Concomitant Factors Leading to an Atypical Osteonecrosis of the Jaw in a Patient with Multiple Myeloma

Table 2

ONM staging and treatment strategies—American Association of Oral and Maxillofacial Surgeons 2009.

ONJ stage	Description	Treatment strategies
At risk category	No apparent necrotic bone in patients who have been treated with either oral or IV bisphosphonates	No treatment indicated; Patient education
Stage 0	No clinical evidence of necrotic bone, but nonspecific clinical findings and symptoms	Systemic management, including use of pain medication and antibiotics
Stage 1	Exposed and necrotic bone in asymptomatic patients without evidence of infection	Antibacterial mouth rinse; Clinical follow-up on quarterly basis; Patient education and review of indications for continued bisphosphonate therapy
Stage 2	Exposed and necrotic bone associated with infection as evidenced by pain and erythema in region of exposed bone with or without purulent drainage	Symptomatic treatment with oral antibiotics; Oral antibacterial mouth rinse; Pain control; Superficial debridement to relieve soft tissue irritation
Stage 3	Exposed and necrotic bone in patients with pain, infection, and one or more of the following: A—exposed and necrotic bone extending beyond the region of alveolar bone, (i.e., inferior border and ramus in the mandible or maxillary sinus and zygoma in the maxilla) resulting in pathologic fracture, B—extraoral fistula and oral antral/oral nasal communication, and C—osteolysis extending to the inferior border of the mandible or the sinus floor	Antibacterial mouth rinse; Antibiotic therapy and pain control; Surgical debridement/resection for longer term palliation of infection and pain.