Table 1.

Staging classification of osteonecrosis of the jaws by bisphosphonates and treatment strategies (from Kyrgidis et al [59], modified on the basis of current evidence).

Osteonecrosis of the jawsstaging	Stage description	Treatment strategies
Future risk category	Candidate patients to be enrolled in bisphosphonate treatment, patients who have enrolled to bisphosphonate treatment for a period shorter than 3 months	“Patient education” (inform patients about the complication, its signs, and symptoms) [74]
		“Maintain optimal oral hygiene” (biannual periodontal scaling, restoration decayed teeth) [63, 74, 75]
		“Provide root canal treatment as usual” [68, 69]
		“Treat active oral infections, remove sites at high risk for infection” (partially impacted wisdom teeth, nonrestorable teeth, teeth with extensive periodontal dehiscence) [60, 74, 75]
		“Check for ill-fitting dentures, retread if necessary” [68, 69]
		Baseline dental evaluation (history taking, clinical examination and panoramic radiographs) [68, 74, 75]
At-risk category	No apparent necrotic bone in patients who have been treated with either oral or IV bisphosphonates	All of the above
		“Prefer conservative dental treatment modalities over dental extractions” (root canal treatment, periodontal scaling and root planning) [68–70, 74]
		Perform extractions and other surgery only when utterly inevitable; in such cases use minimal bone manipulation with appropriate local and systemic antibiotics [68–70, 76]:
		(i) Perform periodontal scaling 3 weeks prior
		(ii) Prescribe amoxicillin 1gr t.i.d. 3 days prior
		(iii) Reflect full thickness mucoperiosteal flap, remove    teeth with minimal cortical trauma
		(iv) Suture and prescribe amocicillin 1 gr t.i.d. for 17    days, chlorexidine 1% rinses t.i.d.
		(vi) Remove sutures and discontinue chlorexidine    rinses 1 week postoperatively
		(v) Prefer single tooth interventions
		(vi) Followup to ensure healing
Stage 0	No clinical evidence of necrotic bone, but non-specific clinical findings and symptoms	All of the above
		“Systemic management”, including use of pain medication and antibiotics [62]
Stage 1 [77]	Exposed bone necrosis or small oral ulceration without exposed bone necrosis, but without symptoms [77]	All of the above
		“Oral antibacterial mouth rinse” (0.12% chlorhexidine rinse, hydrogen peroxide)
		“Impede denture use” [68, 69]
		Discontinuation of bisphosphonate therapy until osteonecrosis heals or underlying disease progresses is not indicated but might be individually considered prior to surgery [62, 78–80]
		Clinical followup on quarterly basis [62]
Stage 2a [77]	Exposed bone necrosis or a small oral fistula without exposed bone necrosis, but with symptoms controlled with medical treatment [77]	All of the above
		Suggest computed tomography scans
		Symptomatic treatment with oral antibiotics (monotherapy or combination therapy with b-lactam, tetracycline, macrolide, metronidazole, or clindamycin) [74]
		“Pain control” with non-steroid anti-inflammatory drugs
Stage 2b [77]	Exposed bone necrosis or a small oral fistula without exposed bone necrosis, but with symptoms not controlled with medical treatment [77]	All of the above
		Superfcial debridement to relieve soft tissue irritation
Stage 3 [77]	Jaw fractures, skin fistula, osteolysis extending to the inferior border [77]	All of the above
		Surgical debridement/resection for longer term palliation of infection and pain under intravenous antibiotic treatment
		Use of doxycycline bone fluorescence to discriminate viable bone [81, 82]