Articles

Medication-Related Osteonecrosis of the Jaw: An Endodontic Perspective

2025-05-07 12:31
Michael Solomonov DMD, Alex Lvovsky DMD, Vered Katzenell DMD, Joe Ben Itzhak DMD, Elena Lipatova, Yehuda Zadik DMD, MHA
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Medication-related osteonecrosis of the jaw (MRONJ) has emerged as a significant concern in endodontic practice. This article provides a concise review of the currently available literature on MRONJ, compiles a list of associated medications, and offers practical guidelines for endodontists to identify patient risk factors.

Introduction

Since Marx first described it in 2003 [1], osteonecrosis of the jaw (ONJ) has been a major concern for practicing dentists and their patients. Over the past decade, the threat of MRONJ has significantly influenced traditional dental practices, including endodontics, restorative dentistry, prosthodontics, periodontics, orthodontics, and oral and maxillofacial surgery [2].

Despite its importance in clinical practice, MRONJ has received limited attention in endodontic literature [3–8]. Sarathy et al. [4] described two cases where patients were referred for endodontic treatment due to symptoms mimicking ONJ, emphasizing the importance of consulting with oral surgeons and oncologists. Katz [3] documented three cases of MRONJ after tooth extractions, with no direct endodontic complications. Kyrgidis et al. [5] reviewed the literature, suggesting that endodontic therapy might delay or avoid extractions in bisphosphonate-treated patients. Moinzadeh et al. [6] discussed clinical implications and prevention strategies in endodontic treatment. Wigler et al. [7] reported a case of MRONJ following extraction of a mandibular molar with a vertical root fracture, noting that timely diagnosis could prevent unnecessary interventions. Alsalleeh et al. [8] highlighted the necessity of thorough dental evaluations before bisphosphonate therapy.

Thus, the purpose of this article is to summarize current knowledge regarding MRONJ and propose clinical considerations specific to endodontic practice.

Medication-Related Osteonecrosis of the Jaw (MRONJ)

MRONJ is defined by the American Association of Oral and Maxillofacial Surgeons (AAOMS) [9] and the American Society for Bone and Mineral Research (ASBMR) [10] as exposed bone (or bone that can be probed through an intraoral or extraoral fistula) in the maxillofacial region that does not heal within eight weeks in a patient with a history of antiresorptive or antiangiogenic therapy, and who has not received craniofacial radiation therapy or has no obvious metastatic disease.

Staging and Management:
  • Stage 0: No clinical evidence of necrotic bone; treat symptomatically.
  • Stage 1: Exposed bone or fistulae without infection; treat with antimicrobial mouth rinses (e.g., chlorhexidine), no surgery.
  • Stage 2: Exposed bone with infection; treat with antimicrobials and systemic antibiotics (e.g., penicillin).
  • Stage 3: Exposed necrotic bone with complications (e.g., fractures, fistulae); surgical intervention combined with antibiotics may be required.

Medications Associated with MRONJ

In addition to bisphosphonates, medications such as denosumab, bevacizumab, and sunitinib have been implicated in MRONJ. Other drugs include aflibercept, azacitidine, everolimus, imatinib, pazopanib, sorafenib, tocilizumab, and trastuzumab [9, 11–19].

Due to the involvement of non-bisphosphonate drugs, AAOMS renamed the condition from "bisphosphonate-related osteonecrosis" to "medication-related osteonecrosis of the jaw."

Table 1. List of medications that can cause the development of MRONJ

*Only in documented cases.

Identifying At-Risk Patients

Identification of a dental patient at risk is achieved through careful review of the patient's medical history, use of structured questionnaires, interviews with the patient, and close communication with previous treating physicians regarding any existing diseases and the use of chronic medications [20]. However, since bisphosphonates may be prescribed on a non-daily basis (e.g., weekly, bi-monthly, monthly, or intravenously once a year), neither the patient nor even their primary care physician may consider these medications as “chronic medications” [21, 22]. Moreover, patients who have discontinued bisphosphonate therapy are still at risk for developing osteonecrosis of the jaw (ONJ) [9], but they may not mention this drug unless specifically asked by the dentist about past medications [22]. Therefore, the fact of having taken these medications may be overlooked, and at-risk patients may not be identified. Situations have been identified where patients do not remember the names of previously taken medications, especially when there were several, as well as among cancer patients who had undergone multiple treatment protocols over the years. Dentists must be familiar with the indications for these medications and seek information from reliable sources (e.g., hospital records), especially with patients suffering from the following conditions: multiple myeloma, metastatic or osteolytic lesions, malignant tumors (such as breast, prostate, or lung cancer), cancer-related hypercalcemia, osteoporosis, osteopenia, chronic corticosteroid use, Paget’s disease, osteogenesis imperfecta, juvenile osteoporosis, fibrous dysplasia, and Gaucher’s disease [23].

Another Possible Reason for Failure to Identify At-Risk Patients
Another possible reason for failing to identify patients at risk is the use of non-bisphosphonate drugs associated with the development of MRONJ. Even dentists familiar with the harmful effects of bisphosphonates may not be aware of these other medications. Thus, dentists may overlook these patients, even when complete medical histories are provided [20]. Therefore, dentists must be aware of the increasing risk of jaw osteonecrosis associated with these drugs and stay updated with the latest research, as additional MRONJ-associated drugs are likely to emerge in the future.

Treatment Planning for At-Risk Patients

In patients with a history of bisphosphonate or related drug use, MRONJ can manifest after oral surgical procedures, due to local inflammation, or without any obvious cause [24–26]. There is also a risk of ONJ developing around previously integrated dental implants, even if bisphosphonate therapy started long after successful osseointegration [27, 28].

Following the AAOMS protocol [9], surgical procedures (tooth extractions, implant placements, apical surgeries, etc.) should be avoided in patients exposed to intravenous bisphosphonates (bevacizumab, denosumab, or sunitinib). In patients who have taken oral bisphosphonates for more than or less than four years but have additional MRONJ risk factors (such as long-term corticosteroid therapy, chronic anemia, poorly controlled diabetes, or other wound-healing impairments), the dentist should carefully consider surgical interventions and consult with the treating physician [9], along with employing atraumatic techniques, antibiotic coverage, and local antiseptic measures. Some clinicians only perform surgeries in patients whose serum C-terminal peptide levels are >150 µg/m [29, 30].

To avoid surgery in at-risk patients, clinicians should attempt to retain teeth that may otherwise be considered non-restorable. Recommended procedures include root canal treatment (or retreatment), sealing the root canal with restorative material (e.g., amalgam or glass ionomer cement), and performing decoronation (removing the crown down to the gum level) (Fig. 2).
The fact that ONJ can appear around dental implants many years after successful osseointegration [27, 28] (Fig. 3) calls for a paradigm shift. The practice of extracting compromised teeth and immediately placing implants without attempting to save the tooth should be reconsidered. Early extractions and implantations in younger patients may lead to complications later in life when patients begin bisphosphonate or other MRONJ-associated therapies.

MRONJ and Endodontic Procedures

Apical Periodontitis

As mentioned earlier, MRONJ may occur following oral surgery or local inflammation (e.g., periodontitis) [25]. ONJ can also arise from inflammatory processes in the alveolar bone, such as apical periodontitis (Fig. 4) [31]. Since endodontic treatment itself does not increase the risk of MRONJ, but apical periodontitis does, endodontic therapy is recommended, especially before initiating antiresorptive therapy.

Apical Surgery

Any surgical manipulation of jawbone carries a risk of ONJ development in patients who have used the mentioned medications. When surgery is indicated, it must be performed following the previously outlined guidelines.

Subgingival Clamps

During endodontic treatment, subgingival clamps should be avoided for rubber dam isolation, as they can damage oral tissues and trigger MRONJ [32]. Many atraumatic isolation techniques exist today, such as ligature methods, spit dam techniques, restoration of the crown stump for supragingival clamping, and projection access techniques [33–35].

Vertical Root Fracture

Vertical root fractures (VRFs) require special attention because no effective therapy currently exists to save such teeth. Among endodontically treated teeth that were extracted, 10–36% were due to VRFs [36, 37]. Various procedures during endodontic treatment and prosthetic work can cause fractures, including excessive dentin removal [38], chemical damage [39, 40], and improper obturation techniques [41, 42]. Prosthetic factors include additional dentin removal, stress generation within the root dentin [43], and improper selection of intraradicular materials [44].

The occurrence of VRF in at-risk patients poses a dilemma, as extraction may lead to MRONJ [45], while retaining a fractured tooth can also trigger MRONJ due to surrounding bone inflammation. VRF is a primary indication for tooth extraction in these patients, but clinicians must adhere to strict atraumatic techniques (preferably by a specialist), systemic and local antimicrobial measures, and avoid placing any materials in the socket.

Prevention is the best approach [46]. If unavoidable, minimally invasive endodontic and prosthetic techniques should be employed [47]. These techniques include conservative access cavity preparation [48], avoiding the use of instruments with more than 6% taper [49–51], and minimal apical enlargement [52, 53]. Emphasis should be placed on instruments and techniques that minimize microcrack formation [54–56]. Use sodium hypochlorite at moderate concentrations (2.5–3.5%) [39, 40]. If necessary, temporary calcium hydroxide dressings may be used for up to 1 month [57, 58]. During obturation, the use of NiTi spreaders [59] and pre-fitted pluggers [60, 61] is recommended.

From a prosthetic standpoint, avoid using intraradicular posts [62, 63]. If absolutely necessary, posts should be placed after removing filling material with a heated plugger [64]. The post space should be prepared to maximum length [65] without compromising apical seal [66, 67] or removing too much healthy dentin [64]. Cementing posts with venting is recommended to reduce stress in the root dentin [68].

Conclusions

The emergence of MRONJ (Medication-Related Osteonecrosis of the Jaw) is reshaping modern dental practice. Despite relatively limited attention in endodontic literature, endodontics plays a crucial role in preventing MRONJ by preserving the integrity of the dentition, properly preparing teeth before the initiation of antiresorptive therapy, and carefully managing at-risk patients. Endodontic treatment and the decoronation of non-restorable teeth serve as powerful tools for the prevention of MRONJ in these individuals.

The endodontist must identify such patients as early as possible and recognize potential MRONJ lesions.
As previously mentioned, osteonecrosis of the jaw may develop many years after surgical procedures, even if those procedures were performed when the patient was not yet under antiresorptive treatment.

This critically important discovery has enormous implications for practicing dentists, as improperly treated teeth in the past can lead to significant future complications and patient suffering. Since patients are aging and the demand for antiresorptive therapy will continue to rise, preserving natural tooth structure through minimally invasive dental procedures should be a priority for all patients to minimize the risk of vertical root fractures.

Finally, the endodontist should always consider the possibility of MRONJ when diagnosing orofacial pain and intraoral symptoms in at-risk patients, even in the absence of exposed bone in the oral cavity.

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1 Medication-Related Osteonecrosis of the Jaws (MRONJ).

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