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Bisphosphonate-related Osteonecrosis of the Jaw

General Considerations

  • Bisphosphonates are commonly prescribed for the treatment and prevention of
    • Osteoporosis (e.g. alendronate, risendronate, ibandronate)
    • Osteolytic lesions in metastatic bone tumors (e.g. breast, prostate, multiple myeloma) (e.g. zoledronate, pamidronate)
    • Hypercalcemia associated with malignancy
  • Bind and inhibit osteoclastic activity
  • There has been an association described between bisphosphonates, usually in higher doses in cancer patients, and avascular necrosis, especially of the mandible
    • Incidence has been most strongly correlated with pamidronate (Aredia) and zoledronic acid (Zometa)
  • Many develop after tooth extraction which may serve as a trigger
  • Latency of 5-36 months after therapy before osteonecrosis occurs
  • More common with IV administration of drug than oral

Clinical Findings

  • Exposed, non-vital bone
  • Pain
  • Swelling
  • Trismus

Imaging Findings

  • Confined to mandible (majority) and maxilla
  • Mixed lytic and sclerotic lesion of the jaw
  • Sequestration
  • Pathologic fracture
  • Periosteal reaction
  • MRI-low T1 and T2 with exposed bone and low T1 and high T2 in unexposed bone

Differential Diagnosis

  • Metastatic bone lesion
  • Osteomyelitis


  • Difficult
  • Discontinue bisphosphonate therapy
  • Avoid dental extractions
  • Medical therapy may include antibiotics used locally and systemically
  • Surgical curettage has been used
  • Chemical debridement with antiseptic irrigations
  • Long-term antibiotic treatment may be useful


  • Pathologic fracture
  • Osteomyelitis
  • Draining fistulae

Bisphosphonate-related Osteonecrosis of the Jaw

Bisphosphonate-related Osteonecrosis of the Jaw

Bisphosphonate-related Osteonecrosis of the Jaw. Upper photo. Blue arrows point to a large lytic lesion in the right side of the mandible in a patient who had been on high-dose bisphosphonates for multiple myeloma. A tooth (white arrow) had recently been extracted. Lower photo: White arrows point to a lytic lesion in the right side of the mandible with a dense sequestrum within it.
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Biphosphonates and oral cavity avascular bone necrosis. J Clin Oncol 2003;21:4253-4


Bisphosphonate-related osteonecrosis of the jaw: the Florence experience. A Borgioli, M Duvina, L Brancato, C Viviani, ML Brandi, and P Tonelli. Clin Cases Miner Bone Metab. 2007 Jan–Apr; 4(1): 48–52.


eMedicine. Bisphosphonate-Related Osteonecrosis of the Jaw. RH Blanchaert, and  CM Harris