Osteonecrosis of the Jaw

Osteonecrosis of the jaw is a rare but serious condition where bone tissue in the jaw dies and becomes exposed through the gums. While uncommon, it can occur in people taking certain medications for osteoporosis or cancer, particularly after dental procedures.

Table of contents

• What is osteonecrosis of the jaw?
• Causes and risk factors
• Signs and symptoms
• How is it diagnosed?
• Treatment options
• Prevention and dental care
• Living with osteonecrosis of the jaw

What is osteonecrosis of the jaw?

Osteonecrosis of the jaw is a condition where bone cells in your jawbone die and the bone becomes exposed through an opening in your gums^[1]. The term “osteonecrosis” comes from “osteo,” meaning bone, and “necrosis,” meaning death. Healthcare providers also call this condition avascular necrosis, which refers to the lack of blood flow to the bone tissue^[1].

When osteonecrosis occurs, blood cannot reach the exposed area of bone, causing more bone tissue to die^[1]. The affected bone typically pokes through the gum tissue and remains exposed for at least eight weeks^[2].

This condition is uncommon. It affects approximately 2 out of every 100 people with cancer who receive certain medications that help with bone loss and ease bone pain^[1]. People who don’t have cancer or who don’t take these medicines can also develop osteonecrosis of the jaw, but it’s even rarer^[1].

Causes and risk factors

Osteonecrosis of the jaw tends to occur after oral surgery like tooth removal (extraction), dental implants, or dental bone grafts that may leave some of your jawbone exposed^[1]. When gum tissue doesn’t heal after a dental procedure and the jawbone is left exposed, the bone doesn’t receive blood flow, causing bone cells to die^[1]. In some cases, the condition may develop for no apparent reason^[1].

Several medications and factors can increase the risk of developing this condition. The most important risk factor is taking antiresorptive medications called bisphosphonates^[3]. These medications, given through an IV (intravenous line), slow bone loss and increase bone strength, helping prevent bone fractures. They also ease pain from cancer that spreads to the bones and lower the risk of fractures after certain cancer treatments^[1].

Common bisphosphonates include alendronate (Fosamax), risedronate (Actonel), ibandronate (Boniva), and zoledronic acid (Reclast)^[3]. Another medication called denosumab (Prolia) can also cause osteonecrosis of the jaw^[3]. Patients who receive intravenous bisphosphonates as part of their cancer treatment are at higher risk than those who receive much lower doses for osteoporosis treatment^[3]. Studies haven’t shown a link between lower-dose oral antiresorptive medicines for osteoporosis and osteonecrosis of the jaw^[1].

Other risk factors that can increase your chances of developing this condition include^[1]:

• Being 65 or older
• Receiving chemotherapy
• Having diabetes
• Facial fracture or trauma
• Gum disease, including periodontitis (serious gum infection)
• Long-term use of corticosteroids
• Shingles
• Smoking

Radiation therapy to the head or neck can also lead to a similar condition called osteoradionecrosis, which occurs in 3% to 10% of people who receive radiation therapy for head and neck cancers^[1]. This is a different condition from medication-related osteonecrosis of the jaw.

Signs and symptoms

If you’ve recently had a dental procedure and develop osteonecrosis of the jaw, you may have pain on the side of your mouth where the procedure took place^[1]. However, some people don’t have any symptoms^[1].

Common signs and symptoms include^[1][2]:

• Jaw pain
• Loose teeth
• Mouth sores
• Pus-like discharge in your gums and mouth
• Swollen gums
• Exposed bone that lasts for more than 8 weeks
• Feeling of numbness or “heavy jaw”
• Bad breath

It’s important to note that the bone beginning to weaken and die does not always cause pain^[2]. The most definitive sign is the presence of exposed bone in the mouth that can be seen or probed through an opening in the gum tissue^[4].

How is it diagnosed?

Your doctor or dentist will do a visual examination of your mouth to see whether there is any exposed bone^[2]. During the examination, they will look for areas where bone tissue is visible through the gums.

In addition to the visual examination, your dentist may take an X-ray to better assess the extent of bone damage^[2]. Advanced imaging techniques can help doctors accurately define the size of the affected area^[14].

The condition is diagnosed as osteonecrosis of the jaw if damaged, exposed bone persists in the upper or lower jaw for at least eight weeks^[16]. Your healthcare provider will also review your medical history, including any medications you are taking and recent dental procedures you have had.

Treatment options

Most patients with osteonecrosis of the jaw who are taking antiresorptive therapy for osteoporosis can be healed with conservative treatment and do not require surgery^[2]. Conservative treatments are usually effective and focus on managing symptoms and promoting healing^[3].

Common treatment approaches include^[2][3]:

• Mouth rinses and antibiotics: These help treat infection in the mouth and around the exposed jaw
• Oral analgesics: Pain relievers to ease discomfort
• Mouth guard: A protective device that covers and protects the area of exposed bone
• Medication adjustment: In some cases, changing or scaling back the prescribed medication in consultation with your physician may help with recovery

For some patients, particularly those with Stage 1 osteonecrosis, nonsurgical debridement may be recommended^[16]. Debridement means gently scrubbing the exposed bone to remove dead cells. This can be done at home with an antiseptic mouth rinse twice a day using a cotton swab or soft toothbrush. The gums will regrow underneath the dead bone and eventually push it out^[16].

Surgery is not usually required and could contribute to poor bone healing^[3]. However, if conservative treatments don’t work, oral surgeons may need to remove the dead bone and inject growth factors made from your own blood to promote healing^[16].

If you are being treated for cancer, your dentist or oral surgeon should work closely with your medical oncologist^[2]. Your medical team may consider whether you should continue taking bisphosphonate medications during treatment^[2].

Prevention and dental care

Good oral hygiene and regular dental care are the best ways to lower the risk of osteonecrosis of the jaw^[3]. There are several important steps you can take to reduce your risk.

Before starting treatment with bone-modifying medications, you should^[2][4]:

• Make sure you receive regular dental care
• Have a dental examination and any necessary treatment before you start bone-modifying therapy
• Complete any dental treatments and procedures that require bone healing before initiating therapy

During treatment, it’s important to^[2][3]:

• Maintain good oral hygiene habits to care for your teeth
• Inform your dentist of medications you are taking, particularly if you take antiresorptive therapy
• Avoid invasive dental procedures such as tooth extractions or dental implants when possible
• Consider conservative dental procedures, such as root canal instead of extraction if a tooth can be saved
• Avoid full-mouth dental extractions or periodontal surgery if possible

It is not necessary to stop bisphosphonate use before a dental procedure^[3]. However, it may be best to delay starting the drug therapy until after a scheduled dental procedure^[3].

If you detect any mouth pain or problems while taking these medications, you should seek dental care right away^[3].

Living with osteonecrosis of the jaw

Living with osteonecrosis of the jaw requires careful attention to your oral health and ongoing communication with your healthcare team. While the condition can cause significant pain and reduce quality of life^[23], most cases can be managed effectively with conservative treatment.

Key aspects of managing daily life with this condition include maintaining excellent oral hygiene. This means brushing and flossing after every meal to reduce the risk of infection^[17]. Using an antibacterial mouth rinse twice a day can help reduce the chance of developing infections that could worsen the condition^[16].

Regular dental visits are essential. You should see your dentist regularly for simple cleanings, repair of dental decay, and evaluations to catch potential problems early^[16]. Tell your dentist and oncologist if you have bleeding gums, pain, signs of infection in your mouth, or any unusual feeling in your teeth or gums^[17].

Patients with periodontal disease should consider non-surgical treatments before choosing surgery^[3]. These patients are seen by specialists who have experience in treating osteoporosis with antiresorptive medications and managing the risk of osteonecrosis^[3].

Remember that while osteonecrosis of the jaw is a serious condition, it is rare, and the benefits of taking bone-modifying medications typically outweigh the risks^[8]. With proper dental care and monitoring, many patients can successfully prevent or manage this condition.