DENTAL HYGIENISTS PLAY AN IMPORTANT ROLE
IN RECOGNIZING THE SIGNS OF ANTIRESORPTIVE
AGENT-INDUCED OSTEONECROSIS OF THE JAW.
By Leslie Ann W. Mallory, RDH, MS;
Susan Lynn Tolle, BSDH, MS;
W. Lee Melvin, DMD
After reading this course, the participant should
be able to:
1. Discuss the indications for bisphosphonates and how they work.
2. Identify the risk factors of antiresorptive agent-induced osteonecrosis of the
3. Explain treatment and management strategies for ARONJ.
Bisphosphonates are anti resorptive medications
prescribed to prevent and/or treat
bone diseases. While they are designed to
improve quality of life and increase longevity, these medications
may also cause undesirable side effects. A small percentage of
patients experience antiresorptive agent-induced osteonecrosis
of the jaw (ARONJ) either while taking antiresorptive medications
or several years post-therapy. As the median age of the American
population continues to increase, the number of dental patients
taking antiresorptive medications will probably increase, as well.
As such, dental hygienists need to be well versed in the signs
and symptoms of this serious complication.
Bisphosphonates are a class of drugs given orally or parenterally
to patients with bone loss. The majority of patients treated
for osteoporosis receive the drugs orally. As a group, these
drugs have a phosphorus-carbon-phosphorus backbone, and
work by decreasing the number of osteoclasts.1,2 Two generations
of bisphosphonate medications therefore exist: generation
one contains no nitrogen and generation two contains
nitrogen (Table 1 and Table 2). The structure and function of
varying bisphosphonates are modified by side chains of R1 and
R2, with the R2 side chain determining the antiresorptive
potency. The R2 side chain containing nitrogen is the most
potent and is most often associated with complications. Nitrogen
side chains increase the binding affinity of the bisphosphonate
to hydroxyapatite crystals and decrease bone
resorption. As such, generation two bisphosphonates last the
longest and are the most potent.2 Parenteral
bisphosphonates have a longer duration of
action and are more intense than those administered
Bisphosphonate medications containing
nitrogen have been associated with ARONJ
more than any other antiresorptive therapy.
While rare, ARONJ, or bone death, is a debilitating
side effect. The current consensus,
however, is that the benefits gained from preventing
skeletal fractures outweigh the risks
Osteonecrosis can occur in the hip, arm, knee,
talus, shoulder, and jaw.6,7 It is unclear why
osteonecrosis occurs, but it may be a natural
consequence of local or systemic factors that
impair blood flow.7,8 The American Association
of Oral and Maxillofacial Surgeons (AAOMS)
asserts that three characteristics must be present
to meet the definition of ARONJ: current
or previous treatment with a bisphosphonate,
exposed bone in the maxillofacial region that
has persisted for more than 8 weeks, and no
history of radiation therapy to the jaw.6
Limited evidence is available on the risk
factors related to ARONJ,9 but bisphosphonate
potency, length of use, and the performance
of invasive dentoalveolar surgery all
seem to be related.6,9 Risk also increases if oral
surgery has been or needs to be performed
during antiresorptive treatment or after bisphosphonate
therapy has been discontinued.
Periapical surgery that causes osseous injury
increases risk, although there is much debate
about whether dental implant therapy
increases the likelihood of ARONJ.6,7,9 Studies
also suggest that concomitant diseases, such
as periodontitis and advanced caries, may
increase the risk of developing ARONJ.4,6,9,10
While poor oral hygiene may not be a specific
risk factor, the distinct microflora of the
oral cavity may initiate or cause progression of
ARONJ.11,12, Xerostomia is also related because
salivary hypofunction increases the risk of caries
and ulcerations.4 Bony protuberances (eg,
mandibular and palatal tori) in the oral cavity
are also associated with ARONJ because these
osseous areas are covered with very thin
mucosa, which is easily susceptible to damage
from oral trauma.4–6 Patients with ill-fitting dentures
that cause continuous tissue injury are
also more likely to develop ARONJ.3,4,6
Advanced age may be related, although cancer
and osteoporosis are more common among
older adults and most of the studies were conducted
on this population, so it is unclear what
role age plays.
SIGNS AND SYMPTOMS
Because few treatments are available for
ARONJ, prevention is the best approach. Prevention
starts with an accurate, current
medical history containing a list of all medications
being taken. For patients taking bisphosphonates,
the dosage, frequency, and
duration should be obtained because each
can influence the risk of developing ARONJ.
Recording patients' past usage is also important
due to the drug's long half-life.2,13
Patients should also be queried about past
or present treatment for any other bone diseases.
Patients should then be educated
about the risks and benefits of dental care
while taking bisphosphonates, beginning
signs and symptoms of ARONJ, and the
importance of early treatment.
Oral care providers must be proficient in
identifying the clinical signs of ARONJ. Asymptomatic
signs may be present for weeks or
months before ARONJ is diagnosed.5 Dental
professionals should look for exposed bone on
the maxilla or mandible during the
intraoral examination. The most
common site of ARONJ is the
mandibular posterior lingual region
close to the mylohyoid ridge,
although the alveolar ridge of the
maxilla may also be affected.4–6,13,14
Other signs may include sequestra of
bone or secondary infection with or
without purulent drainage. If the
patient has removable oral prosthetics,
dental professionals must assess
areas where the appliance comes in
contact with tissue, specifically the
lingual flange.3,6 Removable appliances
may cause trauma to underlying
tissues and adjacent mucosa,
thus increasing the risk of developing
As ARONJ progresses, exposed bone with
smooth or ragged borders becomes clinically
apparent.1,14 Bone lesions vary in color from
yellow to grayish-tan and often present with
fragmented friable soft tissue. With progression,
pain may increase due to inflammation
and secondary infection.13,16 More specific
signs may include pathologic fracture, orocutaneous
fistula, oroantral fistula, or oronasal
fistula formation.13 When performing the
extraoral exam, dental hygienists should look
for an extraoral fistula from infected bone,
which strongly indicates progression of
ARONJ. Soft tissue ulcerations, swelling, paresthesia,
suppuration, involvement with intraor
extraoral sinus tracks, tooth mobility, and
extraoral fistulae may also occur.1,14
Radiographs may help determine oral
involvement.17 Dental hygienists must be diligent
in decreasing trauma to areas, such as
exostoses and tori, when exposing radiographs
because these minor traumas may result in poor
healing among patients susceptible to ARONJ.
While radiographs are helpful, early ARONJ may
not appear on dental X-rays, computed tomo -
graphy (CT), or magnetic resonance imaging.
Dental professionals should be familiar with the
AAOMS' staging criteria to better assist in identifying
ARONJ cases (Table 3).9
Eliminating conditions that may be similar
to ARONJ, including aphthous ulcers, gingivitis,
periodontal diseases, alveolar osteitis,
caries, osteomyelitis or malignancies, sinusitis,
temporomandibular disorders (TMDs),
and osteoradionecrosis, assists in treatment
planning.6,3,7 With proper oral hygiene, conditions,
such as ulcers, gingivitis, and alveolar
osteitis, may heal within a short time, while
ARONJ usually will not.5 Caries may be
assessed by radiographs, and if lesions are not
advanced into the alveolar bone, then restorative
treatment may be completed.6,9
Osteomyelitis and other malignancies can be
ruled out by a physician who can review CT
scans and bone biopsies.7,13 Osteoradionecrosis
of the jaw may appear similar to ARONJ.
Dental professionals should contact the oncologist
of patients who have received head and
neck radiation to help definitively diagnose
ARONJ is best diagnosed using the
AAOMS' criteria in the presence of exposed
jaw, a history of bisphosphonate use, and no
prior exposure to radiation of the head and
neck (Table 4).9
The goal of treating patients with ARONJ is
to increase quality of life, control pain, manage
secondary infections, and decrease the
progression of necrosis.9,19 Ideally, all restorative,
preventive, and periodontal therapy
should be completed prior to the start of a
bisphosphonate regimen.6 Specifically, scaling
and root planing and other treatments for
periodontal diseases should be done. Vescovi
and Nammour recommend regular dental
maintenance appointments at 4 months for
cancer patients taking bisphosphonate medications
and 8 months for noncancer patients,
because spontaneous forms of ARONJ may
develop. However, 3-month to 4-month
maintenance appointments for scaling and
root planing and review of self-care strategies
may prove beneficial for controlling biofilm
and oral infection.19
Once bisphosphonate therapy begins,
patients should be managed with less invasive
dental treatments.6,9 For example, scaling and
root planing and minor restorations may be
acceptable, but extractions are contraindicated
due to potential exposure of the alveolar
bone.5,6,9 If possible, questionable teeth
should be treated endodontically, rather than
through extraction, to avoid exposing the
alveolar bone. When antiresorptive therapy
has been completed, the dental team needs
to remember that bisphosphonates have a
long half-life and they could affect future
treatment.13 Although surgical therapy carries
a slight risk of ARONJ, there is no oral or periodontal
surgical procedure, including implant
placement, strictly contraindicated. However,
the American Dental Association recommends
that treatment plans should minimize
periosteal and/or intrabony exposure or disruption.9
Maintaining optimal oral hygiene and
keeping regular and frequent maintenance
appointments are key strategies in preventing
ARONJ.3,17,19 Therapeutic preventive maintenance
procedures are important in reducing
the bacterial load and minimizing oral infection.
Patients must understand the importance
of meticulous oral hygiene and its role
in reducing oral infection and the risk of
ARONJ. Dental hygienists need to educate
patients about daily biofilm removal techniques
and suggest alternative strategies if
dexterity issues preclude optimal self-care.
Antimicrobial mouthrinses, powered toothbrushes
and flossers, and water irrigators may
assist patients improve their oral health care
Control of dental caries is critical to preventing
periapical infections, which can
increase susceptibility to ARONJ. Regular use
of caries preventive agents are valuable.9 Recommending
tobacco cessation therapies to
patients who smoke, as well as counseling
patients to limit alcohol consumption, may
lower the risk of developing ARONJ.19 When
xerostomia is present, strategies for managing
this condition should also be discussed.
Because oral trauma is a risk factor for
patients predisposed to ARONJ, individuals
with removable prosthetic appliances should
have them evaluated during each maintenance
appointment for proper fit and to
review daily oral care instructions. The importance
of leaving the appliance out for at least
6 hours per day should also be emphasized.
Frequent recare appointments enable dental
hygienists to control oral deposits and apply
professional products, such as fluoride varnish
to decrease caries, as well as to closely monitor
Dental hygienists should be aware of any
current dental treatment the patient is
receiving from the dentist and look for signs
of healing. Since extraction sites normally
mucosalize within 14 days to 21 days, the
dentist should be notified if healing has
arrested.1,6,17 Dental hygienists should immediately
report suspicious conditions and
pathology to the dentist and encourage the
patient to report uncomfortable areas
exhibiting pain, swelling, or exposed
Dental professionals need to stay current on
ARONJ as the literature is still evolving on
its risk factors and management. The treatment
and prevention of ARONJ is not welldefined
yet. Hopefully, ongoing and future
research will provide more clarity on this
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