|
| Osteonecrosis of the jawsstaging | Stage description | Treatment strategies |
|
| Future risk category | Candidate patients to be enrolled in bisphosphonate treatment, patients who have enrolled to bisphosphonate treatment for a period shorter than 3 months | “Patient education” (inform patients about the complication, its signs, and symptoms) [74] |
| “Maintain optimal oral hygiene” (biannual periodontal scaling, restoration decayed teeth) [63, 74, 75] |
| “Provide root canal treatment as usual” [68, 69] |
| “Treat active oral infections, remove sites at high risk for infection” (partially impacted wisdom teeth, nonrestorable teeth, teeth with extensive periodontal dehiscence) [60, 74, 75] |
| “Check for ill-fitting dentures, retread if necessary” [68, 69] |
| Baseline dental evaluation (history taking, clinical examination and panoramic radiographs) [68, 74, 75] |
| At-risk category | No apparent necrotic bone in patients who have been treated with either oral or IV bisphosphonates | All of the above |
| “Prefer conservative dental treatment modalities over dental extractions” (root canal treatment, periodontal scaling and root planning) [68–70, 74] |
| Perform extractions and other surgery only when utterly inevitable; in such cases use minimal bone manipulation with appropriate local and systemic antibiotics [68–70, 76]: |
| (i) Perform periodontal scaling 3 weeks prior |
| (ii) Prescribe amoxicillin 1gr t.i.d. 3 days prior |
| (iii) Reflect full thickness mucoperiosteal flap, remove teeth with minimal cortical trauma |
| (iv) Suture and prescribe amocicillin 1 gr t.i.d. for 17 days, chlorexidine 1% rinses t.i.d. |
| (vi) Remove sutures and discontinue chlorexidine rinses 1 week postoperatively |
| (v) Prefer single tooth interventions |
| (vi) Followup to ensure healing |
|
| Stage 0 | No clinical evidence of necrotic bone, but non-specific clinical findings and symptoms | All of the above |
| “Systemic management”, including use of pain medication and antibiotics [62] |
|
| Stage 1 [77] | Exposed bone necrosis or small oral ulceration without exposed bone necrosis, but without symptoms [77] | All of the above |
| “Oral antibacterial mouth rinse” (0.12% chlorhexidine rinse, hydrogen peroxide) |
| “Impede denture use” [68, 69] |
| Discontinuation of bisphosphonate therapy until osteonecrosis heals or underlying disease progresses is not indicated but might be individually considered prior to surgery [62, 78–80] |
| Clinical followup on quarterly basis [62] |
|
| Stage 2a [77] | Exposed bone necrosis or a small oral fistula without exposed bone necrosis, but with symptoms controlled with medical treatment [77] | All of the above |
| Suggest computed tomography scans |
| Symptomatic treatment with oral antibiotics (monotherapy or combination therapy with b-lactam, tetracycline, macrolide, metronidazole, or clindamycin) [74] |
| “Pain control” with non-steroid anti-inflammatory drugs |
|
| Stage 2b [77] | Exposed bone necrosis or a small oral fistula without exposed bone necrosis, but with symptoms not controlled with medical treatment [77] |
All of the above |
| Superficial debridement to relieve soft tissue irritation |
|
| Stage 3 [77] | Jaw fractures, skin fistula, osteolysis extending to the inferior border [77] | All of the above |
| Surgical debridement/resection for longer term palliation of infection and pain under intravenous antibiotic treatment |
| Use of doxycycline bone fluorescence to discriminate viable bone [81, 82] |
|
