**6. Treatment strategies for MRONJ**

#### **6.1. Treatment goals**

The treatment goals for patients at risk of developing or who have MRONJ are prioritization and support of continued cancer treatment in patients receiving intra venous antiresorptive and antiangiogenic therapy [5, 12]. Cancer patients can benefit greatly from the therapeutic effect from antiresorptive agents by controlling SREs.

Maintenance of patient quality of life (QOL) is done by relieving symptoms, including pain, pus discharge, and paresthesia, and by control of infection. Moreover, patient education and routine follow-up for oral health care are needed by dental expert.

#### **6.2. Stage-specific treatment strategies**

Therapeutic strategies based on MRONJ stages are summarized in **Table 1** [5].

Treatment of MRONJ varies with the stages of the disease. However, regardless of the stage, the protocol must include treating dental and periodontal diseases, maintaining and improving oral health with antibacterial mouthwash, and systemically administering antibacterial agents. To ensure success with surgical treatment, the complete elimination of MRONJ lesions and closure of surgical wounds is critical, along with systemic administration of antibacterial agents. For patients with a history of malignant tumors, histopathological examination of all necrotic bones removed will be needed to exclude the possibility that excised MRONJ lesions are tumor metastases to the jaw [12].

**1.** At risk

These patients have no exposed bone and requirement of any treatment. They should be informed of the risks of developing to MRONJ.

**2.** Stage 0

These patients receive the treatment of symptomatic disease and conservative management of caries and periodontal disease. Systemic management, including use of pain medication and antibiotics are indicated. These patients should be prevented of progression to a higher stage.

**3.** Stage 1

These patients are indicated with medical management of the use for oral antimicrobial rinses, such as chlorhexidine 0.12%. No immediate surgery is required.

**4.** Stage 2

These patients are indicated with oral antimicrobial rinses in combination with administrating antibiotic therapy. The debridement to relieve soft tissue irritation and infection control is needed.

**5.** Stage 3

**6. Treatment strategies for MRONJ**

**6.2. Stage-specific treatment strategies**

are tumor metastases to the jaw [12].

gression to a higher stage.

tion control is needed.

**1.** At risk

**2.** Stage 0

**3.** Stage 1

**4.** Stage 2

effect from antiresorptive agents by controlling SREs.

routine follow-up for oral health care are needed by dental expert.

be informed of the risks of developing to MRONJ.

Therapeutic strategies based on MRONJ stages are summarized in **Table 1** [5].

The treatment goals for patients at risk of developing or who have MRONJ are prioritization and support of continued cancer treatment in patients receiving intra venous antiresorptive and antiangiogenic therapy [5, 12]. Cancer patients can benefit greatly from the therapeutic

Maintenance of patient quality of life (QOL) is done by relieving symptoms, including pain, pus discharge, and paresthesia, and by control of infection. Moreover, patient education and

Treatment of MRONJ varies with the stages of the disease. However, regardless of the stage, the protocol must include treating dental and periodontal diseases, maintaining and improving oral health with antibacterial mouthwash, and systemically administering antibacterial agents. To ensure success with surgical treatment, the complete elimination of MRONJ lesions and closure of surgical wounds is critical, along with systemic administration of antibacterial agents. For patients with a history of malignant tumors, histopathological examination of all necrotic bones removed will be needed to exclude the possibility that excised MRONJ lesions

These patients have no exposed bone and requirement of any treatment. They should

These patients receive the treatment of symptomatic disease and conservative management of caries and periodontal disease. Systemic management, including use of pain medication and antibiotics are indicated. These patients should be prevented of pro-

These patients are indicated with medical management of the use for oral antimicrobial

These patients are indicated with oral antimicrobial rinses in combination with administrating antibiotic therapy. The debridement to relieve soft tissue irritation and infec-

rinses, such as chlorhexidine 0.12%. No immediate surgery is required.

**6.1. Treatment goals**

98 Osteonecrosis

These patients are benefit from debridement, including resection, in combination with antibiotic therapy. Symptomatic patients with stage 3 may require resection and immediate reconstruction with reconstruction plate or an obturator.

Regardless of the disease stage, mobile bony sequestra should be removed to facilitate soft tissue healing. The extraction of symptomatic teeth within exposed necrotic bone should be considered because it is unlikely that the extraction will exacerbate the established necrotic process.

#### **6.3. Treatment with parathyroid hormone (teriparatide)**

Systemic administration of low doses of recombinant parathyroid hormone (teriparatide) has been shown to resolve ONJ symptoms and promote a cure. Japanese studies have also shown improved bone regeneration and healing in ONJ lesions with the use of teriparatide [24, 25]. It should also be noted that administration of teriparatide is contraindicated in patients with metastatic bone tumors, and its total dose and period of administration are restricted as well.
