Recent Guidelines for Managing Medication-Related Osteonecrosis of the Jaw (MRONJ)
All patients scheduled to receive bisphosphonates or denosumab should undergo a comprehensive dental examination with radiographs before starting therapy, complete any necessary dental procedures with full mucosal healing, and avoid elective invasive dental surgery during active treatment. 1
Definition and Diagnosis
MRONJ requires all three diagnostic criteria to be present: 1
- Current or previous treatment with a bone-modifying agent (bisphosphonate or denosumab) or angiogenic inhibitor
- Exposed bone or bone probeable through an intraoral/extraoral fistula in the maxillofacial region persisting >8 weeks
- No history of radiation therapy to the jaws or metastatic disease to the jaws
Risk Stratification by Medication Schedule
The incidence of MRONJ varies dramatically based on dosing regimen: 1
- Oncologic doses (monthly IV bisphosphonates or subcutaneous denosumab): 1-9% incidence, increasing substantially after 2 years of treatment
- Osteoporosis doses (every 6 months): 0-1% incidence
- Oral bisphosphonates: 0-0.5% incidence
Prevention Protocol
Pre-Treatment Dental Assessment
Before initiating bone-modifying agents in non-urgent settings, perform: 1
- Comprehensive dental and periodontal examination
- Panoramic radiograph and/or full-mouth intraoral radiographs
- Complete all medically necessary dental procedures before starting therapy
- Ensure full mucosal coverage of bone before initiating bisphosphonates or denosumab
Critical caveat: In urgent oncologic situations (rapidly progressive bone disease, acute hypercalcemia), the benefits of promptly starting therapy may outweigh MRONJ risk, and partial dental evaluation is acceptable. 1
Modifiable Risk Factors to Address
The multidisciplinary team must address these factors before starting therapy: 1
- Poor oral health and dental disease
- Uncontrolled diabetes mellitus
- Tobacco use
- Ill-fitting dentures
Ongoing Dental Care During Treatment
Patients on bone-modifying agents require: 1
- Routine dental follow-up every 6 months
- Maintenance of excellent oral hygiene
- Patient education about MRONJ risk, especially with tooth extractions and invasive procedures
- Notification to dental practitioners about their medication status
Management of Dental Procedures During Treatment
Elective Procedures
Elective dentoalveolar surgery (non-medically necessary extractions, alveoloplasties, dental implants) should NOT be performed during active therapy with bone-modifying agents at oncologic doses. 1
Exceptions may be considered only when a dental specialist with MRONJ expertise has reviewed risks/benefits with the patient and oncology team. 1
Necessary Dental Surgery
If dentoalveolar surgery must be performed: 1
- Evaluate the patient every 6-8 weeks until complete mucosal coverage occurs
- Maintain communication between dental specialist and oncologist regarding healing status
- Consider deferring the next bone-modifying agent dose until healing is complete (at treating physician's discretion)
Important limitation: There is insufficient evidence to support or refute mandatory discontinuation of bone-modifying agents before dental surgery—this decision remains at the treating physician's discretion after discussion with the patient and oral health provider. 1
Treatment of Established MRONJ
Initial Conservative Management
Conservative measures comprise the first-line approach: 1
- Antimicrobial mouth rinses
- Systemic antibiotics when clinically indicated
- Effective oral hygiene maintenance
- Conservative surgical interventions (removal of superficial bone spicules only)
Refractory Disease
Aggressive surgical interventions (mucosal flap elevation, block resection of necrotic bone, soft tissue closure) may be used if: 1
- MRONJ causes persistent symptoms despite conservative treatment
- MRONJ affects function
- Do NOT perform aggressive surgery for asymptomatic bone exposure
The multidisciplinary team must thoroughly discuss risks and benefits before aggressive intervention. 1
Medication Management During Active MRONJ
There is insufficient evidence to mandate discontinuation of bone-modifying agents in patients with established MRONJ—administration may be deferred at the treating physician's discretion after discussion with the patient and oral health provider. 1
The dental specialist should communicate objective healing status (resolved, improving, stable, or progressive) to the oncologist, as this may affect decisions about cessation or recommencement of therapy. 1
Monitoring Requirements
Before Starting Therapy
All patients require: 1
- Serum calcium measurement
- Renal function assessment (for IV bisphosphonates)
- Dental examination where feasible
During Treatment
Monitor for: 1
- Serum calcium levels (especially in first weeks of therapy)
- Renal function and serum creatinine (for IV bisphosphonates)
- Signs/symptoms of MRONJ at routine dental visits
Provide calcium and vitamin D supplementation unless contraindicated (oral bisphosphonates and calcium should be separated by at least 2 hours). 1
Special Populations
Cancer Patients on Adjuvant Therapy
For postmenopausal women with breast cancer receiving adjuvant bisphosphonates, the same prevention strategies apply, though MRONJ risk is substantially lower (0-1.8%) compared to oncologic dosing. 1
Multiple Myeloma Patients
Baseline dental examination and ONJ monitoring are mandatory for all patients receiving bone-modifying agents, with continuation of therapy for up to 2 years recommended; beyond 2 years should be based on clinical judgment. 1
Critical Practice Points
The risk of ONJ increases with frequency, dose, and duration of administration—risk is substantially lower with osteoporosis-indicated schedules compared to oncologic doses. 1
Staging should be performed by a clinician experienced in MRONJ management. 1
Ongoing collaboration among dentist, dental specialist, and oncologist is essential to optimal patient care. 1