MRONJ is an adverse reaction which can occur as a result of medicines used to treat cancer and osteoporosis. Some<unk> s which induce these effects are bisphosphonates, denosumab and antiangiogenic agents. They involve the destruction of bone in a progressive manner, particularly associated with the mandible or maxilla. The overall effects depend on which drug is being used, the dose and the duration of taking this drug. MRONJ is associated with significant severe disease, negative affects on the quality of life and remains to be increasingly challenging to treat. It is debate whether the various management techniques used for MRONJ are effective. The management of people taking the drugs of concern undergo initial management and continuing management. Before either of these are considered the patient must be as dentally fit as possible. Treatment usually involves antimicrobial mouth washes and oral antibiotics to help the immune system fight the attendant infection, and it also often involves local resection of the necrotic bone lesion. Many patients with MRONJ have successful outcomes after treatment, meaning that the local<unk>  is stopped, the infection is cleared, and the mucosa heals and once again covers the bone. The treatment the person receives depends on the severity of<unk>  of the jaw. Conservative Indicated in patients who have evidence of exposed bone but no evidence of infection. It may not necessarily eliminate all the lesions, but it may provide patients with a long term relief. This approach involves a combination of antiseptic mouthwashes and analgesics and the use of teriparatide. However, note that the teriparatide treatment should not be used in cancer patients, or patients with a history of skeletal radiation or active bone metastases. Splints may be used to protect sites of exposed necrotic bone. Non-surgical Indicated for people with exposed bone with symptoms of infection. This treatment modality may also be utilised for patients with other co-morbidities which precludes invasive surgical methods. This approach requires antimicrobial mouthwashes, systemic antibiotics and antifungal<unk>  and analgesics. Surgery Surgical intervention is indicated in patients with symptomatic exposed bone with fistula formation and one or more of the following: exposed and necrotic bone extending beyond the alveolar bone resulting in pathological fracture; extra-oral fistula; oral antral communication or osteolysis extending from the inferior border of the mandible or the sinus floor. Surgical management involves necrotic bone resection, removal of loose sequestra of necrotic bone and reconstructive surgery. The objective of surgical management is to eliminate areas of exposed bone to prevent the risk of further inflammation and infection. The amount of surgical debridement required remains controversial. Other *Hyperbaric oxygen therapy *Ultrasonic therapy Initial management This involves patients who are about to start, or very recently have started, taking the drugs of concern. There is a small portion of observational studies which promote the idea of preventative dental treatment to decrease oral complications in patients taking these drugs. These preventative measures may require a change in the patients’ oral hygiene technique and lifestyle factors such as smoking and alcohol consumption. There is also a benefit in prescribing high fluoridated toothpaste if the patient is of high caries risk. Before prescribing of any kind or when noticing a patient is on the treatment already, it is encouraged to tell the patient of the risk of developing MRONJ, although this risk is small. This is followed by personalised advice given to the patient, involving: a healthy diet, excellent oral hygiene, stop smoking, limited alcohol consumption and regular dental appointments. If a patient has a complex medical history and is of particular high risk it is advised before any treatment to commence, communication with a specialist with regards to the clinical assessment and treatment plan. It is also advised for individuals who take bisphosphonates to never allow the tablet to dissolve in the mouth as this causes damage to the oral mucosa. The patient must follow the instructions given with the tablets. Continuing management This involves patients who have a regime which actively incorporates the drugs of concern and also for the patients whom undergone initial management. In terms of dental treatment all must be done as normal, accompanied by personalised advice to the patient. If there is a need for an extraction or any procedure which implicates bone a discussion with the patient about the risks and benefits must occur. Due to bacterial resistance and possible side effects of antibiotic therapy, they are only prescribed if there is a necessity for them. There is minimal evidence to say the use of prophylactic antibiotics will reduce MRONJ. For some, it is possible to have a drug holiday during which bisphosphonates are discontinued if the benefit of discontinuing the drug outweighs the risks. If it is possible to have a drug holiday, it is recommended that treatment be carried out during that period. Some patients however have been taking the drug for a prolonged period of time and so the bisphosphonate levels have accumulated in the body. In this case, a drug holiday would be of no benefit. Medical management of MRONJ is most commonly performed for patients who have less severe cases or those whom have contraindicating health conditions. The antimicrobials therapies commonly used are topical, oral and intravenous. Topical antimicrobials A commonly used medicament, chlorhexidine gluconate 0.12% is bacteriostatic and bacteriocidal making an effective agent against MRONJ. Advantages of this topical gel is the low cost, ease of use, availability and patient acceptance. The disadvantages of this are the low compliance, patient acceptance, dental staining and risk of opportunistic bacterial resistance. For some patients, it is possible to have a drug holiday during which bisphosphonates are discontinued if the benefit of discontinuing the drug outweighs the risks. If it is possible to have a drug holiday, it is recommended that treatment be carried out during that period. Some patients however have been taking the drug for a prolonged period of time and so the bisphosphonate levels have accumulated in the body. In this case, a drug holiday would be of no benefit. Antibiotics The use of these are based on the clinical evaluation of the condition and if pathogenic bacteria presence is indicated. This is generally a 2-week course for a person with a persistent presentation of the disease or a 4-6 week course for more severe cases. Penicillin is the first line of choice, although if this is contraindicated commonly used antimicrobials are: clindamycin, fluoroquinolones and/or metronidazole. Intravenous antibiotics may be used when specific infections are resist oral therapies. Although this method has perceived greater penetration of tissue there is little evidence of being a substantial greater efficacy when compared to other methods of management.
Medication-related osteonecrosis of the jaw
Osteomyelitis
Metastatic tumor of jaws
Osteoradionecrosis
Osteonecrosis of the jaw
Dysbaric osteonecrosis
Alveolar osteitis
Osteochondritis dissecans