Navigating the complexities and controversies of medication-related osteonecrosis of the jaw (MRONJ): a critical update and consensus statement

Acta Chir Belg. 2024 Feb;124(1):1-11. doi: 10.1080/00015458.2023.2291295. Epub 2024 Jan 24.


Objectives: To provide a critical update identifying the knowledge gaps and controversies in medication-related osteonecrosis of the jaw (MRONJ) within the Belgian healthcare context and outline opportunities for improvement and research in these areas.

Methods: A literature review was performed to identify guidelines from international clinical societies in oncology or oral and maxillofacial surgery on diagnosing, preventing, and treating MRONJ. The recommendations were critically assessed in light of recent developments in the field and confronted with the clinical experience of experts.

Results: Despite progress in the diagnostic criteria of MRONJ, the continued need for an 8-week timeout period should be reconsidered. Furthermore, 3D imaging techniques should be introduced to improve diagnosis and staging. The staging system remains ambiguous regarding Stage 0 MRONJ, and ongoing confusion exists regarding the term non-exposed MRONJ. The prevention of MRONJ should be tailored, considering the individual patient's risk of MRONJ, frailty, and life expectancy. More research seems needed into the efficacy and safety of drug holidays, considering the risks of rebound remodeling on fractures. With renewed interest in surgical and adjunct management techniques, adequately designed clinical studies are needed to help translate trial outcomes into universally applicable treatment guidelines taking into account individual patient characteristics.

Conclusions: Important knowledge gaps remain and hamper the development of clinical guidelines. Several controversies were identified where consensus is lacking, and further harmonization between stakeholders is necessary. Finally, the need for randomized controlled comparative clinical trials in MRONJ resonates harder than ever to identify the best treatment for individual patients.

Keywords: Osteonecrosis; bone density conservation agents; neoplasm metastasis; osteoporosis; prevention; therapeutics.

Publication types

  • Review

MeSH terms

  • Bisphosphonate-Associated Osteonecrosis of the Jaw* / diagnosis
  • Bisphosphonate-Associated Osteonecrosis of the Jaw* / drug therapy
  • Bisphosphonate-Associated Osteonecrosis of the Jaw* / prevention & control
  • Bone Density Conservation Agents* / adverse effects
  • Diphosphonates / adverse effects
  • Fractures, Bone*
  • Humans


  • Diphosphonates
  • Bone Density Conservation Agents