Prevention and management strategies for medication-related osteonecrosis of the jaw: From risk stratification to clinical practice

doi:10.12439/kqhm.1005-4979.2026.01.001

《Journal of Oral and Maxillofacial Surgery》 ›› 2026, Vol. 36 ›› Issue (1): 1-10. doi: 10.12439/kqhm.1005-4979.2026.01.001

• Critical Review • Next Articles

Prevention and management strategies for medication-related osteonecrosis of the jaw: From risk stratification to clinical practice

ZHANG Xueming(), KANG Feiwu()

Shanghai Engineering Research Center of Tooth Restoration and Regeneration & Tongji Research Institute of Stomatology & Department of Oral and Maxillofacial Surgery, Shanghai Tongji Stomatological Hospital and Dental School, Tongji University, Shanghai 200072, China

Received:2025-11-22 Accepted:2025-12-22 Published:2026-02-28 Online:2026-02-13
Contact: KANG Feiwu

药物相关性颌骨坏死防控策略：从风险分级到临床实践

张雪明(), 康非吾()

上海市同济口腔医院口腔颌面外科，同济大学口腔医学院，上海牙组织修复与再生工程技术研究中心，同济大学口腔医学研究所，上海 200072

通讯作者: 康非吾

作者简介:

张雪明，博士，副教授、副主任医师，毕业于北京大学口腔医学院，现任上海市同济口腔医院（同济大学附属口腔医院）口腔颌面外科主任。担任中华口腔医学会口腔颌面头颈肿瘤专业委员会委员、中华口腔医学会口腔颌面修复专业委员会委员、中华口腔医学会口腔医学教育专业委员会委员；上海市口腔医学会口腔颌面外科专业委员会常务委员、上海市口腔医学会口腔颌面头颈肿瘤专业委员会委员。主持国家自然科学基金、上海市科学技术委员会及其他科研项目5项，发表论文10余篇。兼任《口腔颌面外科杂志》、Translational Dental Research编委。研究方向为药物相关性颌骨坏死的预防、诊疗及相关机制研究，数智化技术在口腔颌面外科领域中的应用及唾液腺疾病的诊治。E-mail: zhangxm@tongji.edu.cn

康非吾，主任医师、教授、博士研究生导师，上海市同济口腔医院（同济大学附属口腔医院）副院长，口腔颌面外科学教研室主任。担任中华口腔医学会口腔医疗服务分会副主任委员、中华口腔医学会口腔颌面创伤与正颌专业委员会常务委员、中国医师协会口腔医师分会常务委员、上海市口腔医学会口腔颌面外科专业委员会主任委员、上海市医师协会口腔医师分会副会长、上海市口腔医学会常务理事。兼任《中华口腔医学杂志》《口腔颌面外科杂志》《口腔医学》等杂志编委，研究生规划教材《正颌外科学》编委。主持国家自然科学基金、上海市科学技术委员会、上海市卫生健康委员会、申康医院发展中心等科研课题20余项，发表论文80余篇。入选上海市东方英才拔尖项目，并获得“上海市青年科技启明星”“仁心医者上海市杰出专科医师”等荣誉称号。E-mail: kfw@tongji.edu.cn

基金资助:
上海市东方英才计划拔尖项目(BJWS2024018)

Abstract

Abstract:

This article focuses on the clinical prevention and management of medication-related osteonecrosis of the jaw (MRONJ) in patients treated with bone-modifying agents (BMAs) [bisphosphonates (BPs) and denosumab]. Integrating domestic and international consensus guidelines with clinical practice, it proposes a comprehensive, risk-stratified prevention and management strategy. The article systematically analyzes the three major high-risk factors for MRONJ (medication-related, systemic, and local oral factors), emphasizing the difference in MRONJ risk associated with different drug regimens (low-dose vs. high-dose), and constructs a four-tier (R0–R3) risk stratification system accordingly. For each risk level, the paper elaborates on corresponding key focuses for oral screening, preventive interventions, indications for invasive procedures (such as tooth extraction), and perioperative management protocols. Specific guidance is provided for high-risk (R3) patients regarding drug holidays, radiographic evaluation, minimally invasive surgery, and wound management strategies. The aim of this article is to promote a shift in the clinical approach to MRONJ from a reactive treatment model to a proactive prevention model, providing systematic reference for dentists to effectively reduce the incidence of MRONJ while ensuring the treatment of patients' underlying systemic diseases.

Key words: bone-modifying agents, medication-related osteonecrosis of the jaw, risk assessment, prevention and management strategies, invasive procedures

摘要：

本文聚焦于应用骨改良药物（bone-modifying agents，BMAs）[双膦酸盐类（bisphosphonates，BPs）药物及地舒单抗]患者发生药物相关性颌骨坏死（medication-related osteonecrosis of the jaw，MRONJ）的临床防控问题，结合国内外共识与临床实践，提出一套基于风险分级的全程化防控策略。文章系统分析了诱发MRONJ的三大高危因素（药物因素、全身因素、口腔局部因素），强调不同用药方案（低剂量与高剂量）所致MRONJ的风险差异，并据此构建四层级（R0~R3）的风险分级体系。针对每一层级风险等级，本文详细阐述了相应的口腔筛查重点、预防性干预措施、有创操作（如拔牙）的适应证及围手术期的管理规范，并对高风险（R3）患者的药物假期、影像学评估、微创手术与创口处理策略给出了具体指导。本文旨在推动MRONJ的临床防控从“被动诊治”向“主动预防”的模式转变，为口腔医生在保障患者全身疾病治疗的前提下，科学、有效地降低MRONJ发生率提供系统参考。

ZHANG Xueming, KANG Feiwu. Prevention and management strategies for medication-related osteonecrosis of the jaw: From risk stratification to clinical practice[J]. 《Journal of Oral and Maxillofacial Surgery》, 2026, 36(1): 1-10.

张雪明, 康非吾. 药物相关性颌骨坏死防控策略：从风险分级到临床实践[J]. 《口腔颌面外科杂志》, 2026, 36(1): 1-10.

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URL: https://journal06.magtech.org.cn/Jweb_joms/EN/10.12439/kqhm.1005-4979.2026.01.001

https://journal06.magtech.org.cn/Jweb_joms/EN/Y2026/V36/I1/1

Figures/Tables 4

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药物	低剂量方案	高剂量方案
阿仑膦酸钠	10 mg/d或70 mg/周，口服	-
利塞膦酸钠	5 mg/d或35 mg/周，口服	-
唑来膦酸	5 mg/年，静脉滴注	4 mg/月，静脉滴注
帕米膦酸二钠	-	60~90 mg/月，静脉滴注
因卡膦酸二钠	5 mg/d，口服	5~10 mg/3~4周，静脉滴注
伊班膦酸钠	2 mg/3个月，静脉滴注或150 mg/月，口服	6 mg/3~4周，静脉滴注
米诺膦酸	1 mg/d，口服	-
地舒单抗	60 mg/6个月，皮下注射	120 mg/月，皮下注射

药物	低剂量方案	高剂量方案
阿仑膦酸钠	10 mg/d或70 mg/周，口服	-
利塞膦酸钠	5 mg/d或35 mg/周，口服	-
唑来膦酸	5 mg/年，静脉滴注	4 mg/月，静脉滴注
帕米膦酸二钠	-	60~90 mg/月，静脉滴注
因卡膦酸二钠	5 mg/d，口服	5~10 mg/3~4周，静脉滴注
伊班膦酸钠	2 mg/3个月，静脉滴注或150 mg/月，口服	6 mg/3~4周，静脉滴注
米诺膦酸	1 mg/d，口服	-
地舒单抗	60 mg/6个月，皮下注射	120 mg/月，皮下注射

风险等级	风险水平	分级标准	参考发病率
R0	无风险	已制定BMAs治疗计划，但尚未开始用药	-
R1	极低风险	①低剂量BPs，用药时长小于3年，无其他全身风险因素； ②低剂量地舒单抗，无其他全身风险因素	0~0.04% ^[23]
R2	低、中风险	①低剂量BPs，用药时间大于3年； ②低剂量BPs，用药时间小于3年，伴有全身风险因素； ③骨质疏松患者接受地舒单抗与BPs的序贯治疗	0.10%~0.21% ^[22]
R3	高风险	接受高剂量方案的BPs或地舒单抗治疗	0.5%~18.0% ^{[24-25，27-32]}

风险等级	风险水平	分级标准	参考发病率
R0	无风险	已制定BMAs治疗计划，但尚未开始用药	-
R1	极低风险	①低剂量BPs，用药时长小于3年，无其他全身风险因素； ②低剂量地舒单抗，无其他全身风险因素	0~0.04% ^[23]
R2	低、中风险	①低剂量BPs，用药时间大于3年； ②低剂量BPs，用药时间小于3年，伴有全身风险因素； ③骨质疏松患者接受地舒单抗与BPs的序贯治疗	0.10%~0.21% ^[22]
R3	高风险	接受高剂量方案的BPs或地舒单抗治疗	0.5%~18.0% ^{[24-25，27-32]}

分类	治疗项目	治疗决策
必要且紧急	①紧急情况下的拔牙：包括外伤导致牙折裂或牙脱位、抗炎治疗无效引起牙周或牙槽脓肿的病灶牙；②牙槽脓肿或间隙感染的切开引流术；③急性牙髓炎、根尖周炎的开髓引流	①牙外伤：处理BMAs用药患者牙外伤时较非用药患者更为积极和彻底，建议拔除累及根面的折裂牙或脱位牙，不建议行松牙固定；②炎症反复急性发作的患牙：如抗炎治疗不能控制感染，为避免炎症进一步扩散迁延至颌骨，建议尽早拔除，不必等待窗口期，但术后需注意密切随访，在随访期间出现愈合不良、瘘道形成、小块死骨片排出的情况时，进行及时清创后仍可达到二期愈合；③其他：脓肿切开排脓及开髓不会增加MRONJ的发生风险，可按照常规行牙科急诊处理
必要不紧急	择期拔牙：①残根残冠、阻生牙、既往折裂牙、中重度牙周炎；②牙槽骨或骨隆突修整术；③龋齿充填、根管治疗；④系统性牙周治疗；⑤冠桥或活动义齿修复；⑥定期口腔检查	①建议拔除无法通过保守治疗消除炎症的患牙或存在潜在感染风险的患牙；②进行有创操作时，需注意窗口期的选择、手术操作及围手术期的管理；③龋齿充填、牙髓炎的根管治疗、缺失牙的冠桥或义齿修复、龈上洁治等不涉及颌骨的操作，处理时按照常规作规范化治疗；④对严重的根尖周炎行根管治疗、牙髓再治疗、根尖手术、龈下洁治及根面平整、牙周翻瓣术、引导性骨再生术等治疗效果不佳时，可能会造成感染迁延，或对骨面形成创伤后不能达到软组织屏障的完全重建，存在隐患，需根据患者累积用药剂量、影像学表现等评估MRONJ具体风险后，再作治疗决策；如风险偏高，建议按照R3级管理要点进行处理；⑤每半年至1年进行1次口腔随访，进行必要的牙周基础治疗，对新发现的口腔问题进行处理
非必要不紧急	①牙齿美白、瓷贴面、牙饰等牙科美容项目；②种植牙；③正畸治疗	①不建议进行牙科美容类治疗；②R2级患者发生种植体周MRONJ的风险与BPs累计用药时长相关，如患者种植意愿强烈，可选择采用，但需注意随访，即使在种植初期发生骨结合，也需警惕种植体可能会触发MRONJ；③ BPs治疗患者的骨转换率逐渐降低，而正畸治疗周期长，过程中可能对颌骨造成应力损伤，故应慎重；④地舒单抗治疗患者后续常需序贯应用BPs，作治疗决策时需考虑这一点

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