Bisphosphonate-related osteonecrosis of the jaw: a pictorial review

Radiographics. 2009 Nov;29(7):1971-84. doi: 10.1148/rg.297095050.


Bisphosphonate-related osteonecrosis of the jaw (ONJ) is characterized by nonhealing exposed bone in the maxillofacial region in patients who have undergone bisphosphonate treatment. The underlying etiology is unclear and may be multifactorial. The diagnosis is primarily clinical. Diagnostic tissue sampling may exacerbate the process and is typically avoided, necessitating other diagnostic approaches. The appearance of ONJ at diagnostic imaging is variable and includes sclerotic, lytic, or mixed lesions with possible periosteal reaction, pathologic fractures, and extension to soft tissues. There is a spectrum of signal intensity changes on T1- and T2-weighted magnetic resonance (MR) images with variable enhancement, findings that may correspond to the clinical and histopathologic stage of the process. Bone scintigraphy is sensitive with increased uptake in the area of the lesion. Although the imaging findings are nonspecific, there appears to be a role for imaging in the management of ONJ. Radiography is relatively insensitive but typically employed as the first line of radiologic investigation. Computed tomography and MR imaging are more precise in demonstrating the extent of the lesion. A number of imaging modalities have revealed lesions that may be associated with bisphosphonate exposure in asymptomatic individuals or in the context of nonspecific symptoms. The risk of these lesions advancing to overt clinical disease is unknown at this time. The radiologist should be aware of ONJ and include it in the differential diagnosis when evaluating patients with a history of bisphosphonate therapy without jaw irradiation, so as to avoid potentially harmful biopsies.

Publication types

  • Review

MeSH terms

  • Bone Density Conservation Agents / adverse effects
  • Diphosphonates / adverse effects*
  • Humans
  • Jaw Diseases / chemically induced*
  • Jaw Diseases / diagnosis*
  • Magnetic Resonance Imaging / methods*
  • Osteonecrosis / chemically induced*
  • Osteonecrosis / diagnosis*
  • Tomography, X-Ray Computed / methods*


  • Bone Density Conservation Agents
  • Diphosphonates