the head and neck the patient must be taking or have taken bisphosphonate medication. according to the updated 2009 bronj position paper published by the american association of oral and maxillofacial surgeons, both the potency of and the length of exposure to bisphosphonates are linked to the risk of developing bisphosphonate-associated osteonecrosis of the jaw. in the 2014 aaoms update on mronj, a staging and treatment strategies table was created: staging and treatment strategies *exposed or probable bone in the maxillofacial region without resolution for greater than 8 weeks in patients treated with an antiresorptive and/or an antiangiogenic agent who have not received radiation therapy to the jaws.**regardless of the disease stage, mobile segments of bony sequestrum should be removed without exposing uninvolved bone. the extraction of symptomatic teeth within exposed, necrotic bone should be considered since it is unlikely that the extraction will exacerbate the established necrotic process. mronj staging criteria* (>8 weeks) treatment strategies** picture at risk no apparent necrotic bone in patients who have been treated with either oral or iv bisphosphonates no treatment indicated, patient education n/a 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 n/a 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 basis, 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 prevention tooth extraction is the major risk factor for development of mronj. prevention including the maintenance of good oral hygiene, comprehensive dental examination and dental treatment including extraction of teeth of poor prognosis and dentoalveolar surgery should completed prior to commencing any medication which is likely to cause osteonecrosis (onj). patients with removable prostheses should be examined for areas of mucosal irritation. procedures which are likely to cause direct osseous trauma, e.g. tooth extraction, dental implants, complex restoration, deep root planning, should be avoided in preference of other dental treatments. there are limited data to support or refute the benefits of a drug holiday for osteoporotic patients receiving antiresorptive therapy. however, a theoretical benefit may still apply for those patients with extended exposure histories (>4 yr), and current recommendations are for a 2 month holiday for those at risk. there was low quality evidence suggesting taking antibiotics prior to the dental extraction, as well as the use of post operative techniques for wound closure lowered the risk of patients developing medication-related osteonecrosis of the jaw compared with the usual standard care received for regular dental extractions. post operative wound closure has been suggested to prevent the contamination of the underlying bone. more evidence is needed to assess the use of antibiotics prior to treatment and the use of wound closure to prevent contamination of the bone, as the quality of evidence evaluated was low. patients may be advised to limit alcohol consumption, stop smoking, and practice good dental hygiene. it is also advised for individuals who take bisphosphonates to never allow the tablet to dissolve in the mouth as this causes damage to the oral mucosa. management treatment usually involves antimicrobial mouth washes and oral antibiotics to help the immune system fight the attendant infection, and it also often involves local resection of the necrotic bone lesion. many patients with mronj have successful outcomes after treatment, meaning that the local osteonecrosis is stopped, the infection is cleared, and the mucosa heals and once again covers the bone. the treatment the person receives depends on the severity of osteonecrosis of the jaw. conservative indicated in patients who have evidence of exposed bone but no evidence of infection. it may not necessarily eliminate all the lesions, but it may provide patients with long term relief. this approach involves a combination of antiseptic mouthwashes and analgesics and the use of teriparatide. splints may be used to protect sites of exposed necrotic bone. non-surgical indicated for people with exposed bone with symptoms of infection. this treatment modality may also be utilised for patients with other co-morbidities which precludes invasive surgical methods. this approach requires antimicrobial mouthwashes, systemic antibiotics and antifungal medication and analgesics. surgery surgical intervention is indicated in patients with symptomatic exposed bone with fistula formation and one or more of the following: exposed and necrotic bone extending beyond the alveolar bone resulting in pathological fracture; extra-oral fistula; oral antral communication or osteolysis extending from the inferior border of the mandible or the sinus floor. surgical management involves necrotic bone resection, removal of loose sequestra of necrotic bone and reconstructive surgery. the objective of surgical management is to eliminate areas of exposed bone to prevent the risk of further inflammation and infection. the amount of surgical debridement required remains controversial. other hyperbaric oxygen therapy ultrasonic therapy antibiotics antibiotics are used to treat cases involving infections. penicillin is the first line of choice, although if this is contraindicated commonly used antimicrobials are: clindamycin, fluoroquinolones and/or metronidazole. intravenous antibiotics may be used if the infection resists oral treatment. however, there is little evidence of intravenous antibiotics being more efficacious than other methods of treatment. epidemiology the likelihood of this condition developing varies widely from less than 1/10,000 to 1/100, as many other factors need to be considered, such as the type, dose and frequency of intake of drug, how long it has been taken for, and why it has been taken. in patients taking drugs for cancer, the likelihood of mronj development varies from 0 - 12%. this again, varies with the type of cancer, although prostate cancer and multiple myeloma are reported to be at a higher risk. in patients taking oral drugs for osteoporosis, the likelihood of mronj development varies from 0 - 0.2%.