# MRONJ Treatment Strategies: A Systematic Review and Two Case Reports
## 4 Discussion
### Medical Treatment
#### 4.1.2 Antibiotic Therapy  
The use of antibiotics is justified by the fact that infection is a condition that accompanies, if not determines, the clinical manifestations of the disease, and therefore antibiotic therapy plays a decisive role in the management of related signs and symptoms. The almost complete absence of RCTs on antibiotic treatment in patients with DB ONJ makes it impossible to confidently define the efficacy of individual molecules in treating this disease. The infectious component of pain in individuals with MRONJ responds well to antibiotic treatment in the early stages of the disease but tends to lose efficacy over time [60].  
The protocol found in the literature involves the use of antibiotic combinations of penicillin and metronidazoleae, as first choice: the duration of therapy from a minimum of 7 to a maximum of 14 days, at full dose; the route of administration of choice is oral suspension; possible alternative molecules (e.g., erythromycincin, clindamycin, or ciprofloxacin) are to be used in case of penicillin/cephalosporin allergies [14; 21; 31; 58].  
In the study by [PERSON] et al. (2018) [27], the enrolled patients had ONJ caused by stage II DB intake according to the AAOMS classification and underwent conservative treatment by medication or surgery. Most patients included in the registry (92%) were treated with drugs for ONJ: In total, 80% received antibiotics, and 59% received oral rinses. Of the patients (31%; \(n=102\)) whose ONJ was managed surgically, 55 patients (17%) were treated with minimal surgery (e.g., debridement, sequestration, and curettage). The most commonly used class of antibiotics was extended-spectrum penicillin (212 cycles). The doses of antibiotic therapy varied, although they reflected standard dosing regimens. Most patients required more than one course of therapy: in total, 37% received one course, 44% 2-4 courses, and 19% \(\geq\)5 courses. The average duration of antibiotic use was 28 days. The resolution of ONJ was observed in 35% of the patients (median follow-up time of 11 months); overall, more than half of the patients in the study had a resolution or improvement of ONJ [27].  
The study by [PERSON]. (2022) [43] analyzes the role and effectiveness of conservative therapy and the correlation between overt signs and symptoms and lesion progression in 53 patients with MRONJ caused by DB intake. Every patient in this research received conservative treatment, which included oral hygiene instruction, antibacterial mouthwash, local lavage, and oral antibiotic administration (amoxicillin, clindamycin, and sitafloxacin). Conservative treatment options include the removal of movable bony sequestrum segments and the extraction of symptomatic teeth from the exposed necrotic bone. The results of conservative therapy were favorable in 22.7% of the patients and unfavorable in 77.3% of the patients. While MRONJ lesions are undergoing conservative therapy and seem to progress clinically, this is not always the case. Regardless of the clinical outcomes, patients, particularly those who have periosteal reactions, require ongoing CT scan monitoring [43].  
In the [PERSON] et al. (2021) paper [29], patients were initially given conservative care, including antibiotics and mouthwash (saline or povidone iodine) (penicillin compounds, cephem compounds, or macrolide compounds). Intravenous antibiotic therapy with ampicillin/sulbactam appears to generate clinically adequate bone concentrations with no significant variations between healthy and necrotic tissue; oral therapy (e.g., 875/125 mg twice a day with amoxicillin/clavulanic acid) results in significantly lower concentrations than intravenous administration [61]. The mucosal wound must be completely closed in order to be recognized as cured. By using dental tools, the result was examined visually and felt to determine its adequacy. Only 45% of the patients had to undergo sequestrectomy, and then 55% of the patients recovered with conservative treatment [29].