should be considered as an alternative to placing implants. If extractions or bone surgery are necessary, clinicians should be guided by conservative surgical principles with primary tissue closure, when feasible. During the time immediately before and after any surgical procedures involving bone, the patient should rinse gently with a chlorhexidine-containing rinse until the site has healed. The 2011 ADA advisory statement indicates that endodontic therapy is preferred to surgical manipulation for salvageable teeth (Hellstein et al., 2011; Aminoshariae, Donaldson, Horan, Mackey, Kulild, & Baur, 2022). However, the same caution is advised for endodontic surgical procedures as for oral and maxillofacial surgery. Routine restorative procedures can be performed in a patient receiving antiresorptive therapy, and prosthodontic appliances can be provided to the patient, although they should be promptly adjusted to prevent ulceration and possible bone exposure. Sufficient data is lacking with regard to implant placement in patients receiving oral bisphosphonate therapy; however, the updated ADA advisory statement indicates that patients should be advised of the risk of developing MRONJ following extensive implant procedures or guided bone regeneration to augment a deficient alveolar ridge. Practitioners should be advised that the risk of developing MRONJ following antiresorptive therapy is low and that the short-term success rate (less than 10 years) of implants in this patient population does not appear to differ from the success rate of implants in patients who have not undergone antiresorptive therapy. In summary, antiresorptive therapy is not currently a contraindication to implant therapy. Ultimately, additional studies are needed to determine whether there is a difference in treatment outcomes (Hellstein et al., 2011; Aminoshariae, Donaldson, Horan, Mackey, Kulild, & Baur, 2022). Antiresorptive medications are effective as prophylaxis and intervention for osteoporosis as well as in the management of metastatic diseases. However, as noted above, reports of non-bisphosphonate-related medication-induced osteonecrosis of the jaw have led to the designation MRONJ (Otto, et al. 2018; Ruggiero et al., 2014). To be diagnosed with MRONJ, the patient must: ● Be treated currently or have been treated previously with antiresorptive agents. ● Have exposed bone or bone that can be probed through a fistula in the maxillofacial region for a period of longer than 8 weeks. ● Have no history of radiation therapy to the jaws or obvious metastatic disease to the jaws. This condition can be misdiagnosed, and it is important to remember that exposed bone or sequestra can present in patients not exposed to antiresorptive agents (Ruggiero et al., 2014; Bansal, 2022). Absent or delayed soft tissue healing with bony exposure following dental extraction or spontaneous gingival dehiscence is a clinical sign of MRONJ (Fleisher, Kontio, & Otto, 2016; Probst, Probst, & Bisdas, 2015; Bansal, 2022). Symptoms may be negligible, mild, or severe. Most patients with MRONJ are Tooth discoloration Numerous drugs can cause either extrinsic or intrinsic tooth discoloration (Teoh, Moses, & McCullough, 2019; Kuzenko, Mykhno, Sikora, Bida, & Bida, 2022). Extrinsic tooth discoloration, where the stain develops after tooth eruption, can result from chlorhexidine, linezolid, fluorides, and iron, as well as from habits such as tobacco and betel use. Certain antibiotics (ciprofloxacin, doxycycline, minocycline, and tetracycline) and some essential oils have also been implicated in intrinsic stains, where tooth discoloration occurs during tooth development, and are usually located within the tooth structure. Medications such as tetracycline may result in this type of generalized intrinsic discoloration and has a prevalence of 3%-4% in the general population (Sanchez, Rogers, & Sheridan 2004; Wormser,
asymptomatic, but pain may develop if the bone becomes secondarily infected. In the most severe cases, patients can experience intense pain, extensive sequestration of bone, and sinus tracts that drain to the skin surface. Initially, no radiographic manifestations are seen, but in some cases a large area of necrotic bone is evident on magnetic resonance imaging. The incidence of this condition and the causative risk factors are not well characterized. However, dental alveolar surgery and the duration of antiresorptive therapy continue to be known risk factors for MRONJ. Noted predisposing factors include periodontal disease, smoking, diabetes, glucocorticoid medication use, and prolonged antiresorptive medication therapy (Ruggiero et al., 2014; Bansal, 2022). Management Given the potentially devastating consequences of MRONJ, clinicians must be aware of the pharmacological properties of bisphosphonates and other antiresorptive medications currently available and their indications, risk factors for the development of osteonecrosis, clinical signs and symptoms, and recommendations for patient management. The American Academy of Oral and Maxillofacial Surgeons published a position paper with management recommendations for this condition in 2014 (Ruggiero et al., 2014), and more recent reviews continue to suggest similar approaches (Kilic & Doganay, 2018; Bansal, 2022). The recommendations vary according to the severity of the condition (Stage 0 is the least severe and Stage 3 is the most severe). For patients who are at risk (no apparent bone visible) following oral or intravenous bisphosphonate therapy, no treatment is indicated and the patients should be educated regarding the risks of osteonecrosis of the jaw. Patients at Stage 0 (no clinical evidence of necrotic bone, but nonspecific clinical findings and symptoms) should receive systemic management, which may include pain medication and antibiotic therapy. Patients at Stage 1 (exposed and necrotic bone, asymptomatic, without evidence of infection) should be treated with: ● Oral antibacterial mouth rinse. ● Quarterly clinical follow-up. ● Patient education as well as medical history review. Patients at Stage 2 (symptomatic, exposed and necrotic bone associated with infection with or without purulence) should be treated with: ● Symptomatic treatment with oral antibiotics. ● Oral antibacterial mouth rinse. ● Pain control medication. ● Superficial debridement to relieve soft tissue irritation. The most severe presentation of this condition is Stage 3 (exposed and necrotic bone extending beyond the region of alveolar bone, resulting in pathological fracture, extraoral fistula, oral-antral/oral-nasal communication, or osteolysis), in which
patients should be treated with: ● Oral antibacterial mouth rinse.
● Antibiotic therapy and pain control. ● Debridement/surgical resection. (Ruggiero et al., 2014; Kilic & Doganay, 2018; Bansal, 2022)
Wormser, Strle, Myers, & Cunha, 2019). Tetracycline-related intrinsic staining is caused when the tetracycline molecule combines with calcium by chelation and is subsequently incorporated into the hydroxyapatite crystal of the tooth during mineralization (Kumar, Kumar, Singh, Hooda, & Dutta, 2012). As the tetracycline layer inside the tooth is oxidized by light, it forms visible discoloration and the appearance of the yellow, grey or brown permanent discoloration tends to be on the cervical one-third of the crowns. The degree of staining is related to the duration and timing of drug administration.
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