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Oral Complications of Chemotherapy and Head/Neck Radiation (PDQ®): Supportive care - Health Professional Information [NCI] - Oral Toxicities Not Related to Chemotherapy or Radiation Therapy


It is advisable to discuss with the patient's physician whether discontinuing bisphosphonate therapy will not put the patient's general health at risk. Obtaining an informed consent from the patient before execution of the proposed drug discontinuation and therapy is important.

Spontaneous and asymptomatic BON

Patients may present with asymptomatic exposed necrotic bone anywhere in the oral cavity, although the mylohyoid plate on the posterior mandible and the mandibular tori are the most frequently affected sites. In this case, local measures and effective oral hygiene are important, as is systematic reevaluation of the patient to ensure resolution.

Effects on quality of life

The number of patients who develop BON is small compared with the large number of people who take bisphosphonates. However, some lesions can progress to large sizes and cause severe changes in a patient's quality of life.[1,2] Advanced mandibular lesions, for instance, can cause necrosis of the cortical bone, increasing the risk of fractures.[1] Advanced and nonresponsive infections may require hospitalization and intravenous antibiotic therapy.[1] Advanced cases of BON may require extensive jawbone resection.[29] Therefore, this adverse effect of bisphosphonate therapy may negatively affect quality of life.

New trends

The discontinuation of tobacco use to favor the healing process has been recommended.[30] (Refer to the PDQ summary on Smoking in Cancer Care for more information.) However, the role of tobacco and other comorbidities in the process of BON formation requires further investigation.[9] Several cases of oral osteonecrosis have been reported with drugs other than bisphosphonates, including the following:[31,32]

  • A human monoclonal antibody that inhibits the receptor activator of nuclear factor kappa beta ligand and is under investigation.
  • The antiangiogenic drugs being tested in advanced cancer cases, including bevacizumab, sunitinib, and sorafenib.


  1. Migliorati CA, Casiglia J, Epstein J, et al.: Managing the care of patients with bisphosphonate-associated osteonecrosis: an American Academy of Oral Medicine position paper. J Am Dent Assoc 136 (12): 1658-68, 2005.
  2. Migliorati CA, Siegel MA, Elting LS: Bisphosphonate-associated osteonecrosis: a long-term complication of bisphosphonate treatment. Lancet Oncol 7 (6): 508-14, 2006.
  3. Marx RE: Pamidronate (Aredia) and zoledronate (Zometa) induced avascular necrosis of the jaws: a growing epidemic. J Oral Maxillofac Surg 61 (9): 1115-7, 2003.
  4. Migliorati CA: Bisphosphanates and oral cavity avascular bone necrosis. J Clin Oncol 21 (22): 4253-4, 2003.
  5. American Association of Oral and Maxillofacial Surgeons: Position Paper on Bisphosphonate-Related Osteonecrosis of the Jaws. Rosemont, Ill: AAOMS, 2006. Available online. Last accessed February 27, 2013.
  6. Woo SB, Hellstein JW, Kalmar JR: Narrative [corrected] review: bisphosphonates and osteonecrosis of the jaws. Ann Intern Med 144 (10): 753-61, 2006.
  7. Khosla S, Burr D, Cauley J, et al.: Bisphosphonate-associated osteonecrosis of the jaw: report of a task force of the American Society for Bone and Mineral Research. J Bone Miner Res 22 (10): 1479-91, 2007.
  8. Migliorati CA, Woo SB, Hewson I, et al.: A systematic review of bisphosphonate osteonecrosis (BON) in cancer. Support Care Cancer 18 (8): 1099-106, 2010.
  9. Marx RE, Sawatari Y, Fortin M, et al.: Bisphosphonate-induced exposed bone (osteonecrosis/osteopetrosis) of the jaws: risk factors, recognition, prevention, and treatment. J Oral Maxillofac Surg 63 (11): 1567-75, 2005.
  10. Polizzotto MN, Cousins V, Schwarer AP: Bisphosphonate-associated osteonecrosis of the auditory canal. Br J Haematol 132 (1): 114, 2006.
  11. Khan AM, Sindwani R: Bisphosphonate-related osteonecrosis of the skull base. Laryngoscope 119 (3): 449-52, 2009.
  12. Longo R, Castellana MA, Gasparini G: Bisphosphonate-related osteonecrosis of the jaw and left thumb. J Clin Oncol 27 (35): e242-3, 2009.
  13. Saad F, Brown JE, Van Poznak C, et al.: Incidence, risk factors, and outcomes of osteonecrosis of the jaw: integrated analysis from three blinded active-controlled phase III trials in cancer patients with bone metastases. Ann Oncol 23 (5): 1341-7, 2012.
  14. Vahtsevanos K, Kyrgidis A, Verrou E, et al.: Longitudinal cohort study of risk factors in cancer patients of bisphosphonate-related osteonecrosis of the jaw. J Clin Oncol 27 (32): 5356-62, 2009.
  15. Hoff AO, Toth BB, Altundag K, et al.: Frequency and risk factors associated with osteonecrosis of the jaw in cancer patients treated with intravenous bisphosphonates. J Bone Miner Res 23 (6): 826-36, 2008.
  16. Stopeck AT, Lipton A, Body JJ, et al.: Denosumab compared with zoledronic acid for the treatment of bone metastases in patients with advanced breast cancer: a randomized, double-blind study. J Clin Oncol 28 (35): 5132-9, 2010.
  17. Ripamonti CI, Maniezzo M, Campa T, et al.: Decreased occurrence of osteonecrosis of the jaw after implementation of dental preventive measures in solid tumour patients with bone metastases treated with bisphosphonates. The experience of the National Cancer Institute of Milan. Ann Oncol 20 (1): 137-45, 2009.
  18. Migliorati CA, Schubert MM, Peterson DE, et al.: Bisphosphonate-associated osteonecrosis of mandibular and maxillary bone: an emerging oral complication of supportive cancer therapy. Cancer 104 (1): 83-93, 2005.
  19. Ruggiero SL, Fantasia J, Carlson E: Bisphosphonate-related osteonecrosis of the jaw: background and guidelines for diagnosis, staging and management. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 102 (4): 433-41, 2006.
  20. Carlson ER, Basile JD: The role of surgical resection in the management of bisphosphonate-related osteonecrosis of the jaws. J Oral Maxillofac Surg 67 (5 Suppl): 85-95, 2009.
  21. Stockmann P, Vairaktaris E, Wehrhan F, et al.: Osteotomy and primary wound closure in bisphosphonate-associated osteonecrosis of the jaw: a prospective clinical study with 12 months follow-up. Support Care Cancer 18 (4): 449-60, 2010.
  22. Williamson RA: Surgical management of bisphosphonate induced osteonecrosis of the jaws. Int J Oral Maxillofac Surg 39 (3): 251-5, 2010.
  23. Vescovi P, Manfredi M, Merigo E, et al.: Surgical approach with Er:YAG laser on osteonecrosis of the jaws (ONJ) in patients under bisphosphonate therapy (BPT). Lasers Med Sci 25 (1): 101-13, 2010.
  24. Freiberger JJ, Padilla-Burgos R, Chhoeu AH, et al.: Hyperbaric oxygen treatment and bisphosphonate-induced osteonecrosis of the jaw: a case series. J Oral Maxillofac Surg 65 (7): 1321-7, 2007.
  25. Freiberger JJ: Utility of hyperbaric oxygen in treatment of bisphosphonate-related osteonecrosis of the jaws. J Oral Maxillofac Surg 67 (5 Suppl): 96-106, 2009.
  26. Pautke C, Bauer F, Tischer T, et al.: Fluorescence-guided bone resection in bisphosphonate-associated osteonecrosis of the jaws. J Oral Maxillofac Surg 67 (3): 471-6, 2009.
  27. Dickinson M, Prince HM, Kirsa S, et al.: Osteonecrosis of the jaw complicating bisphosphonate treatment for bone disease in multiple myeloma: an overview with recommendations for prevention and treatment. Intern Med J 39 (5): 304-16, 2009.
  28. Berenson JR, Yellin O, Crowley J, et al.: Prognostic factors and jaw and renal complications among multiple myeloma patients treated with zoledronic acid. Am J Hematol 86 (1): 25-30, 2011.
  29. Chaudhry AN, Ruggiero SL: Osteonecrosis and bisphosphonates in oral and maxillofacial surgery. Oral Maxillofac Surg Clin North Am 19 (2): 199-206, vi, 2007.
  30. Yarom N, Yahalom R, Shoshani Y, et al.: Osteonecrosis of the jaw induced by orally administered bisphosphonates: incidence, clinical features, predisposing factors and treatment outcome. Osteoporos Int 18 (10): 1363-70, 2007.
  31. Migliorati CA, Covington JS 3rd: New oncology drugs and osteonecrosis of the jaw (ONJ). J Tenn Dent Assoc 89 (4): 36-8; quiz 38-9, 2009.
  32. Yarom N, Elad S, Madrid C, et al.: Osteonecrosis of the jaws induced by drugs other than bisphosphonates - a call to update terminology in light of new data. Oral Oncol 46 (1): e1, 2010.

This information is produced and provided by the National Cancer Institute (NCI). The information in this topic may have changed since it was written. For the most current information, contact the National Cancer Institute via the Internet web site at http:// cancer .gov or call 1-800-4-CANCER.

WebMD Public Information from the National Cancer Institute

Last Updated: September 04, 2014
This information is not intended to replace the advice of a doctor. Healthwise disclaims any liability for the decisions you make based on this information.
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