Osteonecrosis of the Jaw (ONJ): Symptoms, Stages, and Treatment

Osteonecrosis of the jaw (ONJ) describes a condition in which parts of the jawbone start to break down and disintegrate. This usually begins when areas of the bone are exposed to the air rather than being covered by the gums. The gums normally protect the bone and bring blood flow to the bone cells. Without that normal blood flow, the cells begin to starve and die. This leads to erosion and destruction of the bone. 

Let’s take a closer look at what causes ONJ, as well as the symptoms, stages, and how to treat it.

Osteonecrosis of the jaw symptoms

The symptoms of ONJ are usually limited to the area where there is bone breakdown. Symptoms include:

• Pain

• Drainage

• Swelling

• Exposed bone

• Bad breath

• Loose teeth

• Gum infection

ONJ develops slowly over time. In general, the symptoms need to be present for 8 weeks or longer to make the diagnosis.

What causes osteonecrosis of the jaw?

ONJ is rare and affects less than 1 in 10,000 people. And it doesn’t typically develop unexpectedly. There are risk factors that make osteonecrosis of the jaw more likely to develop. These include older age and conditions that affect wound healing, like diabetes or smoking. Let’s take a look at other factors that can cause ONJ.

Medications

Antiresorptive medications can increase the risk for ONJ. These are medications that are used to prevent bone breakdown. They are commonly prescribed to people who have osteoporosis, or even to people with bone cancer. Examples include bisphosphonates like alendronate, or antibody treatments like denosumab. It isn’t clear why these medications cause ONJ, but it might be related to how they change the way that bones heal.

Cancer treatment

People who are most likely to develop ONJ are those receiving treatment for cancer that has spread to the bones. It might happen to as many as 1 in 10 people in this situation.

That’s likely because cancer treatments — like chemotherapy and radiation therapy — are also linked to ONJ. While these treatments are designed to kill cancer cells, they can also damage normal cells. This can include bone cells in the jaw.

Dental health

Issues with your dental health can increase your risk for ONJ. In particular, anything that results in abnormal tooth exposure can lead to ONJ. This includes dental conditions, oral infections, or procedures like:

• Gum recession

• Gum or tooth infections

• Dentures

• Tooth extractions 

Osteonecrosis of the jaw stages

ONJ develops slowly over time. ONJ usually progresses in a predictable, step-like pattern. The stages of ONJ are: 

• At-risk category: A person has been treated with high-dose oral or IV bisphosphonates but has no detectable exposed bone.

• Stage 0: A person has nonspecific symptoms (like pain), but there’s no evidence of necrotic (dying) or exposed bone.

• Stage 1: There is evidence of necrotic or exposed bone, but no evidence of infection.

• Stage 2: There is exposed or necrotic bone, plus signs of infection (pain, swelling, redness, drainage).

• Stage 3: There is exposed or necrotic bone with signs of infection extending to the sinuses or distant parts of the jaw, as well as fracture of the jaw and drainage through the skin (fistula).

Treating osteonecrosis of the jaw

There are several treatment options if you have ONJ, and they vary based on the stage. Some examples of how to treat ONJ by stage include:

• At-risk: No treatment needed. But you should be alert for signs and symptoms.

• Stage 0: Pain medications like acetaminophen (Tylenol) or ibuprofen (Advil, Motrin) are used as needed. Your medical provider may consider antibiotics to prevent infection.

• Stage 1: Antibiotic mouth rinses and pain relievers are used with close follow-up every 3 to 4 months. You may have to temporarily stop any antiresorptive medications while the jaw heals.

• Stage 2: Oral antibiotics, mouth rinses, and pain relievers are used along with minor surgery to remove soft tissue.

• Stage 3: Oral antibiotics, mouth rinses, and pain relievers are used with more extensive surgery for long-term pain and infection control as needed.

When ONJ is caught early enough and the affected area is small, it may be able to heal on its own with oral antibiotic rinses and good oral hygiene. The more advanced ONJ becomes, the more likely it is that you’ll need oral antibiotics and surgery to treat it.

Recognizing ONJ in its earliest stages is important. If you have risk factors, you should talk to your healthcare provider and be on the lookout for the earliest symptoms.

Treatments for ONJ depend on what stage it’s diagnosed. Good oral hygiene is the cornerstone of preventing and treating ONJ.

Treatment options include:

• Antiseptic mouth rinses, like chlorhexidine or hydrogen peroxide

• Antibiotics 

• Minor surgical procedures, in which a surgeon removes tiny parts of the affected bone

• Good oral hygiene practices

• Temporarily stopping antiresorptive medications while the jaw heals 

Some people who have this condition may need bigger surgical procedures if a large amount of the jaw is affected, but this is less common.

How to lower your risk of osteonecrosis of the jaw

If you know you are at increased risk of osteonecrosis of the jaw, good oral care is the best way to prevent it. Here are some tips:

• See a dentist before starting antiresorptive medications. They can check for any oral problems that should be treated before starting these therapies.

• Get regular dental appointments to stay on top of any oral problems that may arise.

• Good oral hygiene — like regular tooth brushing and flossing — can prevent osteonecrosis of the jaw by keeping your teeth and gums as healthy as possible. 

Living with osteonecrosis of the jaw: Self-care tips

The American College of Rheumatology has many tips for preventing and living with ONJ. Some ways you can reduce your risk or slow the progression of ONJ include:

• Make sure you brush and floss. See your dentist quarterly.

• Let your dentist know if you have risk factors for ONJ.

• Talk to your dentist about doing the least invasive procedures when possible. For example, a root canal might be a better option than a tooth extraction if possible.

• Avoid full-mouth extractions or periodontal surgery, when possible.

• Let your healthcare provider or dentist know right away if you have any dental pain or signs of infection.

• Discuss with your dentist and provider whether you should consider stopping bisphosphonate treatment or delay a dental procedure.

Why trust our experts?

Written by:

Frank Schwalbe, MD

Frank Schwalbe, MD, is an assistant professor of anesthesiology at the Yale School of Medicine. He has practiced anesthesiology for 30 years.

Edited by:

Karla Robinson, MD

Karla Robinson, MD, is a medical editor for GoodRx. She is a licensed, board-certified family physician with almost 20 years of experience in health through varied clinical, administrative, and educational roles.

Our editorial standards

Meet our experts