Treatment of Osteonecrosis

Bisphosphonates and Dental Treatment

Some patients have developed osteonecrosis of the jaws after taking bisphosphonates, particularly IV bisphosphonates. Patients receive IV bisphosphonates for a number of reasons. They are usually being treated for multiple myeloma, metastatic breast, lung or prostate cancer. Some patients with severe osteoporosis are also given IV bisphosphonates.

Every patient with metastatic bone cancer is a potential challenge. Many patients who receive IV bisphosphonate infusions may forget to disclose it to the dentist. Patients may say that they are on “chemotherapy”, not listing which specific drugs they are taking. It is important for the dentist to be suspicious that patients with metastatic disease may be on bisphosphonates, and question the patient and their oncologist as to which specific drugs they are taking.

For patients taking oral bisphosphonates for longer than three years prior to any invasive surgery, the current recommendation is a “drug holiday” of three months before surgery and three months after surgery. These recommendations are based on anecdotal evidence that may be of benefit, not on any long-term clinical studies.

List of all bisphosphonate drugs currently available in US:

  • Oral Formulations:
    • Etidronate (Didronel)
    • Tiludronate (Skelid)
    • Alendronate (Fosamax)
    • Risedronate (Actonel)
    • Ibandronate (Boniva)
  • IV Formulations:
    • Pamidronate (Aredia)
    • Zoledronate (Zometa)
    • Zoledronate (Reclast)
    • Clodronate (Bonefos)
    • Ibandronate (Boniva IV)

BRONJ Case Definition:

The following working definition of BRONJ has been adopted by the AAOMS. Patients may be considered to have BRONJ if all of the following three characteristics are present:

  1. Current or previous treatment with a bisphosphonate
  2. Exposed, necrotic bone in the maxillofacial region that has persisted for more than eight weeks
  3. No history of radiation therapy to the jaws


Here are three categories of patients:

  1. Patients about to initiate intravenous bisphosphonate therapy
    • If systemic conditions permit, initiation of IV bisphosphonate therapy should be delayed until dental health is optimized
    • Non-restorable teeth and those with a poor prognosis should be extracted. Other elective dentoalveolar surgery necessary should be done at this time.
    • Examine patients with full or partial dentures for areas of mucosal trauma (lingual flange, palatal or mandibular tori, or other exostoses). These areas should be treated if necessary prior to bisphosphonate therapy.
    • If possible, bisphosphonate therapy should be delayed until the extraction site has mucosalized (14-21 days) or until there is adequate osseous healing. Dental prophylaxis, caries control, and conservative restorative dentistry on an ongoing basis are necessary to maintain functionally sound teeth.
  2. Asymptomatic patients receiving intravenous bisphosphonate treatment
    • Procedures that involve direct osseous injury should be avoided. Non-restorable teeth may be treated by crown removal and endodontic treatment of the remaining roots.
    • Placement of dental implants should be avoided in patients exposed to the more potent IV bisphosphonates (zoledronate “Zometa” and pamidronate “Aredia”).
  3. Asymptomatic patients receiving oral bisphosphonate therapy
    • Risk of developing BRON is much smaller than those people treated with IV bisphosphonates
    • BRON can develop spontaneously or after minor trauma
    • These patients seem to have less severe manifestations of necrosis, and respond more readily to stage specific treatment regimens
    • Elective dentoalveolar surgery does not seem to be contraindicated in this group
    • Patients should be informed of the small risk of compromised bone healing. The risk of BRON may be associated with increased duration of treatment with oral bisphosphonates, i.e., greater than three years, and other risk factors including concomitant use of corticosteroids, chemotherapy, diabetes, smoking, excessive alcohol use, and poor oral hygiene


  1. Patients who have taken oral bisphosphonates for less than three years and have no clinical risk factors (corticosteroid therapy, diabetes, smoking, alcohol use, poor oral hygiene, and chemotherapeutic drugs)
    • No alteration or delay in the planned surgery is necessary.
    • If implants are placed, informed consent should be provided related to possible implant failure and possible osteonecrosis of the jaws if the patient continues taking oral bisphosphonates.
    • It is advisable to contact the practitioner who initially prescribed the oral bisphosphonate and suggest monitoring such patients and considering either alternate dosing of the bisphosphonate, drug holidays, or an alterative to bisphosphonate therapy.
    • Implant patients should be on a regular recall schedule
  2. Patients who have taken oral bisphosphonates for less than three years and have also taken corticosteroids concomitantly or have any of the other risk factors listed above
    • The prescribing provider should be contacted to consider discontinuation of the oral bisphosphonate (drug holiday) for at least three months prior to oral surgery (if systemic conditions permit).
    • The bisphosphonate should not be restarted until osseous healing has occurred.
  3. Patients who have taken oral bisphosphonates for more than three years with or without concomitant steroid medication or other risk factors
    • The prescribing provider should be contacted to consider discontinuation of the oral bisphosphonate for three months prior to oral surgery, if systemic conditions permit.
    • The bisphosphonate should not be restarted until osseous healing has occurred.
  4. Patients with an established diagnosis of BRON
    • Treatment objectives are to eliminate pain, control infection of the hard and soft tissues, and minimize the progression or occurrence of bone necrosis
    • Surgical treatment is less predictable than with the established surgical algorithms for osteomyelitis or osteoradionecrosis; therefore, surgery should be delayed if possible
    • Areas of necrotic bone that are a constant source of irritation should be removed or recontoured without exposure of additional bone.
    • Loose segments of bony sequestrum should be removed in patients with pain
    • Patients should avoid elective dentoalveolar surgical procedures.
    • 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.