# Current Trends in Adjuvant Therapies for Medication-Related Osteonecrosis of the Jaw
###### Abstract  
Medication-related osteonecrosis of the jaw (MRON) is a refractory disease, and a standard protocol for its treatment has not yet been established. In addition, owing to the old age of MRONJ patients and various complications, treatment goals focus on relieving the symptoms and improving the quality of life. For this reason, different treatments such as conservative, surgical, and adjunctive treatments have been attempted. In particular, adjunctive treatment, which is effective for promoting healing and reducing recurrence, is gaining increasing interest, and several studies and clinical trials related to it have been published. Representative adjuvant therapies include teriparatide, recombinant human bone morphogenetic protein-2, hyperbaric oxygen, photobiomodulation and platelet concentrates. All have generally shown beneficial effects; however, no standard protocol for adjunctive treatment exists. Therefore, in this literature review, we briefly summarized the different adjuvant therapies and reviewed clinical reports to help decide whether to use adjuvant therapies in treating patients with MRONJ.  
MRONJ; teriparatide; recombinant human bone morphogenetic protein-2; hyperbaric oxygen; photobiomodulation; platelet concentrates +
Footnote †: journal: Medical  
Ever since the first case of MRONJ was described in 2003, attempts have been made to clarify its pathophysiological mechanisms. The evidence-based mechanisms include infection or inflammation, inhibited bone remodeling, altered angiogenesis, soft tissue toxicity, and decreased immune resilience [5]. Furthermore, local jaw infections play a major role in MRONJ development [6]. Chronic exposure to bisphosphonates significantly reduces osteogenic differentiation and impairs stem cell viability, increasing predisposition to MRONJ [7]. Although various underlying mechanisms have been proposed, they remain unclear. Thus, the management of MRONJ remains controversial.  
Several therapeutic strategies ranging from conservative treatment to surgical approaches have been recommended for MRONJ. The conservative treatment involves maintaining good oral hygiene, medication, and antibacterial mouth rinse for patients at stages 0-II [2]. Although conservative treatment stabilizes the patient's condition, the condition improves minimally [8]. Moreover, most patients with MRONJ exhibit infection-related symptoms that do not show improvement with conservative treatment; thus, this treatment is a valid option only for reducing the symptoms and controlling the infection [9]. Surgical treatment may provide better outcomes for all stages of the disease [10,11]. Debridement, sequestrectomy, and resection are recommended for stage III or stage II patients unresponsive to conservative treatment. Conservative surgery may also confer better outcomes for patients at stages I and II of the disease [12,13]. Surgery provides better mucosal healing and aids in relieving symptoms, including bone necrosis [9].  
A good surgical outcome requires adjuvant therapy, such as administration of teriparide, recombinant human bone morphogenetic protein-2, hyperbariic oxygen, photobiomodulation, or platelet concentrates. This therapy is given concurrently with or after surgical treatment but sometimes alone. Although adjuvant therapies promote the recovery of patients with MRONJ [14,15], their exact role in alleviation of MRONJ has never been demonstrated, and a standard protocol is lacking. Here, we discussed the latest understanding of adjuvant therapies for MRONJ.