Medication-Related Osteonecrosis of the Jaw
Publication Date: July 22, 2019
Last Updated: December 15, 2022
Diagnosis
It is recommended that the term “medication-related osteonecrosis of the jaw" (MRONJ) be used when referring to bone necrosis associated with pharmacologic therapies. ( FC , Ins , W )
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Clinicians should confirm the presence of all three of the following criteria in order to establish a diagnosis of MRONJ: 1) Current or previous treatment with a BMA or angiogenic inhibitor, 2) Exposed bone or bone that can be probed through an intraoral or extraoral fistula in the maxillofacial region and that has persisted for longer than 8 weeks, and 3) No history of radiation therapy to the jaws or metastatic disease to the jaws. ( FC , Ins , W )
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Risk Reduction
Coordination of Care
For cancer patients scheduled to receive a BMA in a non-urgent setting, oral care assessment (including a comprehensive dental, periodontal, and oral radiographic exam when feasible to do so) should be undertaken prior to initiating therapy. Based on the assessment, a dental care plan should be developed and implemented. The care plan should be coordinated between the dentist and the oncologist to ensure that medically necessary dental procedures are undertaken prior to initiation of the BMA. Follow-up by the dentist should then be performed on a routine schedule (e.g., every six months) once therapy with a BMA has commenced. ( EB , L , M )
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Modifiable Risk Factors
Members of the multidisciplinary team should address modifiable risk factors for MRONJ with the patient as early as possible. These risk factors include poor oral health, invasive dental procedures, ill-fitting dentures, uncontrolled diabetes mellitus, and tobacco use. ( FC , Ins , M )
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Elective Dentoalveolar Surgery
Elective dentoalveolar surgical procedures (e.g., non-medically necessary extractions, alveoloplasties, and implants) should not be performed during active therapy with a BMA at an oncologic dose. Exceptions may be considered when a dental specialist with expertise in prevention and treatment of MRONJ has reviewed the benefits and risks of the proposed invasive procedure with the patient and the oncology team. ( EB , I , M )
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Dentoalveolar Surgery Follow-Up
If dentoalveolar surgery is performed, patients should be evaluated by the dental specialist on a systematic and frequently scheduled basis (e.g., every 6-8 weeks) until full mucosal coverage of the surgical site has occurred. Communication with the oncologist regarding status of healing is encouraged particularly when considering future use of BMA (Table 2). ( FC , Ins , M )
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Temporary Discontinuation of BMAs Prior to Dentoalveolar Surgery
For patients with cancer who are receiving a BMA at an oncologic dose, there is insufficient evidence to support or refute the need for discontinuation of the BMA prior to dentoalveolar surgery. Administration of the BMA may be deferred at the discretion of the treating physician, in conjunction with discussion with the patient and the oral health provider.
( IC , Ins , W )6539
Staging
A well-established staging system should be used to quantify the severity and extent of MRONJ and to guide management decisions. Options include the 2014 AAOMS staging system, the Common Terminology Criteria for Adverse Events (CTCAE) 5.0 and the 2017 International Task Force on ONJ (osteonecrosis of the jaw) staging system for MRONJ. The same system should be used throughout the patient’s MRONJ course of care. Diagnostic imaging may be used as an adjunct to these staging systems. ( FC , Ins , W )
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Optimally, staging should be performed by a clinician experienced with the management of MRONJ. ( FC , Ins , W )
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Treatment
Initial Treatment of MRONJ
Conservative measures comprise the initial approach to treatment of MRONJ. Conservative measures may include antimicrobial mouth rinses, antibiotics if clinically indicated, effective oral hygiene, and conservative surgical interventions (e.g., removal of a superficial bone spicule). ( FC , Ins , M )
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Treatment of Refractory MRONJ
Aggressive surgical interventions (e.g., mucosal flap elevation, block resection of necrotic bone, soft tissue closure) may be used if MRONJ results in persistent symptoms or impacts function despite initial conservative treatment. Aggressive surgical intervention is not recommended for asymptomatic bone exposure. In advance of the aggressive surgical intervention, the multidisciplinary care team and the patient should thoroughly discuss the risks and benefits of the proposed intervention. ( FC , Ins , W )
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Temporary Discontinuation of BMAs
For patients diagnosed with MRONJ while being treated with BMAs, there is insufficient evidence to support or refute the discontinuation of the BMAs. Administration of the BMA may be deferred at the discretion of the treating physician, in conjunction with discussion with the patient and the oral health provider. ( FC , Ins , W )
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Outcome Measures
During the course of MRONJ treatment, the dentist/dental specialist should communicate with the medical oncologist the objective and subjective status of the lesion – resolved, improving, stable or progressive. The clinical course of MRONJ may impact local and/or systemic treatment decisions with respect to cessation or recommencement of BMAs. ( FC , Ins , W )
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Recommendation Grading
Overview
Title
Medication-Related Osteonecrosis of the Jaw
Authoring Organizations
American Society of Clinical Oncology
Multinational Association of Supportive Care in Cancer
Publication Month/Year
July 22, 2019
Last Updated Month/Year
October 2, 2024
Supplemental Implementation Tools
Document Type
Guideline
External Publication Status
Published
Country of Publication
US
Document Objectives
To provide guidance regarding best practices in the prevention and management of medication-related osteonecrosis of the jaw (MRONJ) in patients with cancer.
Target Patient Population
Adult patients with cancer who are receiving bone-modifying agents (BMAs) for any oncologic indication.
Target Provider Population
Oncologists and other physicians, dentists, dental specialists, oncology nurses, clinical researchers, oncology pharmacists, advanced practitioners
PICO Questions
What are the recommended best practices for preventing and managing medication-related osteonecrosis of the jaw (MRONJ) in patients with cancer?
What is the preferred terminology and definition for osteonecrosis of the jaw associated with pharmacologic therapies in oncology patients?
What steps should be taken to reduce the risk of MRONJ in patients with cancer?
What outcome measures should be used in clinical practice to describe the response of the MRONJ lesion to treatment?
Inclusion Criteria
Male, Female, Adult, Older adult
Health Care Settings
Ambulatory, Hospital, Outpatient
Intended Users
Clinical researcher, dentist, nurse, nurse practitioner, health systems pharmacist, physician, physician assistant
Scope
Management, Prevention
Diseases/Conditions (MeSH)
D059266 - Bisphosphonate-Associated Osteonecrosis of the Jaw, D010020 - Osteonecrosis
Keywords
medication-related osteonecrosis of the jaw, jaw osteonecrosis, Osteonecrosis, supportive care, MRONJ, bone-modifying agents, BMAs
Source Citation
DOI: 10.1200/JCO.19.01186 Journal of Clinical Oncology 37, no. 25 (September 01, 2019) 2270-2290.
Supplemental Methodology Resources
Methodology
Number of Source Documents
132
Literature Search Start Date
January 1, 2003
Literature Search End Date
December 31, 2017
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Specialties Involved
Internal Medicine General, Oncology
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List of Questions
See full-text
Description of Study Criteria
See Supplement
Description of Search Strategy
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eligibility for inclusion in the systematic review of the evidence.
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Description of Study Selection
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Description of Evidence Analysis Methods
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Description of Evidence Grading
High: High confidence that the available evidence reflects the true magnitude and direction of the net effect (i.e., balance of benefits v harms) and that further research is very unlikely to change either the magnitude or direction of this net effect.
Intermediate: Moderate confidence that the available evidence reflects the true magnitude and direction of the net effect. Further research is unlikely to alter the direction of the net effect; however, it might alter the magnitude of the net effect.
Low: Low confidence that the available evidence reflects the true magnitude and direction of the net effect. Further research may change either the magnitude and/or direction this net effect.
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No recommendation: There is insufficient evidence, confidence, or agreement to provide a recommendation to guide clinical practice at this time. The Panel deemed the available evidence as insufficient and concluded it was unlikely that a formal consensus process would achieve the level of agreement needed for a recommendation.
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ASCO provides funding for Guideline Development.
Company/Author Disclosures
ASCO Conflict of Interest Policy complies with the CMSS Code for Interactions with Companies. ASCO requires disclosure by individuals involved in drafting, reviewing, and approving guideline recommendations.
Percentage of Authors Reporting COI
100