Medication-related osteonecrosis of the jaw (MRONJ) can be difficult to treat and causes significant morbidity, but is largely preventable. Originally termed BONJ given the number of cases associated with bisphosphonate use, it is more commonly recognized as MRONJ today since the pathophysiology is due to two pharmacological classes of medications: antiresorptive (including bisphosphonates and receptor activator of nuclear factor kappa-B ligand inhibitors) and antiangiogenic drugs. Newly published guidelines strongly recommend dental assessment and necessary remedial treatment before such drugs are commenced.

MRONJ pathophysiology is still not completely elucidated. There are several suggested hypothesis that could explain its unique localization to the jaws: inflammation or infection, microtrauma, altered bone remodeling or over-suppression of bone resorption, angiogenesis inhibition, bisphosphonate toxicity, peculiar biofilm of the oral cavity, terminal vascularization of the mandible, suppression of immunity, or Vitamin D deficiency. Dental screening and adequate treatment are fundamental to reduce the risk of osteonecrosis in patients under antiresorptive or antiangiogenic therapy, or before initiating the administration.

The treatment of MRONJ is generally difficult and the optimal therapy strategy is still to be established. For this reason, prevention is even more important. It is suggested that a multidisciplinary team approach including a dentist, an oncologist, and a maxillofacial surgeon to evaluate and decide the best therapy for the patient. The choice between a conservative treatment and surgery is not easy, and it should be made on a case by case basis. However, the initial approach should be as conservative as possible. The most important goals of treatment for patients with established MRONJ are primarily the control of infection, bone necrosis progression, and pain. The aim of this program is to present the current knowledge about MRONJ, its preventive measures and management strategies.

Educational objectives
At the end of this program, participants will be able to:

1. Describe the risk factors for osteoporosis to include the normal bone remodeling process

2. Explain the mechanisms of action of the bisphosphonates which may account for their association with ONJ

3. Discuss preventative measures in management of suspected ONJ patients

4. Identify commonly used medications associated with causing MRONJ

5. Discuss current treatment strategies to include an individualized, yet multimodal and evidence-based approach to success in managing these patients