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Head and Neck
Diagnosis
Mandible-Maxilla and TMJ
Treatment-Related Lesions
Medication-Related Osteonecrosis of Jaw (MRONJ)
Medication-Related Osteonecrosis of Jaw (MRONJ)
Surjith Vattoth, MD, FRCR; Patricia A. Hudgins, MD, FACR
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KEY FACTS

  • Terminology

    • Imaging

      • Top Differential Diagnoses

        • Clinical Issues

          • Diagnostic Checklist

            TERMINOLOGY

            • Abbreviations

              • Medication-related osteonecrosis of jaw (MRONJ)

            • Synonyms

              • Antiresorptive drug-related osteonecrosis of jaw (ARONJ); terms MRONJ & ARONJ preferred over others
              • Bisphosphonate-related osteonecrosis of jaw (BRONJ)
              • Denosumab-related osteonecrosis of jaw (DRONJ)

            • Definitions

              • Medication-related exposed bone, or bone that can be probed through intraoral or extraoral fistula in maxillofacial region, persisting > 8 weeks
                • No history of prior craniofacial radiation therapy
              • Induced by antiresorptive drugs, such as bisphosphonates (BP) & denosumab, & antiangiogenics, such as bevacizumab, sunitinib

            IMAGING

            • General Features

              • Radiographic Findings

                • CT Findings

                  • MR Findings

                    • Imaging Recommendations

                      • Nuclear Medicine Findings

                        DIFFERENTIAL DIAGNOSIS

                          PATHOLOGY

                          • General Features

                            • Gross Pathologic & Surgical Features

                              • Microscopic Features

                                CLINICAL ISSUES

                                • Presentation

                                  • Demographics

                                    • Natural History & Prognosis

                                      • Treatment

                                        DIAGNOSTIC CHECKLIST

                                        • Consider

                                          • Image Interpretation Pearls

                                            • Reporting Tips

                                              Selected References

                                              1. AlDhalaan NA et al: Medication-related osteonecrosis of the jaw: a review. Cureus. 12(2):e6944, 2020
                                              2. Li J et al: Positive effect of pentoxifylline on medication-related osteonecrosis of the jaw. J Stomatol Oral Maxillofac Surg. 121(3):264-7, 2020
                                              3. Limones A et al: Medication-related osteonecrosis of the jaws (MRONJ) in cancer patients treated with denosumab VS. zoledronic acid: a systematic review and meta-analysis. Med Oral Patol Oral Cir Bucal. 25(3):e326-36, 2020
                                              4. Ottesen C et al: Efficacy of a high-dose antiresorptive drug holiday to reduce the risk of medication-related osteonecrosis of the jaw (MRONJ): a systematic review. Heliyon. 6(4):e03795, 2020
                                              5. Bodem JP et al: Surgical management of bisphosphonate-related osteonecrosis of the jaw stages II and III. Oral Surg Oral Med Oral Pathol Oral Radiol. 121(4):367-72, 2016
                                              6. Kim HJ et al: Bisphosphonate-related osteonecrosis of the jaw in metastatic breast cancer patients: a review of 25 cases. Maxillofac Plast Reconstr Surg. 38(1):6, 2016
                                              7. Kämmerer PW et al: Surgical evaluation of panoramic radiography and cone beam computed tomography for therapy planning of bisphosphonate-related osteonecrosis of the jaws. Oral Surg Oral Med Oral Pathol Oral Radiol. 121(4):419-24, 2016
                                              8. Melville JC et al: A technique for the treatment of oral-antral fistulas resulting from medication-related osteonecrosis of the maxilla: the combined buccal fat pad flap and radical sinusotomy. Oral Surg Oral Med Oral Pathol Oral Radiol. 122(3):287-91, 2016
                                              9. Rollason V et al: Interventions for treating bisphosphonate-related osteonecrosis of the jaw (BRONJ). Cochrane Database Syst Rev. 2:CD008455, 2016
                                              10. Taguchi A et al: Lack of cooperation between physicians and dentists during osteoporosis treatment may increase fractures and osteonecrosis of the jaw. Curr Med Res Opin. 32(7):1261-8, 2016
                                              11. Krstevska S et al: Osteonecrosis of the jaw after bisphosphonates treatment in patients with multiple myeloma. Med Arch. 69(6):367-70, 2015
                                              12. Bedogni A et al: Oral bisphosphonate-associated osteonecrosis of the jaw after implant surgery: a case report and literature review. J Oral Maxillofac Surg. 68(7):1662-6, 2010
                                              13. Chiu CT et al: Resolution of oral bisphosphonate and steroid-related osteonecrosis of the jaw--a serial case analysis. J Oral Maxillofac Surg. 68(5):1055-63, 2010
                                              14. Filleul O et al: Bisphosphonate-induced osteonecrosis of the jaw: a review of 2,400 patient cases. J Cancer Res Clin Oncol. 136(8):1117-24, 2010
                                              15. Kyrgidis A et al: Dental extractions in patients receiving bisphosphonate therapy. J Oral Maxillofac Surg. 68(7):1704-6; author reply 1706, 2010
                                              16. Lazarovici TS et al: Bisphosphonate-related osteonecrosis of the jaw associated with dental implants. J Oral Maxillofac Surg. 68(4):790-6, 2010
                                              17. Lo JC et al: Prevalence of osteonecrosis of the jaw in patients with oral bisphosphonate exposure. J Oral Maxillofac Surg. 68(2):243-53, 2010
                                              18. Saia G et al: Occurrence of bisphosphonate-related osteonecrosis of the jaw after surgical tooth extraction. J Oral Maxillofac Surg. 68(4):797-804, 2010
                                              19. Setabutr D et al: Necrotizing fasciitis secondary to bisphosphonate-induced osteonecrosis of the jaw. Am J Otolaryngol. 31(2):127-9, 2010
                                              20. Yarom N et al: Is exposure of the jawbone mandatory for establishing the diagnosis of bisphosphonate-related osteonecrosis of the jaw? J Oral Maxillofac Surg. 68(3):705, 2010
                                              21. Arrain Y et al: Bisphosphonates and osteonecrosis of the jaw--current thoughts. Dent Update. 36(7):415-9, 2009
                                              22. Kyrgidis A et al: Bisphosphonate osteonecrosis of the jaws in cancer patients. Breast. 18(5):335, 2009
                                              23. Morag Y et al: Bisphosphonate-related osteonecrosis of the jaw: a pictorial review. Radiographics. 29(7):1971-84, 2009
                                              Related Anatomy
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                                              Related Differential Diagnoses
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                                              References
                                              Tables

                                              Tables

                                              KEY FACTS

                                              • Terminology

                                                • Imaging

                                                  • Top Differential Diagnoses

                                                    • Clinical Issues

                                                      • Diagnostic Checklist

                                                        TERMINOLOGY

                                                        • Abbreviations

                                                          • Medication-related osteonecrosis of jaw (MRONJ)

                                                        • Synonyms

                                                          • Antiresorptive drug-related osteonecrosis of jaw (ARONJ); terms MRONJ & ARONJ preferred over others
                                                          • Bisphosphonate-related osteonecrosis of jaw (BRONJ)
                                                          • Denosumab-related osteonecrosis of jaw (DRONJ)

                                                        • Definitions

                                                          • Medication-related exposed bone, or bone that can be probed through intraoral or extraoral fistula in maxillofacial region, persisting > 8 weeks
                                                            • No history of prior craniofacial radiation therapy
                                                          • Induced by antiresorptive drugs, such as bisphosphonates (BP) & denosumab, & antiangiogenics, such as bevacizumab, sunitinib

                                                        IMAGING

                                                        • General Features

                                                          • Radiographic Findings

                                                            • CT Findings

                                                              • MR Findings

                                                                • Imaging Recommendations

                                                                  • Nuclear Medicine Findings

                                                                    DIFFERENTIAL DIAGNOSIS

                                                                      PATHOLOGY

                                                                      • General Features

                                                                        • Gross Pathologic & Surgical Features

                                                                          • Microscopic Features

                                                                            CLINICAL ISSUES

                                                                            • Presentation

                                                                              • Demographics

                                                                                • Natural History & Prognosis

                                                                                  • Treatment

                                                                                    DIAGNOSTIC CHECKLIST

                                                                                    • Consider

                                                                                      • Image Interpretation Pearls

                                                                                        • Reporting Tips

                                                                                          Selected References

                                                                                          1. AlDhalaan NA et al: Medication-related osteonecrosis of the jaw: a review. Cureus. 12(2):e6944, 2020
                                                                                          2. Li J et al: Positive effect of pentoxifylline on medication-related osteonecrosis of the jaw. J Stomatol Oral Maxillofac Surg. 121(3):264-7, 2020
                                                                                          3. Limones A et al: Medication-related osteonecrosis of the jaws (MRONJ) in cancer patients treated with denosumab VS. zoledronic acid: a systematic review and meta-analysis. Med Oral Patol Oral Cir Bucal. 25(3):e326-36, 2020
                                                                                          4. Ottesen C et al: Efficacy of a high-dose antiresorptive drug holiday to reduce the risk of medication-related osteonecrosis of the jaw (MRONJ): a systematic review. Heliyon. 6(4):e03795, 2020
                                                                                          5. Bodem JP et al: Surgical management of bisphosphonate-related osteonecrosis of the jaw stages II and III. Oral Surg Oral Med Oral Pathol Oral Radiol. 121(4):367-72, 2016
                                                                                          6. Kim HJ et al: Bisphosphonate-related osteonecrosis of the jaw in metastatic breast cancer patients: a review of 25 cases. Maxillofac Plast Reconstr Surg. 38(1):6, 2016
                                                                                          7. Kämmerer PW et al: Surgical evaluation of panoramic radiography and cone beam computed tomography for therapy planning of bisphosphonate-related osteonecrosis of the jaws. Oral Surg Oral Med Oral Pathol Oral Radiol. 121(4):419-24, 2016
                                                                                          8. Melville JC et al: A technique for the treatment of oral-antral fistulas resulting from medication-related osteonecrosis of the maxilla: the combined buccal fat pad flap and radical sinusotomy. Oral Surg Oral Med Oral Pathol Oral Radiol. 122(3):287-91, 2016
                                                                                          9. Rollason V et al: Interventions for treating bisphosphonate-related osteonecrosis of the jaw (BRONJ). Cochrane Database Syst Rev. 2:CD008455, 2016
                                                                                          10. Taguchi A et al: Lack of cooperation between physicians and dentists during osteoporosis treatment may increase fractures and osteonecrosis of the jaw. Curr Med Res Opin. 32(7):1261-8, 2016
                                                                                          11. Krstevska S et al: Osteonecrosis of the jaw after bisphosphonates treatment in patients with multiple myeloma. Med Arch. 69(6):367-70, 2015
                                                                                          12. Bedogni A et al: Oral bisphosphonate-associated osteonecrosis of the jaw after implant surgery: a case report and literature review. J Oral Maxillofac Surg. 68(7):1662-6, 2010
                                                                                          13. Chiu CT et al: Resolution of oral bisphosphonate and steroid-related osteonecrosis of the jaw--a serial case analysis. J Oral Maxillofac Surg. 68(5):1055-63, 2010
                                                                                          14. Filleul O et al: Bisphosphonate-induced osteonecrosis of the jaw: a review of 2,400 patient cases. J Cancer Res Clin Oncol. 136(8):1117-24, 2010
                                                                                          15. Kyrgidis A et al: Dental extractions in patients receiving bisphosphonate therapy. J Oral Maxillofac Surg. 68(7):1704-6; author reply 1706, 2010
                                                                                          16. Lazarovici TS et al: Bisphosphonate-related osteonecrosis of the jaw associated with dental implants. J Oral Maxillofac Surg. 68(4):790-6, 2010
                                                                                          17. Lo JC et al: Prevalence of osteonecrosis of the jaw in patients with oral bisphosphonate exposure. J Oral Maxillofac Surg. 68(2):243-53, 2010
                                                                                          18. Saia G et al: Occurrence of bisphosphonate-related osteonecrosis of the jaw after surgical tooth extraction. J Oral Maxillofac Surg. 68(4):797-804, 2010
                                                                                          19. Setabutr D et al: Necrotizing fasciitis secondary to bisphosphonate-induced osteonecrosis of the jaw. Am J Otolaryngol. 31(2):127-9, 2010
                                                                                          20. Yarom N et al: Is exposure of the jawbone mandatory for establishing the diagnosis of bisphosphonate-related osteonecrosis of the jaw? J Oral Maxillofac Surg. 68(3):705, 2010
                                                                                          21. Arrain Y et al: Bisphosphonates and osteonecrosis of the jaw--current thoughts. Dent Update. 36(7):415-9, 2009
                                                                                          22. Kyrgidis A et al: Bisphosphonate osteonecrosis of the jaws in cancer patients. Breast. 18(5):335, 2009
                                                                                          23. Morag Y et al: Bisphosphonate-related osteonecrosis of the jaw: a pictorial review. Radiographics. 29(7):1971-84, 2009