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.
Contents
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 |
Principles for dental management
Prioritise prevention, effective plaque control, regular review and treatment of infection. For invasive care, assess alternatives and use a careful surgical and follow-up plan consistent with current guidance. Bone turnover markers should not be treated as validated stand-alone predictors of MRONJ risk. Suspected disease warrants appropriate imaging, differential diagnosis and specialist involvement.
Related DentalReach reading
Frequently asked questions
Should antiresorptive medication be stopped before extraction?
Not automatically. The decision is drug-, indication- and patient-specific and requires coordination with the prescriber.
Does every exposed bone area represent MRONJ?
No. Duration, medication history, radiation history and alternative diagnoses must be assessed.
Can a blood test predict MRONJ reliably?
No single marker is a validated stand-alone predictor. Base decisions on the full clinical and medical risk context.
References
- AAOMS MRONJ position paper—2022 update.
- ADA osteoporosis medications and MRONJ resource.
- ADA oncology agents and MRONJ resource.
MRONJ prevention depends on medication indication, regimen, local disease and procedural need; connect these factors through the medical-risk and medication-coordination hub.
MRONJ risk should be assessed without automatically stopping essential treatment; use the medication adverse-effects and dental safety hub.
Explore more with DentalReach
Read the DentalReach dental magazine for professional perspectives, browse clinical dental articles for practical learning, and follow dental news for updates across the profession. You can also read our dental magazine editions.
Continue learning through dental events and conferences, listen to dental podcasts featuring professional conversations, and exchange questions and experiences in our dental forums.
For your next career step, explore dental jobs and opportunities across dental practices and organizations.
