Medication-Related Osteonecrosis of the Jaw

Publication Date: July 22, 2019
Last Updated: December 15, 2022


It is recommended that the term “medication-related osteonecrosis of the jaw" (MRONJ) be used when referring to bone necrosis associated with pharmacologic therapies. ( FC , Ins , W )

Clinicians should confirm the presence of all three of the following criteria in order to establish a diagnosis of MRONJ: 1) Current or previous treatment with a BMA or angiogenic inhibitor, 2) Exposed bone or bone that can be probed through an intraoral or extraoral fistula in the maxillofacial region and that has persisted for longer than 8 weeks, and 3) No history of radiation therapy to the jaws or metastatic disease to the jaws. ( FC , Ins , W )

Risk Reduction

Coordination of Care

For cancer patients scheduled to receive a BMA in a non-urgent setting, oral care assessment (including a comprehensive dental, periodontal, and oral radiographic exam when feasible to do so) should be undertaken prior to initiating therapy. Based on the assessment, a dental care plan should be developed and implemented. The care plan should be coordinated between the dentist and the oncologist to ensure that medically necessary dental procedures are undertaken prior to initiation of the BMA. Follow-up by the dentist should then be performed on a routine schedule (e.g., every six months) once therapy with a BMA has commenced. ( EB , L , M )

Modifiable Risk Factors

Members of the multidisciplinary team should address modifiable risk factors for MRONJ with the patient as early as possible. These risk factors include poor oral health, invasive dental procedures, ill-fitting dentures, uncontrolled diabetes mellitus, and tobacco use. ( FC , Ins , M )

Elective Dentoalveolar Surgery

Elective dentoalveolar surgical procedures (e.g., non-medically necessary extractions, alveoloplasties, and implants) should not be performed during active therapy with a BMA at an oncologic dose. Exceptions may be considered when a dental specialist with expertise in prevention and treatment of MRONJ has reviewed the benefits and risks of the proposed invasive procedure with the patient and the oncology team. ( EB , I , M )

Dentoalveolar Surgery Follow-Up

If dentoalveolar surgery is performed, patients should be evaluated by the dental specialist on a systematic and frequently scheduled basis (e.g., every 6-8 weeks) until full mucosal coverage of the surgical site has occurred. Communication with the oncologist regarding status of healing is encouraged particularly when considering future use of BMA (Table 2). ( FC , Ins , M )

Temporary Discontinuation of BMAs Prior to Dentoalveolar Surgery

For patients with cancer who are receiving a BMA at an oncologic dose, there is insufficient evidence to support or refute the need for discontinuation of the BMA prior to dentoalveolar surgery. Administration of the BMA may be deferred at the discretion of the treating physician, in conjunction with discussion with the patient and the oral health provider. (, , )


A well-established staging system should be used to quantify the severity and extent of MRONJ and to guide management decisions. Options include the 2014 AAOMS staging system, the Common Terminology Criteria for Adverse Events (CTCAE) 5.0 and the 2017 International Task Force on ONJ (osteonecrosis of the jaw) staging system for MRONJ. The same system should be used throughout the patient’s MRONJ course of care. Diagnostic imaging may be used as an adjunct to these staging systems. ( FC , Ins , W )

Optimally, staging should be performed by a clinician experienced with the management of MRONJ. ( FC , Ins , W )


Initial Treatment of MRONJ
Conservative measures comprise the initial approach to treatment of MRONJ. Conservative measures may include antimicrobial mouth rinses, antibiotics if clinically indicated, effective oral hygiene, and conservative surgical interventions (e.g., removal of a superficial bone spicule). ( FC , Ins , M )
Treatment of Refractory MRONJ
Aggressive surgical interventions (e.g., mucosal flap elevation, block resection of necrotic bone, soft tissue closure) may be used if MRONJ results in persistent symptoms or impacts function despite initial conservative treatment. Aggressive surgical intervention is not recommended for asymptomatic bone exposure. In advance of the aggressive surgical intervention, the multidisciplinary care team and the patient should thoroughly discuss the risks and benefits of the proposed intervention. ( FC , Ins , W )
Temporary Discontinuation of BMAs
For patients diagnosed with MRONJ while being treated with BMAs, there is insufficient evidence to support or refute the discontinuation of the BMAs. Administration of the BMA may be deferred at the discretion of the treating physician, in conjunction with discussion with the patient and the oral health provider. ( FC , Ins , W )
Outcome Measures
During the course of MRONJ treatment, the dentist/dental specialist should communicate with the medical oncologist the objective and subjective status of the lesion – resolved, improving, stable or progressive. The clinical course of MRONJ may impact local and/or systemic treatment decisions with respect to cessation or recommencement of BMAs. ( FC , Ins , W )

Recommendation Grading




Medication-Related Osteonecrosis of the Jaw

Authoring Organizations

Publication Month/Year

July 22, 2019

Last Updated Month/Year

December 15, 2022

Document Type


External Publication Status


Country of Publication


Target Patient Population

Adult patients with cancer who are receiving bone-modifying agents (BMAs) for any oncologic indication

Target Provider Population

Oncologists and other physicians, dentists, dental specialists, oncology nurses, clinical researchers, oncology pharmacists

Inclusion Criteria

Female, Male, Adult, Older adult

Health Care Settings

Ambulatory, Hospital, Outpatient

Intended Users

Physician assistant, physician, health systems pharmacist, nurse practitioner, nurse, dentist, clinical researcher


Prevention, Management

Diseases/Conditions (MeSH)

D059266 - Bisphosphonate-Associated Osteonecrosis of the Jaw, D010020 - Osteonecrosis


medication-related osteonecrosis of the jaw, jaw osteonecrosis, Osteonecrosis, supportive care, MRONJ, bone-modifying agents, BMAs

Source Citation

DOI: 10.1200/JCO.19.01186 Journal of Clinical Oncology 37, no. 25 (September 01, 2019) 2270-2290.

Supplemental Methodology Resources

Data Supplement


Number of Source Documents
Literature Search Start Date
January 1, 2003
Literature Search End Date
December 31, 2017
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