What are the management options for osteonecrosis of the jaw?

Management of Osteonecrosis of the Jaw

The initial approach to management of osteonecrosis of the jaw (ONJ) should be conservative, including antimicrobial mouth rinses, antibiotics if clinically indicated, effective oral hygiene, and conservative surgical interventions such as removal of superficial bone spicules. 1

Staging and Assessment

Proper staging is essential for appropriate management of ONJ. Staging should ideally be performed by a clinician experienced with ONJ management 1. Several staging systems exist:

• AAOMS staging system (2014)
• Common Terminology Criteria for Adverse Events (CTCAE) 5.0
• International Task Force on ONJ staging system (2017)

The same staging system should be used throughout the patient's course of care 1.

Treatment Approach Based on Stage

At-Risk Patients

• No apparent necrotic bone but history of antiresorptive therapy
• Management: No treatment indicated, patient education, and reduction of modifiable risk factors 1

Increased Risk

• No clinical evidence of necrotic bone but nonspecific findings, radiographic changes, and symptoms
• Management:
  • Symptomatic management including pain medication
  • Referral to dental specialist
  • Follow-up every 8 weeks with communication to oncologist
  • Patient education and reduction of modifiable risk factors 1

Stage 1 ONJ

• Exposed/necrotic bone or fistulas probing to bone; asymptomatic without infection
• Management:
  • Antibacterial mouth rinse
  • Regular follow-up every 8 weeks by dental specialist
  • Communication with oncologist about lesion status
  • Patient education and reduction of modifiable risk factors 1

Stage 2 ONJ

• Exposed/necrotic bone or fistulas with infection (pain, erythema, purulent drainage)
• Management:
  • Oral antibiotics and topical antibacterial rinse
  • Pain control
  • Debridement to relieve soft tissue irritation
  • Regular follow-up every 8 weeks
  • Patient education and reduction of modifiable risk factors 1

Stage 3 ONJ

• Exposed/necrotic bone with pain, infection, and one or more: bone extending beyond alveolar bone, pathologic fracture, extraoral fistula, oral-antral/oral-nasal communication, or extensive osteolysis
• Management:
  • Oral antibiotics and topical antibacterial rinse
  • Pain control
  • Surgical debridement or resection for long-term palliation
  • Regular follow-up every 8 weeks
  • Patient education and reduction of modifiable risk factors 1

Surgical Management Considerations

• Conservative approach: For early stages, focus on antimicrobial rinses, antibiotics when indicated, and minor debridement of loose sequestra 1
• Aggressive surgical approach: Reserved for refractory cases with persistent symptoms or functional impairment despite conservative treatment 1
• Important: Aggressive surgical intervention is not recommended for asymptomatic bone exposure 1
• Removal of superficial necrotic bone causing soft tissue irritation and loose bony sequestra should be considered regardless of stage 1
• Extraction of symptomatic teeth within exposed necrotic bone can be considered as it is unlikely to exacerbate the established necrotic process 1

Medication Management

For patients diagnosed with ONJ while on bone-modifying agents (BMAs):

• There is insufficient evidence to support or refute discontinuation of BMAs 1
• BMA administration may be deferred at the discretion of the treating physician, in consultation with the patient and oral health provider 1
• For bisphosphonates: Discontinuation may not affect outcomes due to long half-life 1
• For denosumab: Temporary discontinuation may potentially enhance ONJ resolution due to shorter half-life, but must be weighed against risk of skeletal-related events 1

Multidisciplinary Approach

A multidisciplinary approach is crucial for effective ONJ management 2:

• Regular communication between dental specialist and oncologist about lesion status (resolved, improving, stable, or progressive) 1
• Collaboration between oral surgeons, oncologists, dentists, and oral medicine specialists 2
• Consider referral to specialized centers with expertise in ONJ management 2

Experimental Therapies

Several experimental approaches have been studied with varying results:

• Hyperbaric oxygen therapy 1, 3
• Low-level laser treatment 3, 4
• Platelet-rich plasma/growth factors 3, 4
• Bone marrow stem cell intralesional transplantation 3, 4
• Teriparatide (for those without contraindications) 3, 4

Prevention Strategies

Prevention remains critical, especially for high-risk patients:

• Comprehensive oral evaluation before starting antiresorptive therapy 1
• Elimination or stabilization of oral disease prior to initiation of antiresorptive agents 4
• Maintenance of good oral hygiene 1, 4
• Regular dental follow-up 1
• Avoidance of elective dentoalveolar surgery during active therapy with bone-modifying agents at oncologic doses 1

Key Pitfalls to Avoid

• Delayed diagnosis: Early identification and proper staging are essential for optimal outcomes 2
• Aggressive surgical intervention for asymptomatic cases: Conservative management is preferred initially 1
• Poor communication between specialists: Regular updates between dental specialists and oncologists are crucial 1
• Ignoring modifiable risk factors: Address factors like smoking, diabetes, and poor oral hygiene 1, 4
• Inadequate follow-up: Regular monitoring (every 8 weeks) is recommended until healing occurs 1