MRONJ staging Treatment Strategies
At risk
No apparent necrotic bone in patients who have been treated with either oral or intravenous (IV) bisphosphonates. - No treatment indicated.
- Patient education.
Stage 0 No clinical evidence of necrotic bone, but non-specific clinical findings, radiographic changes and symptoms. Systemic management, including the use of pain medication and antibiotics.
Stage 1 Exposed and necrotic bone, or fistulae that probes to bone, in patients who are asymptomatic and have no evidence of infection. - Antibacterial mouth rinse.
- Clinical follow-up on a quarterly bias.
- Patient education and review of indications for continued bisphosphonate therapy.
Stage 2 Exposed and necrotic bone, or fistulae that probes to 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.
- Debridement to relieve soft tissue irritation and infection control.
Stage 3 Exposed and necrotic bone or a fistula that probes to 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, extra-oral 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.

MRONJ = medication-related osteonecrosis of the jaw.