Medical Oncologist
Bone-targeted therapy side effects
Osteonecrosis of the Jaw: — Prevention During Bone-Targeted Treatment
Osteonecrosis of the jaw is a condition where jaw bone becomes exposed and does not heal. It can occur in people taking bisphosphonates or denosumab for cancer. Most people on bone-targeted therapy never develop it — and with the right dental preparation beforehand, the risk is lower still.
Medically reviewed by Dr. Bharati Devi Gorantla, Medical Oncologist, MBBS · MD · DM (Adyar, Chennai) · ECMO · MRCP SCE (UK) · Last reviewed August 2026
- Preventable, not inevitable — A dental check before treatment starts, and avoiding invasive dental procedures during it, significantly reduces risk.
- Tell both teams — Your dentist needs to know you are on bone-targeted therapy. Your oncologist needs to know about any planned dental work.
- Oral hygiene matters throughout — Keeping teeth and gums healthy during treatment is one of the most effective things you can do.
- Early signs are manageable — Caught early, jaw changes can often be managed conservatively. Delay makes treatment harder.
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ONJ is exposed jaw bone that does not heal, linked to bisphosphonates and denosumab used in cancer treatment. It is uncommon but serious. Prevention — a dental check before treatment and avoiding extractions during it — matters more than treating ONJ after it develops. Call your team today if you notice exposed bone, worsening jaw pain, or a mouth wound that is not healing.
If a symptom below applies to you, do not wait for a callback. Call 1800-202-8726 or go to your nearest emergency department.
How do you prevent ONJ during bone-targeted therapy?
- See a dentist before starting bisphosphonates or denosumab. Complete any extractions, implants, or other invasive dental work before treatment begins.
- Tell your dentist you are on bone-targeted therapy — at every visit, not just the first.
- Tell your oncologist about any planned dental work, however minor it seems.
- Brush twice a day with a soft-bristled brush. Hard bristles can injure gum tissue.
- Use an antiseptic mouthwash if your team has recommended one.
- Keep your regular dental check-ups and report any new pain, swelling, or loose teeth promptly.
- Avoid dental implants and tooth extractions during treatment unless your oncologist and dentist both agree it cannot wait.
- If you wear dentures, make sure they fit well — poorly fitting dentures press on the gum and create entry points for infection.
What is osteonecrosis of the jaw and what does home care look like?
ONJ occurs when bone-targeted therapy reduces blood supply to the jaw bone. A portion of bone then becomes exposed — most often after a tooth extraction or gum infection — and cannot heal itself the way it normally would.
If you notice a rough patch of bone you can feel with your tongue, jaw pain that is not improving, or a wound in your mouth that seems slow to close, tell your treatment team. Do not assume it is a normal part of recovery.
When your team has confirmed a very early or minor area, home care usually means keeping the area clean with a recommended rinse, eating a soft diet to avoid trauma to the jaw, and avoiding smoking. Your team will tell you exactly what to use and how often.
**The threshold for calling: any exposed bone you can see or feel, any jaw pain that is getting worse rather than better, or any mouth wound that is not healing or is growing larger. Do not manage these at home without guidance.**
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Dr. C. Raghavendra Reddy
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Dr. Bharati Devi Gorantla
MBBS, MD(General Medicine), DM(Medical Oncology)(Adyar,Chennai), ECMO, MRCP SCE(UK)
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Dr. Owais Mohammed
MBBS, MD (General Medicine), DrNB (Medical Oncology), ECMO, MRCP SCE (Medical Oncology) (UK)
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How do you tell a normal mouth sore from an ONJ warning sign?
| Feature | Likely minor — monitor | Call your team the same day |
|---|---|---|
| Appearance | Soft ulcer on gum or cheek lining, improving steadily | Hard or rough exposed bone, not covered by soft tissue |
| Healing | Getting smaller and less painful day by day | Staying the same, growing, or reopening |
| Pain | Mild, settles with routine oral care | Worsening, not settling, or associated with jaw stiffness |
| After a dental procedure | Normal tenderness for a few days | Wound not closing, bone visible at the extraction site |
| Fever or spreading swelling | Absent | Present — contact team immediately, or go to emergency |
| Typically starts | Any time; most mouth sores resolve on their own | Often noticed after a tooth extraction or invasive dental procedure, sometimes after months of treatment |
Did you know?
AAOMS guidance notes that ONJ risk is substantially higher with intravenous bisphosphonates and with longer duration of treatment. For most patients, the bone protection these therapies provide — reducing fractures, bone pain, and spinal complications — outweighs that risk.
The single most effective intervention oncology has for ONJ is preventing it before it develops.
Source: American Association of Oral and Maxillofacial Surgeons (AAOMS) Position Paper on Medication-Related Osteonecrosis of the Jaw
Questions families ask about ONJ
Does having a tooth pulled always cause ONJ?
No, but a tooth extraction is the most common trigger because it creates a wound in the jaw that must heal. In people on bone-targeted therapy, that healing is slower and less reliable than usual. This is why the guidance is to complete all necessary extractions before treatment begins. If a tooth absolutely must come out during treatment, it can sometimes be done safely with extra precautions and close follow-up — your oncologist and dentist need to agree on that together before anything proceeds. An extraction does not guarantee ONJ will develop; it increases the risk compared with not having one at all.
Can I have a filling, cleaning, or root canal during treatment?
Non-invasive procedures — fillings, routine cleaning, root canals — carry a much lower risk than procedures that involve cutting into bone or gum. Your dentist should still know you are on bone-targeted therapy and document it at every visit. If there is any doubt about whether a procedure is safe to go ahead with, your dentist and oncologist should speak to each other before proceeding. Avoiding all dental care during treatment creates its own problems — neglected teeth and gums are a risk factor for ONJ in their own right.
Will my bone-targeted therapy have to stop if ONJ develops?
Not necessarily. This decision is made jointly between your oncologist and the dental or oral surgery team managing the jaw. Stopping bone-targeted therapy removes the protection it gives your bones against fracture and metastasis, which is a real clinical consequence. For many patients, treatment continues at a modified schedule or is paused temporarily while the jaw is managed conservatively. The decision depends on how severe the ONJ is, how well it responds to conservative management, and how important the bone therapy is for your cancer care at that point.
What does treatment for ONJ actually involve?
For early or minor ONJ, treatment is usually conservative: antiseptic rinses, antibiotics if infection is present, a soft diet, and close monitoring. Surgery is reserved for more advanced cases where a large area of bone is not responding to conservative care and is causing significant pain or infection. Most cases that are caught early do not require surgery. This is the practical reason why reporting jaw symptoms promptly matters — the earlier ONJ is identified, the less intervention it typically needs.
My family member uses herbal or Ayurvedic preparations for oral care. Is that safe?
Please tell your treatment team exactly what is being used, including oil pulling, herbal pastes, or traditional mouth rinses. Some preparations are harmless and others contain compounds that could affect gum or bone tissue, or interact with ongoing treatment. The team cannot advise you without knowing what is being used. This is not a judgement on traditional practice — it is a safety question that depends entirely on the specific preparation. Mentioning it protects your family member, not the other way around.
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Common questions
Frequently asked questions
How common is ONJ in people having cancer treatment?
ONJ is uncommon, and the frequency varies significantly with the type of bone-targeted therapy, how it is given, how long it has been used, and whether dental preparation was done beforehand. AAOMS guidance notes the risk is higher with intravenous bisphosphonates than with oral forms, and higher with longer duration of treatment. For most patients, the bone protection these therapies provide outweighs the ONJ risk. What reduces that risk most is dental preparation before treatment begins and good oral hygiene throughout.
I have already started bone-targeted therapy without seeing a dentist. What should I do?
See a dentist as soon as possible and tell them you are already on bone-targeted therapy. The dental check is still valuable — it identifies problems that need attention and gives you and your team a plan for managing oral health going forward. Ask your oncologist to refer you if you are unsure where to go, and make sure both the oncology and dental teams know you are in both their care. Late preparation is not ideal, but it is far better than none at all.
Does denosumab carry the same ONJ risk as bisphosphonates?
Yes. Denosumab works differently from bisphosphonates but is also a bone-targeted therapy, and it carries a comparable ONJ risk. AAOMS and ASCO guidance treats both drug classes the same way for dental management. The same prevention steps apply: a dental check before starting, telling your dentist throughout treatment, and avoiding invasive dental procedures unless both your oncologist and dentist agree they cannot be delayed.
Can I notice ONJ developing before it becomes serious?
Sometimes, yes. Early signs include jaw discomfort that was not there before, a feeling of roughness inside the mouth, swelling around the jaw, or a wound that is slow to heal after a dental procedure. Not everyone notices these early changes. This is one reason regular dental check-ups matter during treatment — a dentist may see changes before you feel them. Report anything that seems different in your mouth, even if you are unsure it is related to your cancer treatment.
Should I refuse bone-targeted therapy because of the ONJ risk?
For most patients with bone metastases, the protection bone-targeted therapy provides — reducing the risk of fractures, severe bone pain, and spinal cord complications — substantially outweighs the ONJ risk when good dental preparation is in place. Refusing a therapy that is protecting your bones carries its own serious risks. Ask your oncologist to explain specifically what the therapy is intended to prevent and what the ONJ risk looks like in your situation, so the decision is based on your individual facts rather than a general fear.