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AAOMS position paper renames and expands the scope of Bisphosphonate Related Osteonecrosis of the Jaw – now Medication Related Osteonecrosis of the Jaw (MRONJ)

June 26th, 2014

A new position paper on Medication Related Osteonecrosis of the Jaw (MRONJ) released today by the American Association of Oral and Maxillofacial Surgeons expands the scope of the condition previously referred to as Bisphosphonate-Related Osteonecrosis of the Jaw (BRONJ) and changes its name to reflect the antiresorptive (denosumab) and antiangiogenic therapies that have recently been associated with the condition.
In addition to changing the name of the condition, the MRONJ position paper provides guidance to:

  1. physicians, dentists, dental specialists, and patients in making medical decisions relating to the risk of developing MRONJ, as well as the risks and benefits of those medications related to osteonecrosis of the jaw (ONJ);
  2. clinicians regarding diagnosis of MRONJ in patients with a history of exposure to antiresorptive and/or antiangiogenic agents; and to
  3. clinicians regarding MRONJ prevention measures and management strategies for patients with MRONJ, based on their disease stage.

MRONJ appears as a non-healing exposed bone in the mouth and may affect patients undergoing intravenous cancer-related therapy, or more rarely, patients treated with oral or IV bisphosphonates for osteoporosis.
Written by the members of the distinguished AAOMS Special Committee that prepared previous position papers on BRONJ in 2006 and 2009, the new MRONJ paper contains revisions to diagnosis, staging, and management strategies, and highlights the status of current research relating to this condition. 
In order to distinguish Medication Related ONJ from other delayed healing conditions and to address concerns about under-reporting of the disease, the new position paper redefines the diagnosis characteristics of MRONJ as follows:
Patients may be considered to have MRONJ if all of the following characteristics are present:

  1. Current or previous treatment with antiresorptive or antiangiogenic agents;
  2. Exposed bone or bone that can be probed through an intraoral or extraoral fistula(e) in the maxillofacial region that has persisted for more than eight weeks; and
  3. No history of radiation therapy to the jaws or obvious metastatic disease to the jaws.

The majority of patients on antiresorptive or antiangiogenic therapy who experience MRONJ do so following a dental procedure, such as a tooth extraction. Therefore if systemic conditions permit, the position paper suggests that the start of antiresorptive therapy should be delayed until the patient’s dental health is optimized. The MRONJ position paper further recommends that patients who are about to be prescribed antiresorptive or antiangiogenic therapy should undergo a thorough oral examination and a radiographic assessment when indicated in order to identify both acute infection and sites of potential infection that could be exacerbated once drug therapy begin. The paper cautions that any decisions relating to drug therapy must be made in conjunction with the treating physician, dentist and other specialists involved in caring for the patient.

MRONJ is painful and difficult to treat. While osteonecrosis of the jaw has been recognized by dental and medical practitioners for many years, the identification of bisphosphonates as a contributory factor to the condition was first reported by oral and maxillofacial surgeons about 10 years ago when they noticed an increase in the number of patients exhibiting the signs of ONJ. A review of these cases indicated that bisphosphonate therapy was a common thread.

In 2006, the AAOMS appointed the Special Committee on BRONJ to review the existing literature and prepare a position paper that synthesized the findings for the dental and medical communities. This Special Committee was reconstituted in 2009 and again in 2013 to review current research findings. The 2014 Position Paper on Medication Related Osteonecrosis of the Jaws offers the most recent and up to date diagnosis and treatment information to dental and medical professionals, clinicians and patients.

The complete 2014 MRONJ Position Paper is available at aaoms.org.