Medication-related osteonecrosis of the jaw (MRONJ) is an uncommon but important adverse event associated mainly with antiresorptive or antiangiogenic therapy. Dental decisions should balance MRONJ risk against the serious harm of interrupting essential osteoporosis or cancer treatment without medical coordination.
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Recognising suspected MRONJ
The AAOMS case definition considers current or previous treatment with an antiresorptive alone or with immune modulators or antiangiogenic agents; exposed bone, or bone probeable through a fistula, persisting for more than eight weeks; and no history of jaw radiation or obvious metastatic disease to the jaws. Pain, swelling, infection, altered sensation or radiographic change may require assessment even before exposed bone is present.
Pre-treatment and ongoing assessment
- Record the exact drug, indication, route, dose schedule, duration and last administration.
- Distinguish osteoporosis regimens from higher-risk oncology regimens.
- Assess periodontal and periapical infection, non-restorable teeth, dentures, implants and oral hygiene.
- Complete necessary preventive and stabilising care before high-risk therapy when medically feasible.
- Coordinate invasive decisions with the prescribing team; do not independently stop medication.
- Explain uncertainty, alternatives, expected benefit, MRONJ risk and review arrangements.
Risk-context table
| Context | Clinical implication | Approach |
|---|---|---|
| Osteoporosis-dose antiresorptive therapy | MRONJ risk is generally low | Continue necessary dentistry with individual assessment |
| Oncology-dose antiresorptive or antiangiogenic therapy | Higher risk and medical complexity | Coordinate closely before bone-invasive care |
| Active periodontal or periapical infection | Local inflammatory burden | Control disease promptly; avoid neglecting infection |
| Persistent exposed or probeable bone | Possible MRONJ | Document duration, exclude alternatives and refer |
| Proposed drug holiday | Benefit and harm are uncertain and drug-specific | Shared decision with prescriber; never stop autonomously |
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