Skip to Content

If you’ve undergone certain types of chemotherapy or have been prescribed certain drugs to manage osteoporosis, you may have been warned about a rare but serious condition known as MRONJ. MRONJ stands for Medication-Related Osteonecrosis of the Jaw, and it can be debilitating, causing excruciating pain and impacting the sufferer’s ability to eat, sleep, and carry on daily life.

This month, we’ll examine MRONJ, its risk factors, symptoms, and how a skilled oral surgeon may be able to provide relief.

What Is MRONJ?

Let’s take MRONJ apart, word for word:

  • Medication-related: MRONJ is actually considered an adverse reaction to two different classes of drugs, both used with certain chemotherapy treatments and in treatments for osteoporosis.
  • Osteonecrosis: This medical term simply means “death of bone tissue.”
  • Of the Jaw: MRONJ almost always affects the mandible, or lower jaw. Cases in the maxilla, or upper jaw, are considerably less common.

Patients suffering from MRONJ experience the steady death of the bone tissue in their jaws. While this necrosis usually follows a tooth extraction or other dental or surgical procedure that impacts the jaw, it can also occur spontaneously.

MRONJ is relatively rare. Studies have shown that individuals taking one of the medications that are responsible for MRONJ have between a .06% and a 1.47% risk of developing the condition, depending on their dosage and other risk factors. Osteoporosis patients generally use lower doses of the medication and have a correspondingly lower risk of MRONJ than cancer patients.

Doctor points to filled root canal in dental x-ray.

What Are the Symptoms of MRONJ?

Several different symptoms can accompany MRONJ. While the dead bone tissue itself is not inherently painful, the surrounding tissues will usually become inflamed. Common symptoms include:

  • Pain, tingling, or numbness in the jaw
  • Feeling like the lower jaw is “heavy”
  • Loose teeth
  • Swelling of the gums or other oral tissues
  • Difficulty chewing or opening the mouth
  • An extraction site that doesn’t heal
  • Exposed bone that isn’t covered by gum tissue

What Causes MRONJ?

MRONJ is caused by a severe adverse reaction to one or both of two classes of drugs. The important thing to remember is this: if you’ve been prescribed one of these drugs, the risks associated with NOT taking the drug are considerably more hazardous than the very slight risk of developing MRONJ.


Bisphosphonates make up a class of drugs that are used to reduce bone loss. They are the most common drugs used to treat osteoporosis. Larger doses are administered to certain metastatic cancer patients, both to help prevent fractures and to prevent the cancer from spreading into bone tissue.


Denosumab is sold under the names Prolia and Xgeva. It is a monoclonal antibody that is used for the same purposes as bisphosphates.

The exact nature of the adverse reaction that causes bone tissue to start dying in certain patients using these medications is still being investigated.

It’s also important to note that other conditions can lead to necrosis in the jawbone. MRONJ refers specifically to the condition in a patient who has used bisphosphonates or denosumab.

What Are Some Other Risk Factors Associated With MRONJ?

While taking bisphosphonates or denosumab are the defining risk factors for MRONJ, several other risk factors exist:

  • Dental/oral procedures: Most cases of MRONJ occur after a tooth extraction or other procedure that somehow impacts the jaw. In these cases, the extraction site or surgical wound never heals properly, leaving the patient with exposed bone tissue.
  • Age: MRONJ is more common in people over 65 years of age.
  • Smoking: As it does with almost every medical condition, smoking can increase a patient’s risk of MRONJ.
  • Periodontitis: Patients with gum disease are far more likely to develop MRONJ than patients with healthy gums.
  • Diabetes: Those managing diabetes or suffering from unmanaged diabetes have an increased risk of MRONJ.

Can MRONJ Be Prevented?

While MRONJ cannot be wholly prevented, there are steps that you can take to reduce your risk of developing MRONJ if you’re being treated with bisphosphates or denosumab. The one thing you should not do is stop taking your medication: the dangers associated with stopping your cancer or osteoporosis treatment far outweigh the risk of developing MRONJ.

  • If you are about to start treatment with bisphosphonates or denosumab, talk to your doctor and your dentist. Before you start taking the medication, go in for a thorough dental and oral exam so that your dentist or oral surgeon can identify any emerging issues and schedule any necessary procedures.
  • Practice good oral hygiene to help prevent periodontitis. Gum disease is a significant risk factor for MRONJ, so twice-daily brushing, flossing, and use of a fluoride mouthwash can help lower your risk.
  • If you smoke, quit as soon as possible. Quitting won’t just reduce your risk of MRONJ; it will dramatically reduce your risk for thousands of other medical conditions.
  • Reduce your sugar intake. In addition to avoiding the inevitable damage sugars cause to teeth, you’ll also reduce your risk of diabetes, another MRONJ risk factor.

Can MRONJ Be Treated?

MRONJ can be treated, although treating it can be a challenge. There are differing levels of treatment, depending on the severity of each case:

Conservative MRONJ Treatment

Conservative treatment is an option when there’s no sign of a secondary infection and the bone loss is minor. Antiseptic mouthwash helps prevent an infection, analgesics help control pain, and a drug called teriparatide helps reduce further bone loss.

Non-Surgical MRONJ Treatment

Non-surgical options are available for patients who have symptoms of infection due to MRONJ and whose bone loss has not reached a certain level of severity. In these cases, treatment is the same as the conservative treatment option, with the addition of antibiotics and antifungals to fight the infection.

Surgical MRONJ Treatment

For advanced cases of MRONJ, surgical treatment may be required. The surgery may involve simply scraping away affected necrotic bone tissue (debridement) or removing entire sections of the jawbone (resectioning). The goal is to ensure that no bone tissue remains exposed and that all infected or necrotic tissue is removed.

Athens Oral Surgery Can Help You Navigate MRONJ

If you’re just starting treatment for cancer or osteoporosis, Dr. Tomlinson and his team will be happy to answer any concerns you may have about your risk for MRONJ and work with you to schedule any needed procedures before you start treatment. If you have taken bisphosphonates or denosumab and are beginning to experience symptoms of MRONJ, we can perform a thorough examination and provide you with a diagnosis and treatment options. Call 706-549-5033 to schedule an appointment.

Related Articles:

What to Look For When Choosing an Oral Surgeon

Jaw Surgery: What Happens During & After Surgery?