Recommendations, including specific medications, diagnostic criteria, treatment options, and implant considerations outlined in the AAOMS position paper on MRONJ:

1. Specific Medications Associated with MRONJ:
   • Bisphosphonates: The risk of MRONJ is higher in patients receiving high-dose intravenous bisphosphonates for cancer treatment compared to those receiving oral bisphosphonates for osteoporosis.
   • Denosumab: MRONJ can also occur in patients receiving denosumab, particularly those with cancer-related bone metastases or osteoporosis.
2. Diagnostic Criteria and Staging:
   • Exposed Bone: Diagnosis of MRONJ is based on the presence of exposed bone in the maxillofacial region lasting for more than eight weeks in patients with a history of antiresorptive or antiangiogenic therapy.
   • Clinical Signs: Clinical signs include pain, swelling, erythema, fistula formation, and soft tissue infection. Radiographic imaging may reveal areas of osteolysis, sclerosis, or sequestra associated with MRONJ.
   • Staging System: The AAOMS staging system categorizes MRONJ into four stages based on severity:
     • Stage 0: Asymptomatic exposed bone.
     • Stage 1: Exposed bone with pain and inflammation.
     • Stage 2: Exposed bone with pain, inflammation, and evidence of infection.
     • Stage 3: Exposed bone with pain, inflammation, infection, and pathological fracture or extraoral fistula.
3. Management Strategies:
   • Conservative Measures: Conservative management includes pain control, antimicrobial therapy, and local debridement to remove necrotic tissue. Use of chlorhexidine mouthwash and antibiotic therapy may help manage infection.
   • Surgical Intervention: Surgical options include sequestrectomy, soft tissue closure, and removal of necrotic bone. Adjunctive therapies like platelet-rich plasma (PRP) or hyperbaric oxygen therapy (HBOT) may enhance wound healing.
   • Drug Holiday: Temporary cessation of antiresorptive or antiangiogenic therapy (drug holiday) may be considered in patients at high risk of MRONJ, particularly if they require invasive dental procedures.
4. Implant Considerations and Recommendations:
   • Risk Assessment: Before considering dental implant placement, clinicians should perform a comprehensive risk assessment, considering factors such as medication history, oral health status, and risk of MRONJ development.
   • Alternative Treatments: For patients with a history of MRONJ or at high risk of developing the condition, alternative treatment options, such as removable prostheses or fixed partial dentures, should be considered.
   • Monitoring and Maintenance: Close monitoring and maintenance of oral health are essential for patients with dental implants and a history of or at risk of MRONJ. Regular dental visits, meticulous oral hygiene practices, and avoidance of invasive procedures can help minimize the risk of implant-related complications.

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