2026 Catalog: All Courses

November 2025 Periodontal Pearl:
Reading Materials:
https://aaoms.org/wp-content/uploads/2024/03/mronj_position_paper.pdf

https://aaoms-annual-meeting-2025.eventscribe.net/fsPopup.asp?PresentationID=1581123&mode=presInfo

https://pubmed.ncbi.nlm.nih.gov/32404281/

Updates on MRONJ and MRONJ Management

Definition MRONJ: History of or current use of antiresorptive or antiangiogenic agents, exposed bone or bone probed through an intraoral or extraoral fistula persisting for >8 weeks. No h/o radiation therapy to the jaw, and excludes dental etiology for infection.
RECOGNIZE THE MEDICATIONS
[so many different names- and new ones too!]
Cancer Drugs   Osteoporosis Drugs
Bisphosphonates
   Pamidronate [Aredia]
   Zoledronate [Zometa]
Denosumab [Xgeva]
Angiogenesis inhibitors
Tryosine kinase inhibitors
   Sunitinib [Sutent]
   Sorafenib [Nexavar]
Anti VEGF monoclonal antibody
   Bevacizumab [Avastin]
Other drugs [eg, Rituximab, everolimus, doxorubicin, methotrexate, adalimumab, epacadostat/pembrolizumab]   Bisphosphonates   
   Alendronate [Fosamax]
   Risendronate [Actonel]
   Ibandronate [Boniva]
   Zolendronate [Reclast]
Denosumab [Prolia]
Romosozumab [Evenity]

AAOMS Position Paper 2022: “Antiresorptive medication, coupled with inflammation or infection, is necessary and sufficient to induce MRONJ.”

Updates/Paradigm shift in care:
•   Contrary to what we were taught in the past, bisphosphonate uptake is NOT preferential to the jaws, and bone turnover is NOT over suppressed. 1
•   Bone turnover markers no longer used.
[eg. CTX]
•   Infection can increase the risk of ONJ.
•   Have a lower threshold for extracting infected teeth for patients receiving these medications.
Occurrence: Low risk. < 5 with bisphosphonate treatment for cancer,
< 0.05 with bisphosphonate use with osteoporosis
[Typically, patients with cancer are receiving IV forms of bisphosphonates, and have other comorbidities. However, beware-more physicians are prescribing IV bisphosphonates for osteoporosis! Be sure to ask your patients which kind they are receiving.]
Location of Occurrence: Mandible [75] vs maxilla [25], In both jaws, 4.5
Risk Factors:
Local: Dentoalveolar surgery- can expose existing lesion. Preexisting dental, periapical, periodontal and periimplant infections. Poorly fitting dentures [especially the posterior lingual plate region], PDL widening.
Systemic: Comorbid conditions, oxidative stress, steroids, immunosuppressive drugs, low serum albumin.
Antiresorptive drugs: Current estimates for risk of MRONJ among osteoporotic patients exposed to Bisphosphonates after tooth extractions range from 0-0.15; for Denosumab, 1; Denosumab increases risks over 2 years and plateaus.
For cancer patients, the risk of developing MRONJ after tooth extraction varies, but clusters between 1-5
For Zolendronate up to 2-year use: 1-4, after 2 years: 3.8-18;2

MRONJ PREVENTION STRATEGY
   Non malignant
[osteoporosis]   Malignant
[eg. Cancers, multiple myeloma]
Pretherapy
[if you’re lucky enough to see them prior to the patient starting the med]   •   Educate patient about the potential risks associated with longer antiresorptive use
•   Optimize dental health   •   Educate patient about the higher risks of MRONJ and importance of regimented dental care
•    Optimize dental health prior to initiation of ART [Antiresorptive Therapy]
During antiresorptive therapy
   •   NO change in operative plan for most patients
•   Consider other medications [chemotherapy, steroids or antiangiogenics]
•   Degree of underlying infections/inflammation and extent surgery to be performed
•   Drug holidays are controversial   •   Educate patient about higher MRONJ risk in setting of malignant disease
•   Educate patient about the importance of regimented dental care and prevention
•   Avoid dentoalveolar surgery if possible
•   Consider root retention technique to avoid extractions
•   Remove infected teeth if RCT or root retention is not viable
•   Dental implants are contraindicated
•   Drug holidays are controversial
There is increasing evidence that untreated infection increases the risks of developing MRONJ.

Pre, Peri-, Post operative Management option:
Pentoxifylline 400mg PO BID x 3months Tocopherol 1000 IU [400mg] PO BID x 3 months.


STAGING OF MRONJ3,4
Stage 0   No clinical evidence of necrotic bone. Nonspecific
symptoms or clinical and radiographic findings.    Stage 0
Symptoms:
•   Dental pain not explained by odontogenic cause.
•   Dull aching pain in the jaw which ay radiate
•   Sinus pain, which may be associated with inflammation and thickening of the maxillary sinus wall.
•   Altered neurosensory function.

Clinical findings:
•   Loosening of teeth not explained by chronic periodontal disease
•   Intraoral or extraoral swelling.

Non-Specific Radiographic findings:
•   Alveolar bone loss or resorption not attributable to chronic periodontal disease
•   Changes to trabecular pattern sclerotic bone and no new bone in extraction sockets
•   Regions of osteosclerosis involving the alveolar bone and or the surrounding basilar bone.
•   Thickening/obscuring of the PDL [thickening of the lamina dura, sclerosis and decreased size of PDL space]

Stage 1   Exposed and necrotic bone or fistula, that probes to the bone in patients who are asymptomatic and no evidence of infection/inflammation. Radiographic findings that may also be seen in Stage 0       
Stage 2   Exposed and necrotic bone or fistula, that probes to the bone in patients who are symptomatic. These patients are symptomatic with evidence of infection/inflammation. Radiographic findings that may also be seen in Stage 0       
Stage 3   Exposed and necrotic bone or fistula, that probes to the bone in with evidence of infection, and one or more of the following:
•   Exposed necrotic bone extending beyond the region of alveolar bone [i.e., inferior border or ramus in the mandible, maxillary sinus or zygoma in the maxilla]
•   Pathologic fracture
•   Oral antral/oral nasal communication
Osteolysis extending to the inferior border of the mandible or sinus floor [via radiographic imaging]   


   

MANAGEMENT OF MRONJ3,4
Stage 0   Stage 1   Stage 2   Stage 3
Pain control,
Close follow up/assessment
Re-stage   Local wound care to exposed bone, antimicrobial rinses, removal of mobile/well-formed sequestrum   Local wound care to exposed bone, antimicrobial rinses, removal of mobile/well-formed sequestrum   Local wound care to exposed bone, antimicrobial rinses, removal of mobile/well-formed sequestrum
      Systemic antibiotics
Pain control   Systemic antibiotics
Pain control
•   Local Wound care:    
o   The highest rate of success is reported from use of a cotton swab or toothbrush to mechanically clean exposed bone or fistula with chlorhexidine.
o   Local wound care may not be as effective as surgical management.
Updates/Paradigm shift in care:
•   If symptoms progress with conservative treatment [pain, swelling, etc.], or there is increased bone exposure and radiographic bone destruction, consider surgical treatment, whether its extraction and/or debridement. May require at this point, referral to OS.
•   Early Surgical treatment is recommended for patients who fail nonsurgical management.
•   Conservative treatment is less successful in advanced stages.
Drug Holiday: Controversial. No evidence to support doing this. Not recommended. Only to be stopped by the physician prescribing the med. Prolia has a rebound hyper-osteoclastic effect for ~2 months after stopping, where these patients are at higher risks of skeletal fractures. 3,4

References:
1 Lesclous P, Cloitre A, Catros S, Devoize L, Louvet B, Châtel C, Foissac F, Roux C. Alendronate or Zoledronic acid do not impair wound healing after tooth extraction in postmenopausal women with osteoporosis. Bone. 2020 Aug;137:115412. doi: 10.1016/j.bone.2020.115412. Epub 2020 May 20. PMID: 32404281.
2. Ng, T.L., Tu, M.M., Ibrahim, M.F.K. et al. Long-term impact of bone-modifying agents for the treatment of bone metastases: a systematic review. Support Care Cancer 29, 925–943 [2021]. https://doi.org/10.1007/s00520-020-05556-0
3 AAOMS Position Paper 2022
4 Fleisher, Kenneth E. [2025] Current Management for MRONJ: An Evidence Based Approach [eventScribe Live] https://www.eventscribeapp.com/live/videoPlayer.asp?lsfp=YnlUTFVyanUzZXFHS0FXdUQxMnl0elc2YXZveWVXeHdPR2RsYUlhODJtcz0=

1]   Know the stages of MRONJ
2]   Understand management of the different stages of MRONJ
3]   Know the history of MRONJ

The speaker has no conflicts of interest to report.

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None of the faculty/planners for this activity has a conflict of interest, and there is no use of unlabeled or investigative pharmaceutical products or medical devices. No images have been falsified or manipulated to misrepresent treatment outcomes.The educational objectives, content, and selection of educational methods and instructors are conducted independent of any commercial entity.

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