{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,19]],"date-time":"2026-09-19T09:14:32Z","timestamp":1789809272787,"version":"4.0.1"},"reference-count":48,"publisher":"MDPI AG","issue":"1","license":[{"start":{"date-parts":[[2017,3,16]],"date-time":"2017-03-16T00:00:00Z","timestamp":1489622400000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Dentistry Journal"],"abstract":"<jats:p>Osteonecrosis of the jaws (ONJ) in osteoporosis patients has been defined as rare, but the number of reported cases is increasing. We report a case of delayed ONJ diagnosis in a patient, who was being treated with alendronate, developing bone alterations both in maxilla and in mandible. Underestimation of ONJ incidence and missed or delayed ONJ diagnosis in osteoporosis patients might derive from lack of awareness of health providers as well as from an ONJ definition that is too restricted. The more recent definition of medication-related osteonecrosis of the jaws (MRONJ) released in 2014 by the American Association of Oral Maxillofacial Surgeons (AAOMS) accept fistula, besides bone exposure, as a major sign of disease, but it seems to be insufficient since it excludes all cases of ONJ disease without bone exposure. A new MRONJ definition is needed to avoid missing or delayed diagnosis.<\/jats:p>","DOI":"10.3390\/dj5010013","type":"journal-article","created":{"date-parts":[[2017,3,16]],"date-time":"2017-03-16T11:24:28Z","timestamp":1489663468000},"page":"13","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":15,"title":["Osteonecrosis of the Jaw (ONJ) in Osteoporosis Patients: Report of Delayed Diagnosis of a Multisite Case and Commentary about Risks Coming from a Restricted ONJ Definition"],"prefix":"10.3390","volume":"5","author":[{"ORCID":"https:\/\/orcid.org\/0000-0003-1627-4164","authenticated-orcid":false,"given":"Mario","family":"Migliario","sequence":"first","affiliation":[{"name":"Dental Clinic, Health Sciences Department, University of Eastern Piedmont \u201cA. Avogadro\u201d, 28100, Novara, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Giovanni","family":"Mergoni","sequence":"additional","affiliation":[{"name":"Oral Medicine and Laser Surgery Unit, University Center of Dentistry, Department of Medicine and Surgery, University of Parma, 43121, Parma, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Paolo","family":"Vescovi","sequence":"additional","affiliation":[{"name":"Oral Medicine and Laser Surgery Unit, University Center of Dentistry, Department of Medicine and Surgery, University of Parma, 43121, Parma, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Iolanda De","family":"Martino","sequence":"additional","affiliation":[{"name":"Centro di Documentazione Osteonecrosi dei Mascellari, 15121,Alessandria, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Manuela","family":"Alessio","sequence":"additional","affiliation":[{"name":"Centro di Documentazione Osteonecrosi dei Mascellari, 15121,Alessandria, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Luca","family":"Benzi","sequence":"additional","affiliation":[{"name":"Radiology Unit, Alessandria Hospital, 15121, Alessandria, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Filippo","family":"Ren\u00f2","sequence":"additional","affiliation":[{"name":"Innovative Research Laboratory for Wound Healing, Health Sciences Department, University of Eastern Piedmont \u201cA. Avogadro\u201d, 28100, Novara, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Vittorio","family":"Fusco","sequence":"additional","affiliation":[{"name":"Centro di Documentazione Osteonecrosi dei Mascellari, 15121,Alessandria, Italy"},{"name":"Oncology Unit, Alessandria Hospital, 15121, Alessandria, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2017,3,16]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"13","DOI":"10.1016\/j.joms.2008.10.005","article-title":"Bisphosphonate-related osteonecrosis of the jaw (BRONJ): Initial discovery and subsequent development","volume":"67","author":"Ruggiero","year":"2009","journal-title":"J. Oral Maxillofac. Surg."},{"key":"ref_2","doi-asserted-by":"crossref","unstructured":"Advisory Task Force on Bisphosphonate-Related Ostenonecrosis of the Jaws, American Association of Oral and Maxillofacial Surgeons (2007). American Association of Oral and Maxillofacial Surgeons Position Paper on Bisphosphonate-Related Osteonecrosis of the Jaws. J. Oral Maxillofac. Surg., 65, 369\u2013376.","DOI":"10.1016\/j.joms.2006.11.003"},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"1479","DOI":"10.1359\/jbmr.0707onj","article-title":"Bisphosphonate-associated osteonecrosis of the jaw: Report of a task force of the American Society for Bone and Mineral Research","volume":"22","author":"Khosla","year":"2007","journal-title":"J. Bone Miner. Res."},{"key":"ref_4","first-page":"2","article-title":"American Association of Oral and Maxillofacial Surgeons Position Paper on Bisphosphonate-Related Osteonecrosis of the Jaw\u20142009 Update","volume":"67","author":"Ruggiero","year":"2009","journal-title":"J. Oral Maxillofac. Surg."},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"1516","DOI":"10.1016\/j.joms.2008.02.012","article-title":"Non exposed bisphosphonate-related osteonecrosis of the jaws: Another clinical variant?","volume":"66","author":"Junquera","year":"2008","journal-title":"J. Oral Maxillofac. Surg."},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"593","DOI":"10.1016\/j.joms.2008.09.031","article-title":"Sinus tracts\u2014An early sign of bisphosphonate-associated osteonecrosis of the jaws?","volume":"67","author":"Mawardi","year":"2009","journal-title":"J. Oral Maxillofac. Surg."},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"1060","DOI":"10.1016\/j.amjmed.2010.04.033","article-title":"Nonexposed variant of bisphosphonate-associated osteonecrosis of the jaw: A case series","volume":"123","author":"Fedele","year":"2010","journal-title":"Am. J. Med."},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"2698","DOI":"10.1016\/j.joms.2009.07.097","article-title":"American Association of Oral and Maxillofacial Surgeons position paper: Bisphosphonate-Related Osteonecrosis of the Jaws\u20142009 update: The need to refine the BRONJ definition","volume":"67","author":"Colella","year":"2009","journal-title":"J. Oral Maxillofac. Surg."},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"621","DOI":"10.1111\/j.1601-0825.2012.01903.x","article-title":"Learning from experience. Proposal of a refined definition and staging system for bisphosphonate-related osteonecrosis of the jaw (BRONJ)","volume":"18","author":"Bedogni","year":"2012","journal-title":"Oral Dis."},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"204","DOI":"10.1016\/j.oooo.2013.10.010","article-title":"Comparison of non-exposed and exposed bisphosphonate-induced osteonecrosis of the jaws: A retrospective analysis from the Copenhagen cohort and a proposal for an updated classification system","volume":"117","author":"Schiodt","year":"2014","journal-title":"Oral Surg. Oral Med. Oral Pathol. Oral Radiol."},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"1113","DOI":"10.1002\/jbmr.2525","article-title":"Comments on \u201cdiagnosis and management of osteonecrosis of the jaw: A systematic review and international consensus","volume":"30","author":"Otto","year":"2015","journal-title":"J. Bone Miner.Res."},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"345","DOI":"10.1007\/s00520-016-3147-9","article-title":"Definition and estimation of osteonecrosis of jaw (ONJ), and optimal duration of antiresorptive treatment in bone metastatic cancer patients: supplementary data from the denosumab extension study?","volume":"25","author":"Fusco","year":"2016","journal-title":"Support. Care Cancer"},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"1938","DOI":"10.1016\/j.joms.2014.04.031","article-title":"American Association of Oral and Maxillofacial Surgeons, American Association of Oral and Maxillofacial Surgeons position paper on medication-related osteonecrosis of the jaw\u20142014 update","volume":"72","author":"Ruggiero","year":"2014","journal-title":"J. Oral Maxillofac. Surg."},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"3","DOI":"10.1002\/jbmr.2405","article-title":"International Task Force on Osteonecrosis of the Jaw, Diagnosis and management of osteonecrosis of the jaw: A systematic review and international consensus","volume":"30","author":"Khan","year":"2015","journal-title":"J. Bone Miner. Res."},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"61","DOI":"10.1016\/j.joms.2009.01.007","article-title":"The pathogenesis of bisphosphonate-related osteonecrosis of the jaw: So many hypotheses, so few data","volume":"67","author":"Allen","year":"2009","journal-title":"J. Oral Maxillofac. Surg."},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"938","DOI":"10.1016\/j.oraloncology.2012.03.028","article-title":"Bisphosphonate-related osteonecrosis of the jaws\u2014A review","volume":"48","author":"Walter","year":"2012","journal-title":"Oral Oncol."},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"257","DOI":"10.2217\/fon.13.211","article-title":"Epidemiology, clinical manifestations, risk reduction and treatment strategies of jaw osteonecrosis in cancer patients exposed to antiresorptive agents","volume":"10","author":"Campisi","year":"2014","journal-title":"Future Oncol."},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"219","DOI":"10.1007\/s11914-016-0318-z","article-title":"Osteonecrosis of the Jaw\u2014A Bone Site-Specific Effect of Bisphosphonates","volume":"14","author":"Vermeer","year":"2016","journal-title":"Curr. Osteoporos. Rep."},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"1166","DOI":"10.1016\/S1470-2045(08)70305-X","article-title":"Pharmacovigilance and reporting oversight in US FDA fast-track process: bisphosphonates and osteonecrosis of the jaw","volume":"9","author":"Edwards","year":"2009","journal-title":"Lancet Oncol."},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"9","DOI":"10.5125\/jkaoms.2013.39.1.9","article-title":"Bisphosphonates-related osteonecrosis of the jaw in Korea: A preliminary report","volume":"39","author":"Lee","year":"2013","journal-title":"J. Korean Assoc. Oral Maxillofac. Surg."},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"989","DOI":"10.1002\/pds.3622","article-title":"Notoriety bias in a database of spontaneous reports: The example of osteonecrosis of the jaw under bisphosphonate therapy in the French national pharmacovigilance database","volume":"23","author":"Kanagaratnam","year":"2014","journal-title":"Pharmacoepidemiol. Drug. Saf."},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"S31","DOI":"10.1517\/14740338.2014.951329","article-title":"Bisphosphonate-related osteonecrosis of the jaw: An Italian post-marketing surveillance analysis","volume":"13","author":"Parretta","year":"2014","journal-title":"Expert Opin. Drug Saf."},{"key":"ref_23","first-page":"7","article-title":"Existing data sources for clinical epidemiology: Scandinavian Cohort for osteonecrosis of the jaw\u2014Work in progress and challenges","volume":"7","author":"Schiodt","year":"2015","journal-title":"Clin. Epidemiol."},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"450","DOI":"10.1111\/fcp.12211","article-title":"Bisphosphonate-related osteonecrosis of the jaw: Data from the French national pharmacovigilance database","volume":"30","author":"Gaboriau","year":"2016","journal-title":"Fundam. Clin. Pharmacol."},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"878","DOI":"10.1111\/j.1365-2753.2009.01203.x","article-title":"Bisphosphonate-associated osteonecrosis of the jaw. Knowledge and attitudes of dentists and dental students: A preliminary study","volume":"16","year":"2010","journal-title":"J. Eval. Clin. Pract."},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"90","DOI":"10.1111\/j.2041-1626.2010.00024.x","article-title":"Survey of Korean dentists on the awareness on bisphosphonate-related osteonecrosis of the jaws","volume":"1","author":"Yoo","year":"2010","journal-title":"J. Investig. Clin. Dent."},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"2825","DOI":"10.1007\/s00520-015-2649-1","article-title":"Bisphosphonate-related osteonecrosis of the jaw: Awareness and level of knowledge of Lebanese physicians","volume":"23","author":"Osta","year":"2015","journal-title":"Support. Care Cancer."},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"3421","DOI":"10.1007\/s00520-015-2689-6","article-title":"Knowledge and attitudes of Brazilian dental students and dentists regarding bisphosphonate-related osteonecrosis of the jaw","volume":"23","author":"Brasil","year":"2015","journal-title":"Support. Care Cancer."},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"1095","DOI":"10.1016\/j.joms.2014.12.040","article-title":"Knowledge, practices, and opinions of Ontario dentists when treating patients receiving bisphosphonates","volume":"73","author":"Alhussain","year":"2015","journal-title":"J. Oral Maxillofac. Surg."},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"603","DOI":"10.1016\/j.bjoms.2014.04.009","article-title":"Staging of osteonecrosis of the jaw requires computed tomography for accurate definition of the extent of bony disease","volume":"52","author":"Bedogni","year":"2014","journal-title":"Br. J. Oral Maxillofac. Surg."},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"13","DOI":"10.1016\/j.bjoms.2014.09.001","article-title":"Up to a quarter of patients with osteonecrosis of the jaw associated with antiresorptive agents remain undiagnosed","volume":"53","author":"Fedele","year":"2015","journal-title":"Br. J. Oral Maxillofac. Surg."},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"804","DOI":"10.1016\/j.oooo.2012.08.458","article-title":"Prevalence of cone beam computed tomography imaging findings according to the clinical stage of bisphosphonate-related osteonecrosis of the jaw","volume":"114","author":"Wilde","year":"2012","journal-title":"Oral Surg. Oral Med. Oral Pathol. Oral Radiol."},{"key":"ref_33","doi-asserted-by":"crossref","first-page":"127","DOI":"10.1016\/j.amjoto.2008.11.002","article-title":"Necrotizing fasciitis secondary to bisphosphonate-induced osteonecrosis of the jaw","volume":"31","author":"Setabutr","year":"2010","journal-title":"Am. J. Otolaryngol."},{"key":"ref_34","first-page":"33","article-title":"Osteonecrosis of jaw (ONJ): Sometimes a life-threatening event. Literature review and two cases","volume":"5","author":"Randi","year":"2014","journal-title":"Ann. Stomatol. (Roma)"},{"key":"ref_35","first-page":"3","article-title":"Necrotizing fasciitis as a rare complication of osteonecrosis of the jaw in a patient with multiple myeloma treated with lenalidomide: Case report and review of the literature","volume":"5","author":"Mondello","year":"2014","journal-title":"SpringerPlus"},{"key":"ref_36","doi-asserted-by":"crossref","first-page":"76","DOI":"10.1016\/j.jcma.2013.08.013","article-title":"Bisphosphonate-related osteonecrosis of the jaw complicated by Ludwig\u2019s angina","volume":"78","author":"Yang","year":"2015","journal-title":"J. Chin. Med. Assoc."},{"key":"ref_37","doi-asserted-by":"crossref","first-page":"311","DOI":"10.1111\/j.1834-7819.2010.01240.x","article-title":"Bisphosphonate associated osteonecrosis: An unusual case","volume":"55","author":"Mehanna","year":"2010","journal-title":"Aust. Dent. J."},{"key":"ref_38","doi-asserted-by":"crossref","first-page":"218","DOI":"10.1093\/rheumatology\/kes351","article-title":"Fulminant course of osteonecrosis of the jaw in a rheumatoid arthritis patient following oral bisphosphonate intake and biologic therapy","volume":"52","author":"Ebker","year":"2013","journal-title":"Rheumatology (Oxf.)"},{"key":"ref_39","doi-asserted-by":"crossref","first-page":"1203","DOI":"10.1016\/j.jcms.2014.02.009","article-title":"Lethal cervical abscess following bisphosphonate related osteonecrosis of the jaw","volume":"42","author":"Kaehling","year":"2014","journal-title":"J. Craniomaxillofac. Surg."},{"key":"ref_40","first-page":"5070187","article-title":"Denosumab Related Osteonecrosis of the Jaw with Spontaneous Necrosis of the Soft Palate: Report of a Life Threatening Case","volume":"2016","author":"Qaisi","year":"2016","journal-title":"Case Rep. Dent."},{"key":"ref_41","doi-asserted-by":"crossref","first-page":"303","DOI":"10.1016\/j.jcms.2011.05.003","article-title":"Bisphosphonate-related osteonecrosis of the jaws\u2014Characteristics, risk factors, clinical features, localization and impact on oncological treatment","volume":"40","author":"Otto","year":"2012","journal-title":"J. Craniomaxillofac. Surg."},{"key":"ref_42","doi-asserted-by":"crossref","first-page":"543","DOI":"10.1111\/odi.12490","article-title":"BRONJ in patients with rheumatoid arthritis: A multicenter case series","volume":"22","author":"Bedogni","year":"2016","journal-title":"Oral Dis."},{"key":"ref_43","first-page":"142","article-title":"Bisphosphonates and osteonecrosis: An open matter","volume":"9","author":"Vescovi","year":"2012","journal-title":"Clin. Cases Miner. Bone Metab."},{"key":"ref_44","doi-asserted-by":"crossref","first-page":"2221","DOI":"10.1007\/s00784-014-1205-6","article-title":"Analysis of reasons for osteonecrosis of the jaws","volume":"18","author":"Walter","year":"2014","journal-title":"Clin. Oral Investig."},{"key":"ref_45","doi-asserted-by":"crossref","first-page":"2773","DOI":"10.1007\/s00198-015-3234-7","article-title":"The effect of 8 or 5 years of denosumab treatment in postmenopausal women with osteoporosis: Results from the FREEDOM Extension study","volume":"26","author":"Papapoulos","year":"2015","journal-title":"Osteoporos. Int."},{"key":"ref_46","doi-asserted-by":"crossref","first-page":"1145","DOI":"10.1007\/s00198-016-3840-z","article-title":"Osteonecrosis of the jaw (ONJ) and atypical femoral fracture (AFF) in an osteoporotic patient chronically treated with bisphosphonates","volume":"28","author":"Blanco","year":"2017","journal-title":"Osteoporos. Int."},{"key":"ref_47","doi-asserted-by":"crossref","first-page":"324","DOI":"10.1111\/odi.12447","article-title":"Medication-related osteonecrosis of the jaw associated with bisphosphonates and denosumab in osteoporosis","volume":"22","author":"Bagan","year":"2016","journal-title":"Oral Dis."},{"key":"ref_48","unstructured":"European Medicines Agency (EMA) PSUR\/PSUSA Submission and Expected PRAC Outcome Dates for Bisphosphonates and Denosumab. Available online: http:\/\/www.ema.europa.eu\/docs\/en_GB\/document_library\/Other\/2015\/03\/WC500184239.pdf."}],"container-title":["Dentistry Journal"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2304-6767\/5\/1\/13\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,10,11]],"date-time":"2025-10-11T18:30:35Z","timestamp":1760207435000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2304-6767\/5\/1\/13"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2017,3,16]]},"references-count":48,"journal-issue":{"issue":"1","published-online":{"date-parts":[[2017,3]]}},"alternative-id":["dj5010013"],"URL":"https:\/\/doi.org\/10.3390\/dj5010013","relation":{},"ISSN":["2304-6767"],"issn-type":[{"value":"2304-6767","type":"electronic"}],"subject":[],"published":{"date-parts":[[2017,3,16]]}}}