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Osteonecrosis of the Jaw (ONJ)

(ON of the Jaw)

By

Stuart B. Goodman

, MD, PhD, Stanford University

Last full review/revision May 2020| Content last modified May 2020
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Osteonecrosis of the jaw is an oral lesion involving bare mandibular or maxillary bone. It may cause pain or may be asymptomatic. Diagnosis is by the presence of exposed bone for at least 8 weeks. Treatment is limited debridement, antibiotics, and oral rinses.

Osteonecrosis of the jaw (ONJ) has no unanimously accepted definition or etiology but is generally held to be an oral lesion involving bare mandibular or maxillary bone.

ONJ may occur spontaneously or after dental extraction or trauma, high-dose IV bisphosphonate therapy, or high-dose denosumab 120 mg subcutaneously once/month (eg, for cancer treatment). ONJ may be a refractory osteomyelitis rather than true osteonecrosis, particularly when associated with bisphosphonate use.

There is no evidence that routine use of oral bisphosphonates for treatment or prevention of osteoporosis increases risk of ONJ. Currently, otherwise appropriate bisphosphonate use should not be discouraged. However, it seems reasonable to do any necessary oral surgery before beginning IV bisphosphonate therapy and to encourage good oral hygiene and regular dental care while patients are taking bisphosphonates (1, 2).

General references

  • 1. Hellstein JW, Adler RA, Edwards B, et al: Managing the care of patients receiving antiresorptive therapy for prevention and treatment of osteoporosis: Executive summary of recommendations from the American Dental Association Council on Scientific Affairs. J Am Dent Assoc 142(11):1243−1251, 2011. doi: 10.14219/jada.archive.2011.0108.

  • 2. Khan A, Morrison A, Cheung A, et al: Osteonecrosis of the jaw (ONJ): Diagnosis and management in 2015. Osteoporos Int 27(3):853–859, 2016. doi: 10.1007/s00198-015-3335-3.

Symptoms and Signs

Osteonecrosis of the jaw may be asymptomatic for long periods. Symptoms tend to develop along with signs, although pain may precede signs. In later stages, ONJ usually manifests with pain and purulent discharge from exposed bone in the mandible or, much less often, the maxilla. The teeth and gingiva may be involved. Intraoral or extraoral fistulas may develop.

Diagnosis

  • Clinical evaluation

Osteonecrosis of the jaw is diagnosed when exposed, necrotic bone is present in the maxilla or mandible for at least 8 weeks.

Treatment

  • Limited debridement, antibiotics, and oral rinses

Once established, osteonecrosis of the jaw is challenging to treat and should be managed by an oral surgeon with experience treating ONJ. Treatment of ONJ typically involves limited debridement, antibiotics, and antibacterial oral rinses (eg, chlorhexidine; 1).

Surgical resection of the affected area may worsen the condition and should not be the initial treatment.

Treatment reference

  • 1. Hellstein JW, Adler RA, Edwards B, et al: Managing the care of patients receiving antiresorptive therapy for prevention and treatment of osteoporosis: Executive summary of recommendations from the American Dental Association Council on Scientific Affairs. J Am Dent Assoc 142(11):1243−1251, 2011. doi: 10.14219/jada.archive.2011.0108.

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