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Oral Complications of Chemotherapy and Head/Neck Radiation (PDQ®)

  • Updated: 04/23/2014

Table 6. ONJ Staging System

BRONJ (ONJ) Staging Treatment Strategies 
BRONJ = bisphosphonate-related osteonecrosis of the jaw; IV = intravenous; ONJ = osteonecrosis of the jaw associated with medications.
At-risk category: No apparent necrotic bone in patients who have been treated with either oral or IV bisphosphonates.No treatment indicated; patient education.
Stage 0: No clinical evidence of necrotic bone, but nonspecific clinical findings and symptoms.Systemic management, including the use of pain medication and antibiotics.
Stage 1: Exposed and necrotic bone in patients who are asymptomatic and have no evidence of infection.Antibacterial mouth rinse; clinical follow-up on a quarterly basis; patient education and review of indications for continued bisphosphonate therapy.
Stage 2: Exposed and necrotic bone associated with infection, as evidenced by pain and erythema in the region of the exposed bone, with or without purulent drainage.Symptomatic treatment with oral antibiotics; oral antibacterial mouth rinse; pain control; superficial debridement to relieve irritation of soft tissue.
Stage 3: Exposed and necrotic bone in patients with pain, infection, and one or more of the following: exposed and necrotic bone extending beyond the region of alveolar bone (i.e., inferior border and ramus in the mandible, maxillary sinus and zygoma in the maxilla), resulting in pathologic fracture, extraoral fistula, oral antral/oral nasal communication, or osteolysis extending to the inferior border of the mandible of sinus floor.Antibacterial mouth rinse; antibiotic therapy and pain control; surgical debridement/resection for longer-term palliation of infection and pain.