El papel de los odontólogos en la atención integral para la prevención oportuna de la osteonecrosis maxilar asociada a medicamentos

The role of dentists in comprehensive care to timely prevent medication-related osteonecrosis of the jaw

Los primeros casos de osteonecrosis maxilar relacionada con
medicamentos (MRONJ) se reportaron en 2003 y se asociaron al uso de
bisfosfonatos.¹ Desde entonces, si bien se han logrado múltiples
avances respecto a su definición, clasificación, diagnóstico y
tratamiento, también han surgido varias controversias.²

Dear Editor:

The first cases of medication-related osteonecrosis of the jaw (MRONJ) were reported in 2003 and were associated with the use of bisphosphonates.¹ Since then, multiple advances have been made regarding its definition, classification, diagnosis, and treatment, but several controversies have also emerged.²

Letter to the editor

Juan Pablo Rodríguez-Mora1

1 Universidad Nacional de Colombia - Bogota Campus - Faculty of Dentistry - Oral and Maxillofacial Pathology Research Line - Bogotá D.C. - Colombia.

Open access

Received: 09/12/2025

Accepted: 01/04/2026

Corresponding author: Juan Pablo Rodríguez-Mora. Facultad de Odontología, Universidad Nacional de Colombia. Bogotá D.C. Colombia. E-mail: juanpablorodriguezmora17@gmail.com.

Keywords: Bisphosphonate-Associated Osteonecrosis of the Jaw; Osteonecrosis; Bisphosphonates; Osteonecrosis: Dental Care; Primary Prevention (MeSH).

Palabras clave: Osteonecrosis de los Maxilares Asociada a Difosfonatos; Bifosfonatos; Osteonecrosis; Atención Odontológica; Prevención Primaria (DeCS).

How to cite: Rodríguez-Mora JP. The role of dentists in comprehensive care to timely prevent medication-related osteonecrosis of the jaw. Rev. Fac. Med. 2026;74:e124504. English. doi: https://doi.org/10.15446/revfacmed.v74.124504.

Cómo citar: Rodríguez-Mora JP. [El papel de los odontólogos en la atención integral para la prevención oportuna de la osteonecrosis maxilar asociada a medicamentos]. Rev. Fac. Med. 2026;74:e124504. English. doi: https://doi.org/10.15446/revfacmed.v74.124504.

Copyright: ©2026 The Author(s). This is an open access article distributed under the terms of the Creative Commons Attribution 4.0 International License, which permits unrestricted use, distribution, and reproduction in any medium, as long as the original author and source are credited.

Since 2007, and through its updates in 2009, 2014, and 2022, the American Association of Oral and Maxillofacial Surgeons (AAOMS)2 has led the academic discussion on MRONJ. The AAOMS has refined its definition based on clinical characteristics such as the presence of a fistula or exposed bone in patients with no history of radiotherapy or metastasis to the jaw who receive antiresorptive therapy, either alone or in combination with immunomodulators or antiangiogenic drugs. This definition serves as a global reference for epidemiological studies and has been adopted by expert consensuses in countries such as China3 and Colombia.1

However, the most recent position paper on MRONJ from the Italian Society of Oral Pathology and Medicine (SIPMO) and the Italian Society of Maxillofacial Surgery (SICMF)4 proposes an integrative approach that goes beyond clinical course. It defines the condition as a drug-induced adverse reaction in patients presenting with the following characteristics: 1) current or previous treatment with bone-modifying agents or antiangiogenic agents, 2) clinical and radiological findings of progressive bone destruction, and 3) no history of radiation therapy to the jaws or the presence of primary oral malignancy or metastatic disease to the jaws.4 This new approach implies a substantial shift in both the understanding of the disease and the proposed care model.

Despite these conceptual differences, international consensuses agree on a fundamental point: MRONJ is largely preventable. The risk of developing this complication depends not only on the underlying disease, that is, osteoporosis and cancer, but also on factors like the presence of associated comorbidities (diabetes, end-stage renal disease, and mineral metabolism disorders, among others), genetic predisposition, age, sex, tobacco use, and oral health status, which is one of the main factors. Treatment-related characteristics such as the type of medication used (e.g., bisphosphonates, RANKL inhibitors, antiangiogenic drugs), the route of administration, duration, frequency, and cumulative dose also play a significant role.1-4

Although it has been established that a dentist must perform a complete oral cavity examination and indicate relevant preventive treatments before starting pharmacological therapy in patients with cancer or osteoporosis, cases of MRONJ with oral infectious foci continue to occur. This situation highlights flaws in the comprehensive care of these patients, as these failures result from limited awareness regarding the impact of oral diseases on the development of this complication. Furthermore, they also stem from a lack of knowledge or clarity among medical teams about the role of the dentist in the prevention and multidisciplinary management of MRONJ.

Treatment planning for patients at risk of developing MRONJ requires a thorough clinical examination of the oral cavity and a radiographic assessment. The objective is to identify both acute infections and potential sites of infection to prevent sequelae that could be exacerbated once therapy begins.2,5 This assessment must include aspects such as patient motivation and education regarding dental care, fluoride application, and use of chlorhexidine rinses. It should also evaluate tooth mobility, periodontal disease, root fragments, caries, periapical lesions, edentulism, and denture stability.2 Furthermore, oral hygiene habits and lifestyle factors such as diet, alcohol consumption, physical activity, and tobacco use should be investigated.1,5 In patients with dental implants, it is necessary to carefully assess the health of peri-implant tissues.5

Based on the above, it is clear that dentists are the healthcare professionals with the clinical training required to perform a comprehensive semiological evaluation of the oral cavity. They are also the ones equipped to implement effective strategies for oral health prevention, promotion, and maintenance (Table 1). In patients with cancer (primary or metastatic) or osteoporosis, this assessment should ideally be performed before the initiation of therapies with bone-modifying agents (BMA) whenever systemic conditions allow.3-4

To perform this evaluation, the Italian consensus (SIPMO-SICMF) proposes a scale that guides the indication for dental procedures based on cumulative exposure to BMAs, categorized as high or low.4 Meanwhile, the Colombian consensus includes recommendations based on specific clinical scenarios.1 In both cases, dentists are responsible for making timely referrals to specialists, including periodontists, endodontists, prosthodontists, stomatologists, or oral and maxillofacial surgeons, depending on the complexity of the treatment.

Table 1. Minimally invasive, intermediate, and invasive dental interventions in patients at risk of medication-related osteonecrosis of the jaw.

Minimally invasive or non-invasive	Supragingival/subgingival scaling (ultrasonic debridement) Plaque control Dental prophylaxis/coronal polishing Fluoride varnish application Pit and fissure sealants Resin infiltration in caries lesions Composite resin restorations Provisional reconstructions Prosthetic rehabilitation Occlusal adjustment Relining and adjustment of removable prostheses Preparation and adaptation of muscle-relaxing splints Adjustment of total prostheses to avoid traumatic ulcers Control of plaque retentive factors
Intermediate	Primary endodontic treatment Endodontic retreatment
Invasive	Dental extractions (including third molars) Alveoloplasty Pre-prosthetic surgery Bone curettage Sequestrectomy Apicectomies Root resection Periodontal surgical procedures Surgical management of peri-implantitis Incisional or excisional biopsy Drainage of abscesses with bone or subperiosteal involvement Reduction and surgical management of dentoalveolar trauma

Source: Own elaboration.

Maintaining good oral health in these patients is a fundamental requirement for the prevention of MRONJ, but achieving this goal requires a multidisciplinary approach.1-5 The dentist is responsible for educating and motivating patients to reduce their risk through appropriate and personalized oral hygiene habits, including electric or manual brushing and the use of dental floss, fluoridated toothpastes, antibacterial rinses, and interdental devices.5 In turn, the medical team is responsible for promoting periodic dental check-ups every 4 to 6 months depending on individual needs.5 These strategies are highly cost-effective for reducing the risk of MRONJ before or during treatment, as they prevent diseases associated with biofilm dysbiosis, such as caries and periodontitis, which represent infectious foci in bone with diminished repair capacity.6 It is also essential for dentists to constantly update their knowledge of MRONJ, understand bone metabolism, and recognize the importance of BMA therapies, whose benefits always outweigh the risks, especially in preventing pathological fractures and skeletal-related events.1-4

Given the aging population and the increase in polymedicated patients—many of whom are treated with BMAs, especially for osteoporosis and cancer—it is fundamental to assign dentists a more active role in the comprehensive management of these patients to reduce the incidence of this complication. Oral health is a pillar of general health and its importance must be recognized by medical teams, particularly in the context of individuals at a higher risk for oral health-related complications such as MRONJ.

Conflicts of interests

None stated by the authors.

Funding

None stated by the authors.

Acknowledgments

None stated by the authors.

References

1.Chalem M, Medina A, Sarmiento AK, Gonzalez D, Olarte C, Pinilla E, et al. Therapeutic approach and management algorithms in medication-related osteonecrosis of the jaw (MONJ): recommendations of a multidisciplinary group of experts. Arch Osteoporos. 2020;15(1). doi: 10.1007/s11657-020-00761-0. PMID: 32623599.

2.Ruggiero SL, Dodson TB, Aghaloo T, Carlson ER, Ward BB, Kademani D. American Association of Oral and Maxillofacial Surgeons’ Position Paper on Medication-Related Osteonecrosis of the Jaws—2022 Update. J Oral Maxillofac Surg. 2022;80(5):920-43. doi: 10.1016/j.joms.2022.02.008. PMID: 35300956.

3.Ruan HJ, Chen H, Hou JS, An JG, Guo YX, Liu B, et al. Chinese expert consensus on the diagnosis and clinical management of medication-related osteonecrosis of the jaw. J Bone Oncol. 2024;49:100650. doi: 10.1016/j.jbo.2024.100650. PMID: 39651419; PMCID: PMC11621599.

4.Bedogni A, Mauceri R, Fusco V, Bertoldo F, Bettini G, Di Fede O, et al. Italian position paper (SIPMO‐SICMF) on medication‐related osteonecrosis of the jaw (MRONJ). Oral Dis. 2024;30(6):3679-709. doi: 10.1111/odi.14887. PMID: 38317291.

5.Mauceri R, Coniglio R, Abbinante A, Carcieri P, Tomassi D, Panzarella V, et al. The preventive care of medication-related osteonecrosis of the jaw (MRONJ): a position paper by Italian experts for dental hygienists. Support Care Cancer. 2022;30(8):6429-40. doi: 10.1007/s00520-022-06940-8. PMID: 35292850; PMCID: PMC9213300.

6.Radaic A, Kapila YL. The oralome and its dysbiosis: New insights into oral microbiome-host interactions. Comput Struct Biotechnol J. 2021;19:1335-60. doi: 10.1016/j.csbj.2021.02.010. PMID: 33777334; PMCID: PMC7960681.