What the intake form skips: bisphosphonates and MRONJ

Disclosure. Dr. Maloney has no commercial relationship with any clinic, marketplace, manufacturer, or industry body referenced in this piece. She did not receive payment, travel, accommodation, equipment, or any other consideration in connection with this piece. The publication’s standing disclosures (default: none) are documented at /disclosures/. Last reviewed: 2026-06-08.

This is the second piece in the What the Intake Form Skips series. The first piece covered undiagnosed diabetes. This piece covers bisphosphonates and MRONJ.

The question is simple. It takes ten seconds to ask and ten seconds to answer. “Are you currently taking, or have you ever taken, any medication for bone density, osteoporosis, or cancer bone disease, including alendronate, Fosamax, risedronate, Actonel, zoledronic acid, Zometa, or Prolia?”

Most dental tourism intake forms do not ask it.

Medication-related osteonecrosis of the jaw is not a common complication. In the absolute-risk sense, a patient taking oral alendronate for osteoporosis who has a single implant placed has a roughly 0.01 to 0.1% annual risk of developing MRONJ. That number sounds reassuring. What it understates is the severity of the complication when it occurs. MRONJ is not an inconvenience. It is exposed, non-healing, necrotic jawbone. In advanced stages it involves pain, chronic infection, pathological fracture, and in severe cases surgical resection of the affected jaw. It is one of the few dental complications that can meaningfully and permanently alter a patient’s quality of life.

The AAOMS 2022 position paper on MRONJ calls it a condition that is “often difficult to manage, and treatment is generally not curative.” That sentence belongs in every dental tourism consent form, alongside the question that would identify the patients at risk.

The drug classes and their mechanism

Bisphosphonates bind to bone mineral (hydroxyapatite) and inhibit osteoclast function. Osteoclasts are the cells that resorb bone as part of normal bone remodelling. Bisphosphonates suppress that resorption, which is why they reduce fracture risk in osteoporosis and metastatic bone disease.

The consequence relevant here: when bone is surgically traumatised — by extraction, implant drilling, or periodontal surgery — normal healing requires osteoclast and osteoblast coordination. Bisphosphonates persist in bone for years after the last dose (oral alendronate’s bone half-life is estimated at ten years or more). The bone around the surgical site cannot remodel normally. If the blood supply to the affected area is also compromised, the bone does not heal. The socket or implant site remains exposed. Infection sets in. MRONJ results.

Denosumab (Prolia) works differently — it is a RANK-L inhibitor rather than a bisphosphonate — but produces similar MRONJ risk through its suppression of osteoclast activity. Its bone half-life is shorter than bisphosphonates (the effect reverses after the drug is cleared), which is relevant for planning drug holidays.

Antiangiogenic agents used in oncology (bevacizumab, sunitinib, cabozantinib, and others) add a separate mechanism: compromised blood supply to bone. These agents, primarily used in cancer treatment, are not commonly seen in the general dental tourism patient, but their MRONJ risk is real and they are increasingly in use.

Who takes these medications

The demographic profile of the dental tourism patient who travels for major reconstruction overlaps significantly with the demographic profile of the patient who takes bisphosphonates for osteoporosis. Both groups are disproportionately older (over 55), female, and in markets where prescription drug costs have driven dental avoidance. An Australian woman, 62 years old, on alendronate for five years following a wrist fracture, who is considering full-arch dental reconstruction because she cannot afford it in Sydney, is not an edge case. She is a representative dental tourism patient with a medication history that is directly relevant to her implant safety.

She may not know the medication name. She may call it “my bone tablet.” She may have forgotten she takes it. The intake form does not ask. The clinic proceeds.

Why the dental tourism intake does not catch this

The same structural problem applies here as in the diabetes piece. Identifying and managing MRONJ risk requires a conversation that takes time, may require coordination with the prescribing physician, and in some cases leads to treatment deferral or additional pre-operative management (such as a drug holiday). Each of these steps adds friction to the booking conversion.

A further complication is language. Many dental tourism patients are not attending clinics in their first language. The medication names on the intake form — if the form exists at all — may not match the brand names the patient knows from their home country. An Australian patient taking Fosamax does not necessarily recognise alendronate. A Vietnamese-language intake form may list neither.

The treating clinic may also have limited familiarity with the full MRONJ literature if they are primarily performing high-volume implant surgery and are not accustomed to the older, systemically complex patient profile that the dental tourism market increasingly presents.

What you should do

Before proceeding with any extraction, implant placement, or periodontal surgery in any dental context — domestic or international — provide your prescribing physician and the treating dental surgeon with a complete medication history. This includes:

All current medications by generic and brand name. Including over-the-counter supplements, hormonal therapies, and recently completed courses.

Any medications you have taken for bone density at any point. Bisphosphonates persist in bone for years. Past exposure matters even if you are not currently taking the medication.

Any current or recent cancer treatment. Oncology patients taking antiangiogenic or antiresorptive agents have substantially higher MRONJ risk and should not have elective dentoalveolar surgery without oncologist input.

The standard pre-operative guidance from the AAOMS for patients on oral bisphosphonates is: the decision to proceed is based on duration of therapy, concurrent risk factors (particularly corticosteroid use), and individual patient risk assessment. For patients on long-duration therapy (more than four years), a drug holiday of two to three months before and after the procedure has been proposed by some authorities, though the evidence base for holiday duration is not uniform. Your prescribing physician and oral surgeon should make this determination together. Not after you have flown to Istanbul.

The falsification condition

I would revise this estimate of risk if a large registry study (N greater than 5,000, multi-centre, including dental tourism settings) showed MRONJ incidence in patients receiving implant surgery without bisphosphonate screening was not meaningfully higher than in screened populations. No such study exists in the dental tourism context. The mechanism is not contested. The question is only whether the absolute risk is high enough to justify mandatory screening in all patients or only in high-risk groups.

My position: the question costs nothing, the medication history reveals the risk, and the consequence of missing it is severe. Ask the question.

Related reading: What the intake form skips: undiagnosed diabetes and implant failure · What the intake form skips: smoking and implant failure · Fit to fly after implant surgery · Peri-implantitis: bone loss cascade · The dental tourism trust gap