Skeletal Radiology

, Volume 38, Issue 1, pp 5–9 | Cite as

Osteonecrosis of the jaw

  • Ian R. ReidEmail author
  • Tim Cundy
Review Article


Osteonecrosis of the jaw (ONJ) was first reported in the dental literature in 2003. The term was coined to describe a spectrum of dental problems seen in cancer patients treated with high doses of intravenous bisphosphonates for the prevention of skeletal-related events. By consensus, the syndrome is now defined by the presence of exposed bone in the mouth which fails to heal after appropriate intervention over a period of 6 or 8 weeks. It is most common in patients with breast or prostate cancers, or multiple myeloma treated with bisphosphonates, of whom about 5% develop the condition. In patients receiving the much lower drug doses used in osteoporosis, the incidence appears to be ∼1/100,000 patient-years, probably comparable to that in the general population. It is likely that ONJ results from direct drug toxicity to cells of bone and soft tissue. The bone in ONJ lesions does not appear to be ‘frozen’ but rather there is very active bone resorption taking place, which is likely to be responsible for the local release at high concentrations of bisphosphonates. Infection probably plays a pivotal role in driving this resorption, so its active management is critical. Obvious abnormalities are apparent with a variety of radiologic modalities, and it is not clear that radiographs are inferior to other approaches. Most authors favor a conservative approach to surgical debridement of the lesions.


Bisphosphonates Jaw Osteonecrosis Infection Radiographs 


  1. 1.
    Marx RE. Pamidronate (Aredia) and zoledronate (Zometa) induced avascular necrosis of the jaws: a growing epidemic. J Oral Maxillofac Surg 2003; 61: 1115–1117.CrossRefGoogle Scholar
  2. 2.
    Ruggiero SL, Mehrotra B, Rosenberg TJ, Engroff SL. Osteonecrosis of the jaws associated with the use of bisphosphonates: a review of 63 cases. J Oral Maxillofac Surg 2004; 62: 527–534.CrossRefGoogle Scholar
  3. 3.
    Khosla S, Burr D, Cauley J, et al. Bisphosphonate-associated osteonecrosis of the jaw: report of a task force of the American Society for Bone and Mineral Research. J Bone Mineral Res 2007; 22: 1479–1491.CrossRefGoogle Scholar
  4. 4.
    American Association of Oral and Maxillofacial Surgeons. American Association of Oral and Maxillofacial Surgeons position paper on bisphosphonate-related osteonecrosis of the jaws. J Oral Maxillofac Surg 2007; 65: 369–376.CrossRefGoogle Scholar
  5. 5.
    Abu-Id MH, Warnke PH, Gottschalk J, et al. “Bis-phossy jaws”—high and low risk factors for bisphosphonate-induced osteonecrosis of the jaw. J Cranio-Maxillofac Surg 2008; 36: 95–103.CrossRefGoogle Scholar
  6. 6.
    Wessel JH, Dodson TB, Zavras AI. Zoledronate, smoking, and obesity are strong risk factors for osteonecrosis of the jaw: a case–control study. J Oral Maxillofac Surg 2008; 66: 625–631.CrossRefGoogle Scholar
  7. 7.
    Durie BGM, Katz M, Crowley J. Osteonecrosis of the jaw and bisphosphonates. N Engl J Med 2005; 353: 99–100.CrossRefGoogle Scholar
  8. 8.
    Wilkinson GS, Kuo YF, Freeman JL, Goodwin JS. Intravenous bisphosphonate therapy and inflammatory conditions or surgery of the jaw: a population-based analysis. J Natl Canc Inst 2007; 99: 1016–1024.CrossRefGoogle Scholar
  9. 9.
    Cartsos VM, Zhu S, Zavras AI. Bisphosphonate use and the risk of adverse jaw outcomes. JADA 2008; 139: 23–30.PubMedGoogle Scholar
  10. 10.
    Hansen T, Kunkel M, Weber A, Kirkpatrick CJ. Osteonecrosis of the jaws in patients treated with bisphosphonates—histomorphologic analysis in comparison with infected osteoradionecrosis. J Oral Pathol Med 2006; 35: 155–160.CrossRefGoogle Scholar
  11. 11.
    Reid IR, Bolland MJ, Grey AB. Is bisphosphonate-associated osteonecrosis of the jaw caused by soft tissue toxicity. Bone 2007; 41: 318–320.CrossRefGoogle Scholar
  12. 12.
    Bisdas S, Pinho NC, Smolarz A, Sader R, Vogl TJ, Mack MG. Bisphosphonate-induced osteonecrosis of the jaws: CT and MRI spectrum of findings in 32 patients. Clin Radiol 2008; 63: 71–77.CrossRefGoogle Scholar
  13. 13.
    Phal PM, Myall RWT, Assael LA, Weissman JL. Imaging findings of bisphosphonate-associated osteonecrosis of the jaws. Amer J Neuroradiol 2007; 28: 1139–1145.CrossRefGoogle Scholar
  14. 14.
    Chiandussi S, Biasotto M, Dore F, Cavalli F, Cova MA, Di Lenarda R. Clinical and diagnostic imaging of bisphosphonate-associated osteonecrosis of the jaws. Dentomaxillofac Radiol 2006; 35: 236–243.CrossRefGoogle Scholar
  15. 15.
    Wutzl A, Eisenmenger G, Hoffmann M, et al. Osteonecrosis of the jaws and bisphosphonate treatment in cancer patients. Wiener Klinische Wochenschrift 2006; 118: 473–478.CrossRefGoogle Scholar
  16. 16.
    Bedogni A, Blandamura S, Lokmic Z, et al. Bisphosphonate-associated jawbone osteonecrosis: a correlation between imaging techniques and histopathology. Oral Med Oral Pathol Oral Radiol Endodontol 2008; 105: 358–364.CrossRefGoogle Scholar
  17. 17.
    Groetz KA, Al-Nawas B. Persisting alveolar sockets—a radiologic symptom of BP-ONJ. J Oral Maxillofac Surg 2006; 64: 1571–1572.CrossRefGoogle Scholar
  18. 18.
    Corso A, Varettoni M, Zappasodi P, et al. A different schedule of zoledronic acid can reduce the risk of the osteonecrosis of the jaw in patients with multiple myeloma. Leukemia 2007; 21: 1545–1548.CrossRefGoogle Scholar

Copyright information

© ISS 2008

Authors and Affiliations

  1. 1.Faculty of Medical and Health SciencesUniversity of AucklandAucklandNew Zealand

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