Treatment of Bisphosphonate-Related Osteonecrosis of the Jaw (BRONJ)
Treatment of BRONJ should follow a stage-based approach, with conservative management as the initial strategy for early stages and surgical intervention reserved for advanced or refractory cases. 1, 2
Staging and Initial Assessment
BRONJ is classified into stages that guide treatment:
- At-risk patients: No apparent necrotic bone but history of antiresorptive therapy
- Stage 0: No clinical evidence of necrotic bone but nonspecific findings
- Stage 1: Exposed/necrotic bone or fistulas; asymptomatic without infection
- Stage 2: Exposed/necrotic bone or fistulas with infection
- Stage 3: Exposed/necrotic bone with pain, infection, and complications (pathologic fracture, extraoral fistula, osteolysis extending beyond alveolar bone)
Treatment Approach by Stage
Stage 1 BRONJ
- Antibacterial mouth rinses (0.12% chlorhexidine)
- Patient education about oral hygiene
- Regular follow-up every 8 weeks by dental specialist
- Removal of mobile bone fragments that irritate soft tissue 1
Stage 2 BRONJ
- Antibacterial mouth rinses
- Systemic antibiotics for infection control
- Pain management with appropriate analgesics
- Conservative debridement to relieve soft tissue irritation
- Regular follow-up every 8 weeks 1
Stage 3 BRONJ
- Antibacterial mouth rinses
- Systemic antibiotics for infection control
- Pain management
- Surgical debridement or resection for long-term palliation
- Evaluation of removed bone fragments to rule out malignancy 1, 2
Medication Management
- For patients on bisphosphonates: Discontinuing bisphosphonates at BRONJ diagnosis is unlikely to affect outcomes due to their long half-life 1
- For patients on denosumab: Temporary discontinuation may potentially enhance BRONJ resolution due to shorter half-life, but must be weighed against risk of skeletal-related events 1
- Decision to continue or discontinue bone-modifying agents should be made in consultation between the treating physician, patient, and oral health provider 1
Surgical Approaches
Conservative approach: Preferred for early stages
Aggressive surgical approach: Reserved for:
Adjunctive Therapies
Several adjunctive therapies have been investigated:
- Low-Level Laser Therapy (LLLT): May stimulate cell proliferation and soft tissue healing 4
- Ozone therapy: May stimulate cell proliferation during and after oral surgery 4
- Hyperbaric oxygen therapy: Benefits remain unclear, but may be helpful in combination with conventional therapy 4
Multidisciplinary Management
- 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
Common Pitfalls to Avoid
- Aggressive surgical intervention for asymptomatic cases: Conservative management is preferred initially 2
- Poor communication between specialists: Regular updates between dental specialists and oncologists are crucial 1, 2
- Ignoring modifiable risk factors: Address factors such as smoking, diabetes, and poor oral hygiene 2
- Inadequate follow-up: Regular monitoring every 8 weeks is recommended until healing occurs 1, 2
- Elective dental procedures in patients with established BRONJ: These may result in additional areas of exposed necrotic bone 1
Prevention Strategies
- Comprehensive oral evaluation before starting antiresorptive therapy
- Maintenance of good oral hygiene
- Regular dental follow-up
- Avoidance of elective dental procedures during active therapy with bone-modifying agents 2
The management of BRONJ remains challenging, but a stage-based approach with appropriate conservative or surgical interventions based on disease severity offers the best outcomes for patients.