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Medication-Related Osteonecrosis of the Jaw (MRONJ) is defined as a complication, which affects the jawbone of patients that meet all of the following criteria: (a) patients were in the past or are now on treatment with bone targeting agents (BTAs) and/or antiangiogenics, (b) they have exposed bone or bone that can be probed through an intraoral or extraoral fistula for more than 8 weeks, and (c) they have no history of radiotherapy or obvious metastatic disease to the jaws. Since the first reports, in 2003, plethora of articles on MRONJ significantly increased our knowledge of this potentially serious complication. However, controversies about the definition and clinical presentation, risk factors, radiological findings, staging and early diagnosis, prevention and treatment may affect the successful management and the quality of life of cancer patients. The purpose of this article is to present the current knowledge about MRONJ and the recent advances to best clinical practice and treatment. Important questions will be discussed, including the following: (1) Should we wait for 8 weeks when a patient on antiresorptive therapy, presents with exposed necrotic jawbone? (2) Can we exclude the diagnosis of osteonecrosis if a patient presents without exposed bone? (3) Is the dental extraction a risk factor for MRONJ? (4) Should we perform the dental extraction, when a patient on antiresorptives, presents with a symptomatic tooth? (5) What is the role of dental or periodontal infection? (6) Shall we re-start the antiresorptives following healing of previous MRONJ?

Objectives: To prospectively evaluate the imaging characteristics of Medication-Related Osteonecrosis of the Jaw (MRONJ), observed in the Orthopantomogram (OPG) and in Cone Beam Computed Tomography (CBCT), in patients with cancer. Materials and Methods: Cancer patients, who received Bone Targeting Agents (BTAs) and developed MRONJ, were prospectively included in the study. MRONJ was staged following the American Association of Oral and Maxillofacial Surgery (AAOMS) 2014 criteria. Four predefined radiological findings, osteolytic changes, sclerosis, periosteal reaction, and sequestration were assessed and were scored as “absent”, “localized”, “extensive” and “beyond the alveolar bone”. Results: Ninety-eight cancer patients were enrolled. Eighty patients (81.6%) received BTAs for over a year; 19 (19.4%) received BTAs between 13 to 24 months and 61 patients (62.2%) received BTAs for over 24 months. The majority of the patients (n=58, 59.2%) had stage 2 MRONJ and 35 (35.7%) were at MRONJ stage 3.Fifty-two (53.06%) patients were assessed with OPG and 89 (90.81%) with CBCT and CBCT was found more effective in detecting sclerosis and sequestration than OPG.Forty-three (43.87%) patients were assessed with both OPG and CBCT and were available for comparisons between OPG and CBCT. CBCT was significantly more accurate than OPG in interpreting the “beyond the alveolar bone” osteolytic changes, sclerosis, periosteal reaction and sequestration, in all MRONJ stages. P-value was 0.0002

Objectives The objectives of this study were to define the incidence, pain, and healing in cancer patients treated with intravenous bisphosphonates. Study design The study included long-term follow-up of 99 bisphosphonate-using patients (group A) and conservative treatment of 67 patients with bisphosphonate-related osteonecrosis of the jaw (BRONJ, group B) using 3 antibiotic schemes and oral hygiene. Results The frequency of zoledronic acid single-agent use was 85.9% and 69.8% in group A and B, respectively. Median follow-up was 13 months (group A) and 16 months (group B). Two patients in group A developed BRONJ (2%). Of those with BRONJ in group B who completed follow-up, healing occurred in 14.9% (7/47) and pain subsided in 80.9% (38/47). Healing was significant in patients who received pamidronate followed by zoledronic acid ( P = .023) and with BRONJ stages 0 and stage I ( P = .003). Conclusions This case series suggests that oral hygiene and conservative antibiotic therapy play a role in healing and pain alleviation in BRONJ. Oral hygiene and follow-up may decrease incidence of BRONJ.