Platelet-rich fibrin for the prevention of medication-related osteonecrosis of the jaw after tooth extraction: a systematic review and meta-analysis.

Abstract

Background: Medication-related osteonecrosis of the jaw (MRONJ) is a serious complication associated with antiresorptive and antiangiogenic therapies, particularly following tooth extraction. Platelet-rich fibrin (PRF) has been proposed as a biologically active adjunct capable of enhancing tissue repair and potentially reducing the risk of MRONJ. This systematic review and meta-analysis evaluated the effectiveness of PRF in preventing MRONJ and improving postoperative healing in patients undergoing tooth extraction while receiving these medications.

Methods: A comprehensive search of PubMed, EMBASE, and CENTRAL was conducted from inception to 1 June 2026. Studies comparing tooth extraction with PRF versus tooth extraction alone in patients receiving antiresorptive and/or antiangiogenic therapy were included. Risk ratios (RRs) with 95% confidence intervals (CIs) were pooled using random-effects models. An exploratory subgroup analysis by PRF subtype (L-PRF versus A-PRF) was conducted for the healing outcome, and a sensitivity analysis restricted to studies with moderate risk of bias was performed for the MRONJ outcome. The certainty of evidence was assessed using the GRADE approach. The primary outcome was MRONJ occurrence, and the secondary outcome was postoperative healing.

Results: Seven studies were included in the qualitative synthesis, and seven contributed data to at least one meta-analysis. For MRONJ, six study cohorts involving 370 patients were analysed. PRF was associated with a significantly lower risk of MRONJ compared with extraction alone (RR = 0.29; 95% CI: 0.15-0.57; p = 0.0003; I² = 30%). A sensitivity analysis restricted to the two moderate-risk-of-bias studies yielded a consistent directional effect (RR = 0.13; 95% CI: 0.02-0.69; p = 0.02; I² = 0%), though based on very limited data. For postoperative healing, six studies involving 512 patients were included. PRF was associated with improved healing outcomes overall (RR = 1.31; 95% CI: 1.11-1.54; p = 0.001; I² = 69%). Subgroup analysis by PRF subtype demonstrated a significant effect for L-PRF (RR = 1.36; 95% CI: 1.07-1.73; p = 0.01; I² = 75%) but not for A-PRF (RR = 1.22; 95% CI: 0.99-1.52; p = 0.07; I² = 31%), with no statistically significant difference between subgroups (p = 0.51). The certainty of evidence was rated as Very Low for both outcomes according to GRADE.

Conclusion: Current evidence suggests that adjunctive PRF may be associated with a reduced risk of MRONJ and improved healing following tooth extraction in patients receiving antiresorptive and/or antiangiogenic medications. However, these findings are based predominantly on observational studies with serious risk of bias and relatively small sample sizes, and the certainty of evidence is Very Low. Further well-designed randomised controlled trials are needed to confirm the magnitude and consistency of these potential benefits.