Management of Osteonecrosis of the Jaw (ONJ) in Osteoporosis Patients – Evidence‑Based Recommendations

1. Antiresorptive Therapy Discontinuation

• ASCO/MASCC 2019 guidelines state that evidence is insufficient to definitively support or refute discontinuation of bone‑modifying agents in cancer patients, highlighting the uncertainty of this decision in that population. Strength of evidence: insufficient. 1, 2
• Low‑level evidence indicates that temporary discontinuation of denosumab may enhance MRONJ (medication‑related ONJ) resolution, supporting drug holiday in osteoporosis patients with established ONJ. Strength of evidence: low. 3, 4
• Pharmacokinetic data show bisphosphonates have extremely long skeletal half‑lives; stopping them at ONJ diagnosis does not produce rapid clinical improvement, whereas continued dosing worsens the necrotic lesion. Strength of evidence: low‑level. 3, 4

2. ONJ Staging and Stage‑Specific Treatment (AAOMS)

• The American Association of Oral and Maxillofacial Surgeons (AAOMS) staging system is the accepted framework for categorizing ONJ severity and guiding therapy. 1, 2, 3

2.1 General Follow‑up

• Patients at any stage should be reviewed by a dental specialist every 8 weeks, with clear communication to the prescribing physician. Strength of evidence: expert consensus. 1, 2

2.2 Stage 2 (Painful exposed bone with infection)

• Management comprises broad‑spectrum oral antibiotics plus antibacterial mouth rinse, appropriate analgesia, and conservative surgical debridement to relieve soft‑tissue irritation and control infection; follow‑up remains at 8‑week intervals. Strength of evidence: expert consensus. 1, 2

2.3 Stage 3 (Extensive bone involvement, pathologic fracture, extra‑oral fistula)

• Treatment includes oral antibiotics, topical antibacterial rinse, aggressive pain control, and surgical debridement or resection for long‑term palliation of infection and pain; ongoing specialist follow‑up is recommended. Strength of evidence: expert consensus. 1, 2

3. Universal Surgical Principles

• Removal of superficial necrotic bone that causes soft‑tissue irritation and loose sequestra should be performed without exposing uninvolved bone. Strength of evidence: expert consensus. 1, 2, 4
• Extraction of symptomatic teeth located within exposed necrotic bone is considered safe and is unlikely to exacerbate the necrotic process. Strength of evidence: expert consensus. 1, 2, 4

Management of Jaw Bone Necrosis

Primary Objectives

• The American College of Oncology recommends controlling pain, managing soft tissue and bone infection, and minimizing the progression or appearance of new bone necrosis as the primary objectives in treating jaw bone necrosis 5, 6, 7

Treatment Strategies by Stage

• For stage 1 jaw bone necrosis, the American College of Oncology suggests using antibacterial mouthwash (such as chlorhexidine gluconate or povidone-iodine) at least twice a day, meticulous oral hygiene with patient education on modifiable risk factors, minor conservative surgery to remove dead bone fragments, and monitoring every 8 weeks by a specialist 5, 6, 7, 8
• In stage 2, the American College of Oncology recommends broad-spectrum oral antibiotics combined with antibacterial mouthwash, pain control using pain relievers, and conservative but thorough surgical debridement to reduce soft tissue irritation and control infection 5, 6, 7, 8
• For stage 3, the American College of Oncology advises controlling pain and infection as in stage 2, and considering surgical debridement or resection as necessary to enhance the resolution of bone necrosis 5, 6, 7, 9

Important Surgical Principles

• The American College of Oncology suggests that regardless of the stage, superficial dead bone fragments causing continuous soft tissue irritation and loose bone fragments should be removed or reshaped to optimize soft tissue healing 5, 7, 9
• Extracting symptomatic teeth within the area of exposed bone necrosis should be considered, as it is unlikely to worsen the existing necrotic process 5, 7, 9

Adjunctive Therapies

• For radiation-induced bone necrosis, the American College of Oncology recommends pentoxifylline and tocopherol combined with antibiotics for better outcomes than antibiotics alone in patients without active cancer 8

Common Pitfalls to Avoid

• The American College of Oncology advises against stopping bisphosphonate/denosumab therapy arbitrarily, as evidence is insufficient to support cessation, and decisions should be discussed among the treating physician, patient, and dentist 5, 7, 10
• Routine use of antibiotics is not recommended unless there are clinical signs of infection 8
• Antibiotics alone are insufficient for progressive bone necrosis, and surgical debridement or resection is necessary 8