GP2b - Identifying High-Risk MRONJ​

Abstract: Objectives: Medication-related osteonecrosis of the jaw (MRONJ) is a serious complication associated with antiresorptive and antiangiogenic therapy.¹ While medications associated with MRONJ have been well identified, data to reliably predict surgical outcomes remain limited.¹ This study aims to evaluate surgical risk among MRONJ patients and identify clinical, hematologic, and microbiologic predictors of severity and postoperative outcomes that may influence future risk stratification strategies.

Methods: A retrospective cohort study was conducted by reviewing patient records from the University of Pennsylvania's Oral and Maxillofacial Surgery Department between January 1, 2013 and October 31, 2023. Patients diagnosed with MRONJ who underwent surgical management were included in the study (n = 147). Complete blood count (CBC), comprehensive metabolic panel (CMP), tissue cultures, demographic factors, MRONJ stage, and surgical outcomes were documented and analyzed. The primary outcome variable was postoperative surgical outcome, characterized as improved (resolved or downstaged) or not improved (same stage, upstaged, and/or with complications).

Results: Of the 147 patient charts included in this study, 23 (15.6%) were identified as not improved following surgical treatment of MRONJ. Among patients with a documented CMP (n = 94), those exhibiting improved surgical outcomes had significantly higher preoperative serum albumin levels (3.90 ± 0.394 g/dL vs 3.51 ± 0.457 g/dL, P < .05) corresponding to a 90.7% reduction in odds (OR 0.09; 95% CI: 0.01 to 0.49). Multiple logistic regression analyses of albumin models demonstrate good discrimination (AUC 0.74) with slight improvement upon the addition of covariates (AUC 0.77). Of the 137 patients with a documented CBC, higher preoperative hemoglobin levels were associated with decreased odds of not-improved surgical outcomes (12.00 ± 1.64 vs 11.05 ± 1.59 g/dL, P < .05), corresponding to a 29% reduction in odds (OR 0.71; 95% CI: 0.51 to 0.99). Likewise, higher RBC counts were associated with decreased odds of not-improved surgical outcomes (3.92 ± 0.60 vs 3.48 ± 0.66 ±10⁶/μL, P < .05), corresponding to a 70% reduction in odds (OR 0.30; 95% CI: 0.11 to 0.73). Multiple logistic regression analyses of RBC and hemoglobin models demonstrate more modest discrimination (AUC 0.69 and 0.65, respectively) with slight improvement upon the addition of covariates (AUC 0.73 and 0.70, respectively). Total bacterial burden, proportion of nonresident oropharyngeal bacterial strains, and number of anaerobic strains showed no association with an increase in postoperative complications. Organism group composition, however, demonstrated directional ecological shifts with disease severity, with an increase in anaerobic organisms in 57% of Stage 1 lesions to 80% of Stage 3 lesions.

Conclusions: Identifying clinically relevant predictors of surgical outcomes in MRONJ interventions is essential in preventing postoperative complications. Serum albumin and hematologic markers, such as hemoglobin levels and RBC counts, were associated with better surgical outcomes, while microbiologic factors and infectious disease consultation were not predictive of improved surgical outcomes.² These findings suggest that clinical biomarkers and physiologic status appear to be more informative in preoperative risk stratification than infectious factors. Incorporating albumin, RBC, and hemoglobin into preoperative risk stratification may help guide decision-making regarding conservative versus operative treatment strategies. In one of the largest MRONJ cohorts to date, this study aimed to provide a foundation for future research in identifying high-risk patients to better optimize their conditions before surgery.



1. Ruggiero SL, Dodson TB, Aghaloo T, Carlson ER, Ward BB, Kademani D. American Association of Oral and Maxillofacial Surgeons' Position Paper on Medication-Related Osteonecrosis of the Jaws-2022 Update. J Oral Maxillofac Surg. 2022;80(5):920-943. doi:10.1016/j.joms.2022.02.008

2. Nadella S, Hartmann MM, He P, Bear A, Theken KN, Panchal N. Do infectious disease consultations improve outcomes of surgical management of MRONJ?. Oral Surg Oral Med Oral Pathol Oral Radiol. 2025;140(1):33-40. doi:10.1016/j.oooo.2024.12.019