Stage 0 medication-related osteonecrosis of the jaws: a systematic review on the controversial role of imaging techniques

Objective: Medication-related osteonecrosis of the jaws (MRONJ) is a progressive and debilitating condition that lacks specific clinical symptoms in its early phase. The recognition of stage 0 MRONJ, defined by clinical signs without bone exposure, may improve prognosis and reduce the risk of disease progression. The aim of this systematic review was to evaluate the early imaging features of MRONJ using panoramic radiography (PAN), cone beam CT (CBCT), multislice CT (MSCT), and MRI. Methods: A literature review was conducted in accordance with PRISMA guidelines using PubMed, Embase, Web of Science, and Scopus databases. Original studies in English language published by October 1, 2025, and focusing on imaging techniques in early-stage MRONJ were selected. Results: Osteosclerosis was found in 50.0%, 75.0%, and 87.5% of the studies with PAN, CBCT, and MSCT respectively. Osteolysis was identified in 66.7% of the studies with PAN and 25.0% of the studies with both CBCT and MSCT. Additional features observed less frequently were lamina dura thickening, bone sequestration, nonspecific bone alterations, and lack of post-extraction bone healing. On MRI, the non-exposed affected bone showed low T1 signal intensity, high T2 STIR signal intensity, and an increased apparent diffusion coefficient compared with healthy subjects. Conclusions: Osteosclerosis was the most frequently observed sign, although no imaging technique proved specific features for stage 0 MRONJ. Further studies with larger cohorts together with a standardization of imaging findings and a revaluation of the definition of MRONJ will be needed to identify such disease in its early stages.