Bisphosphonate-Related Osteonecrosis of the Jaw Treatment & Management

Updated: Mar 11, 2019
  • Author: Remy H Blanchaert, Jr, DDS, MD; Chief Editor: Arlen D Meyers, MD, MBA  more...
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Treatment

Medical Therapy

Nonsurgical management of bisphosphonate-related osteonecrosis of the jaw (BRONJ) may consist of the following:

  • Antimicrobial rinses

  • Systemic antibiotics

  • Systemic or topical antifungals

  • Discontinuation of bisphosphonate therapy

  • No dental therapy or minimally invasive dental therapy (ie, root canal therapy instead of extraction)

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Surgical Therapy

Surgical intervention for bisphosphonate-related osteonecrosis of the jaw (BRONJ) remains limited because of the impaired ability of the bone to heal. Because no long-term or controlled studies on the management of bisphosphonate-related osteonecrosis of the jaw (BRONJ) have been published, the article from AAOMS, which is based on the consensus of a panel discussion, is the best available guide to therapy. [3] The suggested treatment of bisphosphonate-related osteonecrosis of the jaw (BRONJ) is determined by the patient’s classification according to the stages described below.

Stage I is as follows:

  • Antimicrobial rinses (ie, chlorhexidine 0.12%)

  • No surgical intervention

Stage II is as follows:

  • Antimicrobial rinses (ie, chlorhexidine 0.12%)

  • Systemic antibiotics or antifungals (infections may exacerbate BRONJ)

  • Analgesics

Stage III is as follows:

  • Antimicrobial rinses (ie, chlorhexidine 0.12%)

  • Systemic antibiotics or antifungals (infections may exacerbate BRONJ)

  • Analgesics

  • Surgical debridement or resection

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Outcome and Prognosis

Long-term data are not available concerning the appropriate management of bisphosphonate-related osteonecrosis of the jaw (BRONJ). Traditional reconstructive efforts are generally not recommended by most experts. The role of adjunctive procedures (ie, hyperbaric oxygen [HBO]) and vascularized tissue transfers in the reconstructive management of bisphosphonate-related osteonecrosis of the jaw (BRONJ) have yet to be elucidated.

A study by Hinson et al indicated that stopping bisphosphonate therapy before or at the start of treatment for bisphosphonate-related osteonecrosis of the jaw (BRONJ) permits faster resolution of maxillofacial symptoms than does discontinuing bisphosphonate use during or continuing it throughout osteonecrosis management. The study, of 84 patients, found that the median time to resolution of osteonecrosis symptoms in patients who halted bisphosphonate therapy before or at the initiation of treatment was 3 and 6 months, respectively, compared with 12 months for patients who remained on bisphosphonate during jaw treatment. [17]

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Future and Controversies

The wide use of oral bisphosphonates and their role in bisphosphonate-related osteonecrosis of the jaw (BRONJ) have yet to be completely determined. Long-term studies identifying the patients who are at risk for this disease process are still pending.

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