Vol.3, No.9, 557-559 (2
doi:10.4236/health.2011.39095
C
opyright © 2011 SciRes. Openly accessible at http://www.scirp.org/journal/HEALTH/
011) Health
Prevention and treatment of osteonecrosis of the jaw
Coha Bozena*, Holik Hrvoje, Knezevic-Pravecek Marijana
Department for Internal Medicine, General Hospital “Dr. Josip Benčević”, Slavonski Brod, Croatia;
*Corresponding Author:
Received July 19th, 2011; revised August 9th, 2011; accepted august 24th, 2011.
ABSTRACT
Purpose: to update recommendations for the
prevention and treatment of osteonecrosis of
the jaw in patients on bisphophonate therapy.
Osteonecrosis of the jaw is a rare and serious
complication of bisphosphonate therapy. Also,
it is one of the important and growing clinical
public health issues, because biphosphonates
are now more commonly used than before.
Bisphophonates are primarly used in the treat-
ment of cancer-related conditions such as bone
metastases, hypercalcemia, lytic skeletal le-
sions. More recently, bisphophonate has been
approved for the management of osteoporosis.
The etiology and pathogenesis remain unknown,
however, two important risk factors have been
identified, i.e. the potency and length of bisp hos-
phonate use, and recent dental intervention.
Recommendations: prior to the introduction of
bisphosphonate therapy, all patients should
undergo complete dental examination, any ac-
tive oral cavity infection should be treated and
the potential sites of new infection removed.
During bisphosphonate therapy, patients should
strictly comply with oral hygiene and avoid any
invasive procedure of the oral cavity.
Keywords: Bisphosphonates; Osteonecrosis; Jaw
1. INTRODUCTION
Osteonecrosis of the jaw is a rare and serious compli-
cation of bisphosphonate therapy, first described in the
literature in 2003. A patient currently or previously
treated with bisphosphonates, having a bone protruding
in the maxillofacial region persisting for more than eight
weeks, without a history of radiotherapy, can be consid-
ered as having osteonecrosis of the jaw associated with
bisphosphonates [1]. Bisphophonates are primarly used
in the treatment cancer-related conditions such us bone
metastases, hypercalcemia, lytic skeletal lesions, but more
recently use to treat varied of other skeletal conditions,
such as heritable skeletal disorders in children, multiple
forms of osteoporosis (juvenile, postmenopausal or invo-
lutional, glucocorticoid-induced, transplant-induced, im-
mobility-induced, and androgen-deprivation-related) [2].
According to literature data, the expected risk of jaw
osteonecrosis in patients suffering from malignant dis-
eases treated with bisphosphonates ranges from 1% to
11%, depending on the type, dosage and duration of
bisphosphonate therapy, and on dental or oral procedure
[2-5]. In patients with multiple myeloma, the prevalence
of jaw osteonecrosis has been estimated to 7% - 10% [2].
The etiology and pathophysiology of jaw osteonecrosis
remain obscure; however, two important risk factors have
been identified, i.e. the potency and length of bisphos-
phonate exposure, and recent dental or oral surgery.
Some 70% of patients developing osteonecrosis of the
jaw had a recent dental or oral surgical procedure in their
history, whereas spontaneous occurrence of jaw os-
teonecrosis was recorded in 30% of patients [4]. The
length of bisphosphonate therapy is strongly associated
with the occurrence of jaw osteonecrosis. The patients
developing jaw osteonecrosis received 35 bisphospho-
nate infusions on an average, in comparison with 15
infusions in those without jaw osteonecrosis. The preva-
lence of jaw osteonecrosis was significantly greater after
the use of zoledronic acid than after pamidronate [4,6].
In their study, Bamias et al. found the expected risk to
be 1% in the first year and 21% in the third year of
treatment with zoledronic acid, whereas for pamidronate
it was 0% in the first two years and 7% after four years
of treatment [6]. The disease more frequently involved
the mandible than the maxilla (63% vs 38%). Several
groups and organizations (American Society of Clinical
Oncology (ASCO), Mayo Clinic, and American Asso-
ciation of Oral and Maxillofacial Surgeons (AAOMS))
published guidelines for the prevention and treatment of
bisphosphonate-related osteonecrosis of the jaw, and
they all agree that prevention is the best approach in the
management of this rare and severe complication [1-3].
In 2009, AAOMS published their guidelines for the pre-

C. Bozena et al. / Health 3 (2011) 557-559
Copyright © 2011 SciRes. Openly accessible at http://www.scirp.org/journal/HEALTH/
558
vention and management of bisphosphonate-related os-
teonecrosis of the jaw [1].
2. RECOMMENDATIONS FOR
PREVENTION
1) Prior to the introduction of bisphosphonate therapy
(if compatible with the patient’s condition), the patient
should undergo thorough dental examination; extraction
of teeth that cannot be saved; elective dentoalveolar sur-
gical procedures should be completed, waiting for bone
healing and mucous membrane epithelialization; and the
patient should be informed on the importance of strict
oral hygiene and possible mucosal trauma, in particular
along the lingual region, occurrence of pain, edema or
bone protrusion [1-5].
2) Asymptomatic patient on bisphosphonate therapy:
strict oral hygiene; avoiding any procedure that may
result in bone lesion; a tooth than cannot be cured may
be treated by crown removal and endodontic therapy of
the remaining roots; avoiding implants; and annual den-
tal examination [1,3,4].
3) Asymptomatic patient on bisphosphonate therapy:
elective dentoalveolar surgical procedures may not be
contraindicated in this patient category, but they should
be informed on the risk of osteonecrosis of the jaw [1,2].
The individuals taking oral bisphosphonates for less than
three years and are free from other clinical risk factors
need not postpone the scheduled operative procedures in
the oral and maxillofacial region[1]. If compatible with
the patient condition, in those taking corticosteroids
along with bisphosphonates therapy interruption for at
least three months prior to the procedure should be con-
sidered, and it should not reintroduced until complete
wound and bone healing [1]. In patients taking oral
bisphosphonates for more than three years, therapy
should be discontinued at least three months prior to the
procedure and resumed upon complete bone healing [1].
3. RECOMMENDATIONS FOR
TREATMENT
The aim of treatment in patients diagnosed with os-
teonecrosis of the jaw is to alleviate pain, control the
infection, and reduce progression or development of
bone necrosis. Surgical treatment is less efficient than in
osteomyelitis or bone osteoradionecrosis, therefore it
should be delayed if possible [1,2]. Surgical treatment is
reserved for patients in the third stage of disease and
those with bone sequestration [1]. Elective surgical pro-
cedures should be avoided [1].
Specific treatment depends on clinical stage. Accord-
ing to AAOMS, there are four stages of the disease, pre-
sented in Table 1. [1]. Discontinuation or reintroduction
of bisphosphonate therapy i.v. depends on the assess-
ment of the risk and benefit for the patient, which should
be done by a hemato-oncologist and oral/maxillofacial
surgeon together [1]. Short-term therapy interruption is
of no use, however, if the patient's condition allows it,
then long-term therapy discontinuation may prove useful
to stabilize osteonecrosis of the jaw, reduce the risk of
new sites of bone necrosis and alleviate disease symp-
toms. In patients with osteonecrosis of the jaw, discon-
tinuation of oral bisphosphonate therapy is associated
Table 1. American Association of Oral and Maxillofacial Surgeons: treatment of bisphosphonate-related osteonecrosis of the jaw
according to four stages.
Stage Treatment
Stage 0
Nonspecific clinical signs and symptoms
No signs of bone necrosis
Analgetics and antibiotics
Stage 1
Bone necrosis in asymptomatic patient and without signs of infection
Antibiotic solutions for mouth wash
Clinical follow up every three months
Patient education, revision of indication for bisphosphonates
Stage 2
Protruding and necrotic bone with signs of infection (pain, redness, with or
without purulent discharge)
Symptomatic therapy with oral antibiotics
Antibacterial solutions for mouth wash
Analgesics
Superficial debridement
Stage 3
Protruding and necrotic bone associated with pain, infection, and one or more
of the following findings: bone necrosis extending beyond alveolar bone (e.g.,
lower edge of mandibular ramus, maxillary sinus and zygomatic part of the
maxilla resulting in bone fracture, extraoral fistulas, oral-antral/oral-nasal
fistulas, osteolysis expanding to the lower edge of the mandible or sinus bed
Antibacterial solutions for mouth wash
Antibiotic therapy
Analgesics
Cleaning and resection

C. Bozena et al. / Health 3 (2011) 557-559
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559559
with gradual improvement of clinical status. A 6- to
12-month interruption may lead to spontaneous seques-
tration or healing following surgical intervention [1].
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