Osteonecrosis of the jaw

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Osteonecrosis of the jaw is particularly associated with exposure to agents that block resorption of bone. Other causes such as phosphorus exposure, the former use of arsenic anhydride in some dental practice[1], herpes zoster[2][3] and oncology therapy caused rare cases before an epidemic of the condition was recognised in the early 21st century[4]. Risks are highest in those with a state of poor dental hygiene, when treatment is with parental products such as intravenous bisphosphonates and denosumab. There is a dose related risk with the nitrogen-containing bisphosphonates.

LogoKeyPointsBox.pngRisk factors for osteonecrosis of the jaw include:

Risk of this side effect in those requiring anti-resorption treatment such as in malignancy or osteoporosis can be minimised by:

  • Identifying those with known risk factors
  • Medication selection
  • Ensuring patients have a dental examination and an individual benefit-risk assessment before starting treatment
  • Delaying treatment in those with unhealed open soft tissue lesions in the mouth that may require dental or oral procedures or where major invasive dental treatment is planned.


The mechanism appears to involve angiogenesis inhibition so will be aggravated by thalidomide and other anti-angiogenesis agents.


Surgery and antibiotics have been the mainstay. Teriparatide response has been reported in small case series[6]. Hyperbaric oxygen has been tried[7].


  1. Bataineh AB, al-Omari MA, Owais AI. Arsenical necrosis of the jaws. International endodontic journal. 1997 Jul; 30(4):283-7.
  2. Cooper JC. Tooth exfoliation and osteonecrosis of the jaw following herpes zoster. British dental journal. 1977 Nov 1; 143(9):297-300.
  3. Mostofi R, Marchmont-Robinson H, Freije S. Spontaneous tooth exfoliation and osteonecrosis following a herpes zoster infection of the fifth cranial nerve. Journal of oral and maxillofacial surgery : official journal of the American Association of Oral and Maxillofacial Surgeons. 1987 Mar; 45(3):264-6.
  4. Marx RE. Pamidronate (Aredia) and zoledronate (Zometa) induced avascular necrosis of the jaws: a growing epidemic. Journal of oral and maxillofacial surgery : official journal of the American Association of Oral and Maxillofacial Surgeons. 2003 Sep; 61(9):1115-7.
  5. Khan AA, Morrison A, Hanley DA, Felsenberg D, McCauley LK, O'Ryan F, Reid IR, Ruggiero SL, Taguchi A, Tetradis S, Watts NB, Brandi ML, Peters E, Guise T, Eastell R, Cheung AM, Morin SN, Masri B, Cooper C, Morgan SL, Obermayer-Pietsch B, Langdahl BL, Al Dabagh R, Davison KS, Kendler DL, Sándor GK, Josse RG, Bhandari M, El Rabbany M, Pierroz DD, Sulimani R, Saunders DP, Brown JP, Compston J. Diagnosis and management of osteonecrosis of the jaw: a systematic review and international consensus. Journal of bone and mineral research : the official journal of the American Society for Bone and Mineral Research. 2015 Jan; 30(1):3-23.(Link to article – subscription may be required.)
  6. Yoshiga D, Yamashita Y, Nakamichi I, Tanaka T, Yamauchi K, Yamamoto N, Nogami S, Kaneuji T, Mitsugi S, Sakurai T, Kiyomiya H, Tominaga K, Morimoto Y, Takahashi T. Weekly teriparatide injections successfully treated advanced bisphosphonate-related osteonecrosis of the jaws. Osteoporosis international : a journal established as result of cooperation between the European Foundation for Osteoporosis and the National Osteoporosis Foundation of the USA. 2013 Aug; 24(8):2365-9.(Link to article – subscription may be required.)
  7. Freiberger JJ, Padilla-Burgos R, McGraw T, Suliman HB, Kraft KH, Stolp BW, Moon RE, Piantadosi CA. What is the role of hyperbaric oxygen in the management of bisphosphonate-related osteonecrosis of the jaw: a randomized controlled trial of hyperbaric oxygen as an adjunct to surgery and antibiotics. Journal of oral and maxillofacial surgery : official journal of the American Association of Oral and Maxillofacial Surgeons. 2012 Jul; 70(7):1573-83.(Link to article – subscription may be required.)