Osteonecrosis of the Jaw (ONJ)
Osteonecrosis of the jaw (ONJ) is a condition where the jawbone is exposed and not covered by gums. The bone weakens and dies. There is no test to measure ONJ risk. Some factors are known to raise this risk in very rare circumstances. Medications that may impact the raise ONJ risk are Bisphosphonates, like alendronate (Fosamax), risedronate (Actonel and Atelvia), ibandronate (Boniva), zoledronic acid (Reclast) and denosumab (Prolia). This may be due to loss of bone’s ability to repair itself, a drop in blood vessel formation, or infection. While there is a very low risk of ONJ occurring in people taking any of these medications, the risk may be slightly higher in people who require invasive dental procedures, such as a dental extraction or dental implant, if they also take bisphosphonates. Patients who receive intravenous (injection into vein) bisphosphonates as part of their cancer treatment are at higher risk for ONJ than those who receive the much lower doses for osteoporosis treatment. Other risk factors include older age, diabetes, gum disease and smoking.
What Are the Signs/Symptoms?
People with ONJ may experience pain, soft tissue swelling and drainage in the mouth, and an exposed jawbone for eight weeks or longer. Other possible signs are bad breath, loose teeth, and signs of infection of the gums.
What Are Common Treatments?
People with osteoporosis who develop ONJ receive conservative treatments, such as oral rinses, antibiotics, and oral analgesics to ease pain. These treatments are usually effective. Surgery is not usually required and could contribute to poor bone healing. These patients are seen by a rheumatologist who has experience in treating osteoporosis with antiresorptive medications and managing the risk of ONJ.
Living with ONJ
Good oral hygiene and regular dental care are the best ways to lower the risk of ONJ. Patients should inform their dentist of medications they are taking, particularly if they take anti-resorptive therapy. Dentists may consider using conservative invasive dental procedures on patients on antiresorptive therapy, such as root canal instead of extraction if the tooth can be saved. Full-mouth dental extractions or periodontal surgery should be avoided if possible. Patients with periodontal disease should consider non-surgical treatments before choosing surgery. If patients detect any mouth pain or problems, they should seek dental care right away. It is not necessary to stop bisphosphonate use before a dental procedure, but it may be best to delay starting the drug therapy until after a scheduled dental procedure.
Updated June 2025 by Kiren Sahni, DO, and reviewed by the American College of Rheumatology Committee on Communications and Marketing.
This information is provided for general education only. Individuals should consult a qualified health care provider for professional medical advice, diagnosis and treatment of a medical or health condition.