJ prevention; medication-related osteonecrosis of the jaw; dental check before zoledronic acid; dental check before denosumab; osteonecrosis of the jaw prevention
- Tags: protocol; bone-health; oral-care; supportive-care

## Connected records

- cancers: [Multiple myeloma](https://onco.cc/cancers/multiple-myeloma/)
- fronts: [Supportive Care & Survivorship](https://onco.cc/fronts/supportive-care/)
- technologies: [Bone-modifying agents (bisphosphonates, denosumab)](https://onco.cc/technologies/bone-modifying-agents/)
- drugs: [Denosumab](https://onco.cc/drugs/denosumab/), [Zoledronic acid](https://onco.cc/drugs/zoledronic-acid/)
- institutions: [American Society of Clinical Oncology (ASCO)](https://onco.cc/institutions/asco/), [Multinational Association of Supportive Care in Cancer](https://onco.cc/institutions/mascc/), [National Institute for Health and Care Excellence](https://onco.cc/institutions/nice/)

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