At New York Periodontics, we believe that patient education, prevention, early diagnosis, and conservative management are essential when treating patients who take medications associated with osteonecrosis of the jaw.
MRONJ, or medication-related osteonecrosis of the jaw, is a rare but serious condition in which areas of the jawbone may become exposed, inflamed, infected, or slow to heal after dental procedures or trauma. BRONJ, or bisphosphonate-related osteonecrosis of the jaw, is a more specific term used when the condition is associated with bisphosphonate medications.
These conditions are uncommon, but they are important for patients to understand, especially before extractions, implant surgery, periodontal surgery, or other procedures involving the jawbone.
MRONJ is most commonly associated with medications that affect bone turnover. These medications are often prescribed to protect patients from fractures, strengthen bone, or manage cancer-related bone disease.
Common medications associated with MRONJ include:
Some antiangiogenic and targeted cancer therapies may also increase MRONJ risk, especially when combined with antiresorptive medications. The American Dental Association notes that MRONJ is a rare but serious adverse effect of bone antiresorptive agents such as bisphosphonates and denosumab.
These medications can be extremely important. For many patients, they reduce the risk of serious fractures, spinal compression fractures, hip fractures, and skeletal complications related to cancer. Dental concerns should not lead patients to stop or delay these medications without speaking to their prescribing physician.
These medications are commonly prescribed for patients with:
The jawbone is unique because it is constantly exposed to bacteria through the teeth, gums, periodontal pockets, extractions, implants, and oral surgical procedures. Medications that reduce bone turnover can affect how the jawbone remodels and heals after trauma, infection, or surgery.
For this reason, it is important for patients to tell their periodontist if they are taking, have taken, or are about to start medications such as Prolia, Reclast, Fosamax, Boniva, Actonel, Zometa, or Xgeva.
Before starting these medications, patients should discuss any ongoing or planned dental treatment with their endocrinologist, rheumatologist, oncologist, primary care physician, or prescribing doctor. When possible, active dental infections, hopeless teeth, periodontal disease, and surgical needs should be evaluated before antiresorptive therapy begins.
The risk of MRONJ depends on the type of medication, dose, duration, medical condition being treated, and the type of dental procedure needed.
Risk factors include:
The ADA notes that patients are at increased risk when antiresorptive agents are used at higher doses and more frequent schedules for cancer-related indications, when the drugs have been used for more than two years, and when patients have periodontitis or dentures.
For most osteoporosis patients taking oral bisphosphonates, the risk of MRONJ is very low. Published estimates vary, but oral bisphosphonate-associated jaw osteonecrosis has historically been reported in the range of approximately 0.07% to 0.10% in osteoporosis patients.
The risk is higher in patients receiving high-dose antiresorptive medications for cancer-related bone disease. The 2022 AAOMS position paper reports that MRONJ risk after tooth extraction in higher-risk patients varies, with estimates clustering around 1% to 5%, although some studies report higher rates depending on the patient population and procedure.
For patients with osteoporosis undergoing extractions, newer reviews still suggest the
condition is uncommon, but the risk is not zero. A 2025 meta-analysis estimated MRONJ
prevalence after tooth extraction in osteoporosis patients at approximately 1.7%, with wide variation depending on patient and treatment factors.
Patients taking antiresorptive or related medications should contact their dentist or periodontist if they notice:
Early evaluation is important. Many cases can be managed more conservatively when diagnosed early.
At New York Periodontics, we treat osteonecrosis of the jaw with a conservative, biologically guided approach whenever possible. Our priority is to diagnose the condition early, control infection, protect the soft tissue, support wound healing, and prevent progression.
With proper diagnosis, careful treatment planning, and the use of biologic materials, we have been successful in managing many cases before they become more aggressive or require major surgical intervention, such as mandibular or maxillary resection.
Depending on the case, treatment may include:
For patients who are currently taking medications such as Prolia, Reclast, Fosamax, Zometa, or related therapies, we carefully evaluate whether dental treatment can be performed safely and whether biologic support may improve healing.
At New York Periodontics, when treatment is necessary, we may use advanced biologic materials and premium surgical materials to help reduce risk and support wound healing. These may include PRF, PDGF, collagen membranes, bone grafting materials, and other regenerative adjuncts selected for the specific clinical situation.
No biologic material can guarantee prevention of MRONJ. However, careful surgical planning, infection control, conservative technique, tension-free closure, biologic support, and close monitoring can help create the most favorable healing environment possible.
Before starting bisphosphonates, Prolia, Reclast, or related medications, patients should ideally have a comprehensive dental and periodontal evaluation. This is especially important if they have loose teeth, active gum disease, failing implants, non-restorable teeth, untreated infection, or anticipated oral surgery.
Patients should discuss planned dental treatment with their endocrinologist, rheumatologist, oncologist, or prescribing physician before beginning therapy. In many situations, completing necessary dental treatment before starting these medications can reduce future risk.
MRONJ and BRONJ are uncommon, but awareness is essential. Patients should not be afraid of necessary medical treatment, and they should not stop medications without physician guidance. These drugs often provide major medical benefits and may be critical for preventing fractures or managing cancer-related bone disease.
At New York Periodontics, our role is to help patients understand their risk, coordinate care with their medical doctors, and perform dental treatment in the safest and most biologically supportive way possible.
For patients already taking these medications, the overall risk of osteonecrosis remains low. When treatment is needed, we use careful diagnosis, conservative surgical technique, biologic materials, and close maintenance to help reduce risk and support successful healing.
