Medication-related osteonecrosis of the jaw: Prevention, diagnosis and management in patients with cancer and bone metastases

Cancer Treat Rev. 2018 Sep;69:177-187. doi: 10.1016/j.ctrv.2018.06.007. Epub 2018 Jun 18.


Medication-related osteonecrosis of the jaw (MRONJ) is primarily an adverse side effect of denosumab or bisphosphonates (particularly when used at high doses to prevent skeletal-related events [SREs] in patients with cancer and bone metastases) or possibly anti-angiogenic cancer treatment. While the implementation of preventive measures over recent years has reduced the risk of MRONJ in patients with bone metastases due to cancer, it is imperative to balance the risk of MRONJ against the beneficial effects of treatment with denosumab or bisphosphonates on the skeletal health of patients. Despite growing awareness of MRONJ within the medical community, there is a lack of large-scale, prospective clinical studies in this rapidly evolving field. Discussing preventive measures with patients and implementing them, both before and during treatment with bisphosphonates or denosumab, is the best option to reduce the risk of MRONJ. In particular, avoiding bone trauma and preventing and treating dental infections before and during denosumab or bisphosphonate therapy is crucial to minimize the risk of MRONJ. If MRONJ develops, conservative (non-surgical) treatment can provide symptom relief, but achieving mucosal closure remains challenging. When management of symptoms and mucosal healing are the ultimate goals of therapy, or after failure of conservative treatment, a surgical approach may be beneficial. This critical review, based on a best-evidence review of currently available literature, provides clear practical guidelines to help to prevent, manage and treat MRONJ. Overall, a multidisciplinary, pragmatic approach to MRONJ should be adopted, prioritizing patient's quality of life and management of their skeletal malignant disease.

Keywords: Bisphosphonates; Denosumab; Medication-related osteonecrosis of the jaw (MRONJ); Side effect; Skeletal-related events (SREs).

Publication types

  • Review

MeSH terms

  • Bisphosphonate-Associated Osteonecrosis of the Jaw / diagnosis*
  • Bisphosphonate-Associated Osteonecrosis of the Jaw / etiology
  • Bisphosphonate-Associated Osteonecrosis of the Jaw / prevention & control*
  • Bone Density Conservation Agents / adverse effects*
  • Bone Neoplasms / drug therapy*
  • Bone Neoplasms / secondary
  • Diphosphonates / adverse effects*
  • Humans
  • Neoplasms / drug therapy*
  • Neoplasms / pathology
  • Quality of Life
  • Risk Factors


  • Bone Density Conservation Agents
  • Diphosphonates