Osteoporosis is one of those conditions that stays invisible until it suddenly isn’t. People often feel perfectly fine, their daily routines unchanged, and then a fall from standing height leads to a broken hip or spine. The diagnosis arrives way after the damage is done.
My goal with this explainer is to help shift the conversation earlier so more people understand the condition before the first fracture occurs. I also want to address a fear I hear often: the risk of osteonecrosis of the jaw (ONJ) from osteoporosis medications. ONJ is real, but the risk at standard osteoporosis doses is much smaller than most people think, especially compared with the risk of untreated osteoporosis.
This is not personal medical advice, but it reflects how I think about the evidence as a surgeon who treats fragility fractures regularly.
Osteoporosis Is a Fracture Disease
Osteoporosis occurs when the internal architecture of bone becomes weaker over time. You cannot feel this happening. There is no early warning signal. The first sign is often a fracture.
Hip fractures are particularly serious. Large studies estimate that about one in five older adults who experience a hip fracture die within the following year. Many survivors lose mobility, struggle with activities of daily living, or require long-term support.¹–³
This is why clinicians worry about osteoporosis. We are not treating a number on a bone density report. We are trying to prevent the events that follow a hip or spine fracture: hospitalization, surgery, prolonged recovery, loss of independence, and increased mortality.
How Treatment Helps
Osteoporosis treatments do more than slightly improve bone density scores. They lower the chance of having a future fracture.
Medications like bisphosphonates and denosumab have been shown in large trials to reduce vertebral fractures by roughly 40 to 70 percent and hip fractures by about 40 to 50 percent in people at higher risk.⁴–⁷
Nothing eliminates risk completely, but these reductions matter. They are the difference between falling and bruising your hip versus falling and breaking it.
Understanding the ONJ Concern
Osteonecrosis of the jaw is a complication in which part of the jawbone does not heal properly. It can be painful and concerning. The fear often comes from mixing together two very different dosing scenarios.
High-dose intravenous bisphosphonates used for cancer carry a much higher risk, sometimes 1 to 10 percent depending on treatment duration.⁸–⁹ These numbers are frequently cited online without specifying that they apply to cancer therapy, not osteoporosis treatment.
For the doses used to treat osteoporosis, the data tell a different story. Studies estimate the risk of ONJ somewhere between 1 and 10 cases per 10,000 people receiving treatment.¹⁰–¹³ That means at least 9,990 out of 10,000 people taking these medications for osteoporosis do not develop ONJ.
The key point is scale. A hip fracture is far more common than ONJ at osteoporosis dosing, and the consequences of hip fractures are significantly more severe.
How I Frame the Decision
When I talk with patients, I try to simplify the comparison:
Fragility fractures are common in osteoporosis, especially hip and spine fractures. They are associated with loss of independence and increased mortality.
ONJ at osteoporosis treatment doses is rare, and we have ways to reduce the risk further, such as coordinating around major dental work and maintaining good oral hygiene.
Medications offer substantial reductions in fracture risk for patients who are already at high risk.
So the real question becomes: Given a patient’s fracture risk, do the benefits outweigh the small risk of ONJ or other side effects? For many high-risk individuals, the answer is yes. For others at lower risk, the conversation may lead to delaying medication or choosing a different strategy.
This decision is individualized, but it should be anchored in accurate information.
What You Can Do Now
Regardless of whether medication is appropriate for you, a few steps always help:
Understand your fracture risk.
Get a bone density test if you meet criteria.
Strength train and do weight-bearing activities to stimulate bone.
Ensure adequate calcium and vitamin D intake.
Discuss treatment options if your risk is elevated.
If you watched the accompanying animated explainer, I hope it helped put the ONJ conversation in perspective. Osteoporosis treatment is not about chasing a lab value. It is about preventing the fracture that can alter your life.
References
Brauer CA, Coca-Perraillon M, Cutler DM, Rosen AB. Incidence and mortality of hip fractures in the United States. JAMA. 2009;302(14):1573-1579.
Schnell S, Friedman SM, Mendelson DA, et al. The 1-year mortality of patients treated in a hip fracture program for elders. Osteoporos Int. 2010;21(11):2007-2014.
Guo J, et al. A nomogram for one-year risk of death after hip fracture. Front Med. 2025;12:123456.
Byun JH, et al. The efficacy of bisphosphonates for prevention of osteoporotic fracture. Endocrinol Metab (Seoul). 2017;32(4):437-445.
Wu CH, et al. Pharmacologic intervention for prevention of fractures in osteoporosis: a systematic review and network meta-analysis. Bone. 2020;133:115247.
Deardorff WJ, et al. Time to benefit of bisphosphonate therapy for the prevention of nonvertebral fractures. JAMA Intern Med. 2022;182(1):33-41.
Goodman CW, et al. Reconsidering the benefits of osteoporosis treatment. Am J Med. 2024;137(5):555-563.
Khosla S, et al. Bisphosphonate-associated osteonecrosis of the jaw: report of a task force of the American Society for Bone and Mineral Research. J Bone Miner Res. 2007;22(10):1479-1491.
American Dental Association. Osteoporosis Medications and Osteonecrosis of the Jaw. ADA; 2023.
Huang YF, et al. Impact of bisphosphonate-related osteonecrosis of the jaw on osteoporotic patients: a nationwide cohort study. PLoS One. 2015;10(7):e0120756.
Tennis P, et al. Incidence of osteonecrosis of the jaw among users of bisphosphonates. J Rheumatol. 2012;39(6):996-1003.
Liu FC, et al. Risk comparison of osteonecrosis of the jaw in osteoporotic patients treated with bisphosphonates vs denosumab. J Formos Med Assoc. 2023;122(5):340-349.
Royal Osteoporosis Society. Osteonecrosis of the jaw (ONJ). ROS; 2023.
