Medication-Related Osteonecrosis of the Jaw

Staging and treatment strategies for Medication-Related Osteonecrosis of the Jaws (MRONJ, also referred to as antiresorptive agent-induced osteonecrosis of the jaw (ARONJ)

Patients may be considered to have MRONJ/ARONJ if all of the following three characteristics are present:

1. Current or previous treatment with a bisphosphonate or an antiresorptive agent;
2. Exposed bone in the maxillofacial region that has persisted for more than eight weeks; and
3. No history of radiation therapy to the jaws.

Adapted from : American Association of Oral and Maxillofacial Surgeons Position Paper on Bisphosphonate-Related Osteonecrosis of the Jaw - 2014 Update.

At Risk
Clinical Presentation No apparent exposed or necrotic bone in a patient who have been treated with oral or IV antiresorptive agents.	Suggested Treatment No treatment needed. Provide patient education.
Stage 0
Clinical Presentation No clinical evidence of necrotic bone, but presence of non-specific signs and symptoms.	Suggested Treatment Symptomatic treatment, including antibiotics and pain medications.
Stage 1
Clinical Presentation Exposed and necrotic bone, or fistulae that probes to bone in a patient without symptoms and no signs of infection.	Suggested Treatment Antibacterial oral rinse. 3 months follow-ups. Provide patient education.
Stage 2
Clinical Presentation Exposed and necrotic bone, or a fistulae that probes to bone, associated with an infection accompanied by pain and erythema, and possible purulent drainage in the area of the lesion.	Suggested Treatment Broad-spectrum antibiotic. Antibacterial oral rinse. Pain control. Superficial debridement.
Stage 3
Clinical Presentation Exposed and necrotic bone or a fistula that probes to bone in patients with pain, infection, and one or more of the following: exposed and necrotic bone extending beyond the region of alveolar bone,(i.e., inferior border and ramus in the mandible, maxillary sinus and zygoma in the maxilla) resulting in pathologic fracture, extra-oral fistula, oral antral/oral nasal communication, or osteolysis extending to the inferior border of the mandible of sinus floor.	Suggested Treatment Antibiotics. Antibacterial oral rinse. Analgesics. Surgical debridement or resection.

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Related Pages

• Images
  • Bisphosphonate Related Osteonecrosis of the Jaw

References/Websites

• References
  • Hellstein JW, et al. Managing the care of patients receiving antiresorptive therapy for prevention and treatment of osteoporosis: Executive summary of recommendations from the American Dental Association Council on Scientific Affairs. JADA 2011;142(11):1243-51
• Websites
  • Gary G. Goodell. American Association of Endodontists. Guidelines for Medication-Related Osteonecrosis Jaw: An Update. February 3, 2020.
  • Ruggiero SL, et al. American Association of Oral and Maxillofacial Surgeons. Medication-Related Osteonecrosis of the Jaw—2014 Update.