Journal of Oral and Maxillofacial Radiology

: 2020  |  Volume : 8  |  Issue : 2  |  Page : 36--40

Medication-related osteonecrosis of the jaw: Should cone-beam CT be considered as standard of care for diagnosis and treatment?

Deeba Kashtwari1, Axel Ruprecht2, Joseph Katz1,  
1 Department of Oral and Maxillofacial Diagnostic Sciences, University of Florida College of Dentistry, Gainesville, FL, USA
2 Department of Oral and Maxillofacial Diagnostic Sciences, University of Florida College of Dentistry, Gainesville, FL; Department of Oral and Maxillofacial Pathology, Radiology and Medicine, University of Lowa, Lowa City, IA, USA

Correspondence Address:
Deeba Kashtwari
Department of Oral and Maxillofacial Diagnostic Sciences, University of Florida College of Dentistry, Gainesville, FL


Medication-related osteonecrosis of the jaw (MRONJ) is a major challenge faced in dental practice. Imaging plays a critical role in diagnosis and treatment planning of this condition. Conventional radiographs are commonly acquired as baseline imaging, but due to limitations such as being a two-dimensional modality and superimposition of adjacent anatomy, certain radiographic features may not be visualized like on a cone-beam computed tomography (CBCT) possibly resulting in either missing the lesion on radiographs or misinterpreting the severity of the disease. This case shows that CBCT could be a good initial choice along with clinical examination to avoid delay in proper diagnosis and management.

How to cite this article:
Kashtwari D, Ruprecht A, Katz J. Medication-related osteonecrosis of the jaw: Should cone-beam CT be considered as standard of care for diagnosis and treatment?.J Oral Maxillofac Radiol 2020;8:36-40

How to cite this URL:
Kashtwari D, Ruprecht A, Katz J. Medication-related osteonecrosis of the jaw: Should cone-beam CT be considered as standard of care for diagnosis and treatment?. J Oral Maxillofac Radiol [serial online] 2020 [cited 2021 Jan 21 ];8:36-40
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Medication-related osteonecrosis of the jaw (MRONJ) is one of the major challenges faced in dental practice.[1] It has been more frequently reported in the mandible than the maxilla and has seen to be associated with various antiresorptive medications such as bisphosphonate, denosumab, and various biological drugs.[2] The American Association of Oral and Maxillofacial Surgeons defines MRONJ as the presence of exposed, necrotic bone in the maxillofacial region that has persisted for >8 weeks in a patient with current or previous bisphosphonate therapy and no history of therapeutic radiation to the jaws.[3] Treatment of MRONJ is conventionally evaluated on a case-by-case basis. There are several treatment strategies that have been considered for management of MRONJ, varying from discontinuing the drug before invasive dental procedures and other conservative therapy to extensive bone debridement and bone resection.[4] However, there is no consensus on any particular approach.[5]

The extent of MRONJ is currently measured by a staging system of 0–3 based on the clinical presentation of the patient. Even though Stages 1–3 can be partly defined by the exposure of the bone in the oral cavity, this gets more complicated in patients with Stage 0 MRONJ where there is no evidence of bone exposure clinically and the diagnosis mostly relies on either nonspecific symptoms or clinical and radiographic findings; hence, imaging plays a critical role in diagnosis and treatment planning of all stages of MRONJ, especially Stage 0.[6] Conventional radiographs are commonly acquired as baseline imaging to determine the area of involvement and evaluate osseous changes, but due to limitations such as being a two-dimensional modality and superimposition of adjacent anatomy, certain radiographic features may not be obvious and may result in either missing the lesion on radiographs or misinterpreting the severity of the disease.[7]

Three-dimensional imaging, such as cone-beam computed tomography (CBCT), is helpful in a thorough evaluation of the patients with MRONJ. Studies have shown a significant impact of CBCT in differential diagnosis and management of patients with Stage 0 MRONJ.[8]

 Case Report

We present a case of a 64-year-old male with multiple myeloma (MM) referred for evaluation to rule out MRONJ in the Oral Medicine Clinic of the University of Florida College of Dentistry. The pertinent medical history indicated the use of Revlimid and Zometa 4 mg every 3 months for the past 2 years that was stopped 6 months ago. Other conditions included congenital heart defect, anemia, hypothyroidism, and psychiatric problems. His major complaint was persistent pain in the left lower jaw that was aggravated by brushing of the area. Intraoral examination revealed severe buccal and lingual bilateral exostoses in both maxilla and mandible [Figure 1].{Figure 1}

An area of exposed bone of 4 mm was noted on the lingual aspect of tooth # 19 with surrounding peripheral erythema. The overlying mucosa was tender. On examination, the area was slightly tender to palpation and #20 was sensitive to percussion. The pantomograph and the bitewing only showed sclerotic changes in the region of missing 17 and 18. Tooth 20 appeared well restored with no radiographic evidence of apical pathosis. There were mandibular tori [Figure 2] and [Figure 3]. The clinical diagnosis was Stage 1 MRONJ in the area of 19. The patient was prescribed chlorhexidine gluconate rinses with oral hygiene instructions.{Figure 2}{Figure 3}

Five months later, patient came back with severe intractable pain in the area. He informed that he had a root canal treatment of #20 done that was suspected by his private dentist to be the cause of his pain. He also completed a course of clindamycin that was prescribed by his oncologist.

Since the clinical course was not compatible with periapical periodontitis in spite of the overfilled #20, a CBCT was ordered that revealed. The pantomographs and periapical radiographs from 2019 3 months before the prescription of CBCT continued to show sclerotic changes but did not demonstrate any lytic changes [Figure 4] and [Figure 5]. Even the intraoral periapical radiograph prescribes on the same day as the cone-beam CT did not exhibit any further radiographic changes [Figure 6].{Figure 4}{Figure 5}{Figure 6}

The cone-beam CT demonstrated a clear mixed lytic and sclerotic lesion in the mandible with possible sequestration at the lingual cortex adjacent to 19 and extending almost to 20. The sclerotic changes surrounding the area reaffirmed the nature of the lesion as inflammatory [Figure 7] and [Figure 8].{Figure 7}{Figure 8}

The patient was hospitalized for debridement/biopsy of the left mandibular tori/exostoses. Histopathology confirmed the presence of necrotic bone without MM recurrence. Management includes a plan for virtual surgical planning and fabrication of a custom crib plate extraction of teeth 19–26, alveoloplasty and bone reduction, and placement of a nonrestorable membrane 2 months before resection to help facilitate soft-tissue healing and provide good environment for future bone graft.


Imaging has played a critical role not only in the diagnosis but also in the progression of the disease as shown by various studies where conventional radiography, cone-beam CT, magnetic resonance imaging as well as bone scans have shown significant contribution so assess this condition.[9],[10] Bone scintigraphy has demonstrated promising results in the detection of early subclinical BRONJ; however, more studies are required to validate its use.[11]

The radiological features of MRONJ if present may include features that are similar to chronic osteomyelitis or osteoradionecrosis such as sequestration, sclerotic changes, widening of the periodontal ligament space, and thickening of the lamina dura.[12],[13] Bisphosphonates are often known to cause sclerotic changes in the bone and increase the susceptibility of the patient to MRONJ. Tori can also precipitate MRONJ.[14],[15] A recent pilot study by Fedele et al. suggests that radiographic features may vary depending on the medication inducing the osteonecrosis.[16]

In patients with a complicated medical history such as multiple myeloma as well as the use of medications, it may be reasonable to consider CBCT as a standard of care in the first instance along with or instead of conventional imaging as deemed clinically appropriate. As the literature suggests, intraoral radiographs and pantomographs lack sensitivity in identifying a true early MRONJ lesion, in both severity and extent.[4],[7],[17] As we see in this case though the two-dimensional radiography showed the cortices intact as well as the bony trabecular pattern as unchanged for 4 years, the CBCT findings clearly elicited the lytic changes and possible sequestration. This case suggests that two-dimensional imaging may not be sufficient for the initial imaging workup for MRONJ, especially in immunocompromised patients. In this case, the clinician could not measure the magnitude of MRONJ using conventional radiography but could do so on the CBCT. After the radiographic interpretation of the CBCT of this case, the extent was considered sufficient for a surgical resection to be planned.

It is interesting to note how coexisting pathology can mask the diagnosis of MRONJ. There are additional trigger factors that can cause MRONJ.[4] As mentioned above, in this case, the patient visited a dentist and received endodontic treatment on tooth 20. There are instances like this case where the pain might be considered of a different origin such as from an odontogenic source. After treatment, it is not relieved because the source of pain is MRONJ.

The diagnosis and staging of MRONJ is based on clinical evaluation. However, in our case, initially, there was just a small area of bone exposure on clinical examination that did not help in determination of the extent of osseous involvement with as much detail as was demonstrated on the CBCT. Early diagnosis of patients with Stage 0 MRONJ is crucial since literature suggests that up to 50% of such patients may progress to the development of clinical MRONJ with bone exposure.[16] A CBCT is a three-dimensional modality which can capture minute osseous changes including subtle trabecular pattern as well as integrity of cortical borders without any superimposition hence and markedly contributing to early diagnosis and management of the disease.[8] The difference in the visualization of changes induced by MRONJ on a CBCT versus conventional radiography implies that along with clinical examination, a cone-beam CT could be a good adjunct in such cases, especially as it has been observed that in some cases, significant osteosclerotic changes were apparent in symptomatic patients with Stage 0 MRONJ.[18]

In conclusion, cone-beam CT which is a three-dimensional imaging should be considered as a part of the diagnostic workup for MRONJ, especially in patients that are immunocompromised or have conditions like tori. Even though our case demonstrated the contribution of CBCT along with clinical examination for effective diagnosis and patient management, a single example would not be adequate to prove the substantial evidence to justify the use of CBCT as baseline imaging. Additional research in this area should be conducted with large sample size to validate our hypothesis.

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Conflicts of interest

There are no conflicts of interest.


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