Osteonecrosis of the Jaw

Xray of drug induced osteonecrosis of the jawa

Drug Induced Osteonecrosis of the Jaws (DIONJ)

Drug Induced Osteonecrosis of the Jaws is bone exposure or infection of the jaw resulting from a side effect of one of several drugs. The definition is exposed bone, in a patient who has not had head or neck radiation or any metastatic disease, in which the exposure fails to heal over a period lasting 8 weeks.

Drug Induced Osteonecrosis of the Jaw symptoms

Patients with DIONJ can have symptoms such as pain, swelling, fistulae, ulcerated soft tissue, and pathological fractures.

What is Drug Induced Osteonecrosis of the Jaws or DIONJ?

DIONJ results in “dead bone” and is a result of taking one of several medications.  It is exposed jaw bone that is often infected and is the result of poor wound healing.  It is on the rise as the number of individuals taking bisphosphontes, or antiresorptive drugs, continues to rise.  Although the chance of getting DIONJ is small, 0-.04%-.1% of oral bisphosphonate users and 2-10% (or .8-20%) of IV bisphosphonate users, the number of individuals taking these medications is huge.  Patients that receive a combination of bisphosphonates and antiangiogenics have a 16% of getting DIONJ.

X-ray of Drug Induced Osteonecrosis of the Jaws
Image with permission from Dr. Guzman


Since a tooth extraction is the trigger for most cases of DIONJ, dentists are paying close attention to individuals taking these drugs. A list of these drugs can be found on my oral surgery medical history form.  Non-nitrogen containing bisphosphonates do no trigger DIONJ; drugs such as Bonefos (clodronate) and Didronel (etidronate) and other first generation bisphosphonates.

Why are these drugs so popular?

  • 1 in 2 women will have a osteoporosis related fracture and 1 in 8 males
  • 10 million Americans have osteoporosis
  • 30% of hip fractures require long-term nursing care
  • 20-30% of hip fractures result in death within a year

Bisphosphonates minimize, prevent, and treat osteoporosis and a list of other ailments including Paget’s disease, multiple myeloma, hypercalcemia, and metastatic breast cancer and prostate  cancer.

Risk factors for Drug Induced Osteonecrosis of the Jaws

  • Oral drug for >2 years
  • IV drug HIGH RISK!!! .7%-6.7% vs oral that is .0004%-.21% Ruggiero  JOMS 2014
  • Invasive procedure (complicated extraction)
  • Taking multiple drugs that cause
  • Length and dosage increases
  • Denture wearer
  • Older than 65
  • Periodontal or gum disease
  • Corticosteroid, immune suppressive drug use
  • Systemic diseases such as diabetes and carcinomatosis
  • Smoking, excessive alcohol, obesity
Intra oral image of DIONJ
Intra oral image of DIONJ patient whose x-ray is above.

Bottom Line

  • See a dentist prior to beginning these medications and have teeth extracted that are potentially going to need extraction.
  • Maintain a strong regimen of home oral health care, brushing and flossing.
  • Visit your dentist at least twice a year for your regular cleanings and examinations.
  • Avoid having a tooth extraction, in other words spend the extra money to save your teeth.
  • Make sure your partial and or denture is fitting properly and most importantly be sure the appliance is not rubbing excessively in any spot(s).

Signs the patient is at high risk of DIONJ

How can dentists treat these patients?

Avoiding extractions at all costs is the main goal. Root canal treatment will be common. Below is a patient that was sent to an oral surgeon to have all his teeth removed but he came to us for second opinion. We spoke with the oral surgeon who was going to refused extraction due to risk. Four root canals and a lot of amalgam patch work kept all the teeth. There are case reports of placing implants in areas that previously had osteonecrosis. Lee JOI 2023 says MRONJ in his case report. However, the patient was only taken oral bisphosphate so it’s possible it was regular osteonecrosis and the patient happened to be on oral bisphosphate since a sizable percent of the population is.

Patients that are high risk for drug induced osteonecrosis need treatment options that avoid extraction.

How can a dentist treat a tooth that needs extraction in order to avoid DIONJ?

Dr. Reznick shares his technique in a video that shows a way to help avoid an extraction. The Association of Dental Implantology recommends CHX topically and antibiotics systemically if taking out a tooth. I have a comment on the comments section that has several studies supporting his technique.

The AAOMS recommends a 2 month drug holiday for anyone taking BPs for over 4 years.

If teeth or pieces of a tooth need to be extracted simply have a ortho rubber band placed on tooth and it will be slowly self-extracted (this may have risks also unsure) or have it slowly removed with orthodontics by pulling it out slowly with braces Forced eruption as an alternative to tooth extraction in long-term use of oral bisphosphonates JADA Dec 12 Smidt

What about a drug holiday?

This is debatable. It seems to work for denosumab but not for other bisphosphonates. Oral users can do a 3 month pre and post treatment holiday. Vaddii 2021 Compendium

Drug Induced Osteonecrosis of the Jaw treatment options for patients

  • Long term local antimicrobials or systemic antimicrobials
  • Cessation of causative medications
  • Hyperbaric oxygen therapy
  • Laser therapy
  • Teriparatide, ozone, pertoxifylline, tocopherol
  • Conservative and aggressive surgical treatment

According to a meta analysis by El-Rabbany JADA 2017 surgical therapy is better than non-surgical and mylohyoid flaps are better than mucoperiosteal flaps.  The rest there is not enough data to support or aren’t important.

Antiresorptive drug associated osteonecrosis of the jaw (ARONJ)

Antiresorptive drug associated osteonecrosis of the jaw (ARONJ) and osteonecrosis of the jaw are both the same disease process as Drug Induced Osteonecrosis of the Jaws.  ARONJ and DIONJ are the same, it’s just that the first term is older.

Medication-related osteonecrosis of the jaw (MRONJ)

Medication-related osteonecrosis of the jaw or MRONJ is yet another term for DIONJ.

Systemic review of medication related osteonecrosis of the jaw and dental implant failures

Guazzo JOI 2017


Marx presentation on surgical management of DIONJ.

Marx presentation on Drug Induced ONJ Definition and Stages.

Great position paper and thread it is from.

Great pdf presentation.

DIONJ list of drugs