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Table 1 Staging and treatment strategies

From: Current perspectives in the management of patients with drug-induced osteonecrosis of the maxilla: experience of the school of Naples Federico II

BRONJ* 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: exposed and necrotic bone extending beyond the region of alveolar bone, (ie, inferior border and ramus in the mandible, maxillary sinus and zygoma in the maxilla) resulting in pathologic fracture, extraoral fistula, oral antral/oral nasal communication, or 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
  1. Abbreviations: BRONJ, bisphosphonate-related osteonecrosis of the jaw; IV, intravenous.
  2. *Exposed bone in maxillofacial region without resolution within 8-12 weeks in persons treated with bisphosphonate who have not undergone radiotherapy to jaws.
  3. †Regardless of disease stage, mobile segments of bony sequestrum should be removed without exposing uninvolved bone;extraction of symptomatic teeth within exposed, necrotic bone should be considered because it is unlikely that extraction will exacerbate established necrotic process.
  4. ‡Discontinuation of IV bisphosphonates has shown no short-term benefit. However, if systemic conditions permit,long-term discontinuation might be beneficial in stabilizing established sites of BRONJ, reducing risk of new site development,and reducing clinical symptoms. Risks and benefits of continuing bisphosphonate therapy should be made only by treating oncologist in consultation with oral and maxillofacial surgeon and patient.
  5. §Discontinuation of oral bisphosphonate therapy in patients with BRONJ has been associated with gradual improvement in clinical disease. Discontinuation of oral bisphosphonates for 6-12 months may result in either spontaneous sequestration or resolution after debridement surgery. If systemic conditions permit, modification or cessation of oral bisphosphonate therapy should be done in consultation with treating physician and patient.