Staging and treatment of medication-related osteonecrosis of the jaw (MRONJ)

MRONJ* staging	Treatment strategies^¶
At risk: No apparent necrotic bone in patients who have been treated with either oral or intravenous bone-modifying agents	No treatment indicated Patient education and reduction of modifiable risk factors
Increased risk: No clinical evidence of necrotic bone, but nonspecific clinical findings, radiographic changes, and symptoms	Systemic management, including the use of pain medication, and close scrutiny and follow-up Refer to dental specialist and follow up every 8 weeks with communication of lesion status to the oncologist Patient education and reduction of modifiable risk factors
Stage 1: Exposed and necrotic bone, or fistulas that probe to bone in patients who are asymptomatic and have no evidence of infection	Antibacterial mouth rinse Clinical follow-up on an every-8-week basis by a dental specialist with communication of lesion status to the oncologist Patient education and reduction of modifiable risk factors
Stage 2: Exposed and necrotic bone or fistulas that probe to bone, associated with infection as evidenced by pain and erythema in the region of the exposed bone with or without purulent drainage	Symptomatic treatment with oral antibiotics and topical antibacterial rinse Pain control Debridement to relieve soft tissue irritation and infection control Clinical follow-up on an every-8-week basis by a dental specialist with communication of lesion status to the oncologist Patient education and reduction of modifiable risk factors
Stage 3: Exposed and necrotic bone or a fistula that probes to bone in a patient with pain, infection, and one or more of the following: exposed and necrotic bone extending beyond the region of alveolar bone (ie, inferior border and ramus in mandible maxillary sinus, and zygoma in the maxilla), resulting in pathologic fracture, extraoral fistula, oral antral or oral nasal communication, or osteolysis extending to the inferior border of the mandible or sinus floor	Symptomatic treatment with oral antibiotics and topical antibacterial rinse Pain control Surgical debridement or resection for long-term palliation of infection and pain Clinical follow-up on an every-8-week basis by a dental specialist with communication of lesion status to the oncologist Patient education and reduction of modifiable risk factors

* Exposed or probable exposed bone in the maxillofacial region without resolution for greater than 8 weeks in patients treated with an antiresorptive and/or an antiangiogenic agent who have not received radiation therapy to the jaws.
¶ Regardless of the disease stage, mobile segments of bony sequestrum should be removed without exposing uninvolved bone. The extraction of symptomatic teeth within exposed, necrotic bone should be considered since it is unlikely that the extraction will exacerbate the established necrotic process.

Originally published in: Ruggiero SL, Dodson TB, Fantasia J, et al. American Association of Oral and Maxillofacial Surgeons Position Paper on Medication-Related Osteonecrosis of the Jaw—2014 Update. J Oral Maxillofac Surg 2014; 72:1949. Table used with the permission of Elsevier Inc. All rights reserved.
Updated and reprinted with permission from:

Yarom N, Shapiro CL, Peterson DE, et al. Medication-Related Osteonecrosis of the Jaw: MASCC/ISOO/ASCO Clinical Practice Guideline. J Clin Oncol 2019. Copyright © 2019 American Society of Clinical Oncology. All rights reserved.

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Staging and treatment of medication-related osteonecrosis of the jaw (MRONJ)