Osteonecrosis of the Jaw (ONJ)

What is ONJ, and which medications may cause it?

ONJ presents as persistently exposed bone following an invasive dental procedure (extractions and implants); it does not occur following root canal procedures, fillings, and dental cleaning. It has been reported mainly in patients on strong antiresorptive medications (bisphosphonates or denosumab) and does not occur with the anabolic bone agents. ONJ develops most often during high-dose, frequent administration of antiresorptive agents for the treatment of multiple myeloma or bone metastases; however, it has also been reported, though much less often, in patients taking antiresorptive agents for osteoporosis. Good oral hygiene and regular dental care are the best preventive measures. Poor oral hygiene, diabetes mellitus, use of GCs, and age >65 years increase the risk for developing ONJ. As discussed earlier, an oral exam should be done by the prescribing provider prior to starting any of the antiresorptive medications. Temporarily stopping antiresorptive therapy for invasive dental procedures (3 months prior to the procedure) is a common practice but has not been shown to prevent ONJ. Some oral surgeons require a serum C-telopeptide to be in the normal range before they will do surgery. When counseling patients, the reported absolute risk of ONJ is 25/100,000 patient years (0.01%–0.15%/year) compared with the absolute fracture risk reduction of 700/100,000 patient years. Therefore, it is 28x more likely a patient will get a fracture than ONJ.


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