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SDCEP guidelines > Bisphosphonates > Flashcards

Bisphosphonates Flashcards

1
Q

What are the types of drugs that increase risk of MRONJ?

A
  • Anti-resorptive drugs - bisphosphonates or denosumab
  • Anti-angiogenic drugs - bevacizumab or sunitinib
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2
Q

What is MRONJ?

A

Medication Related Osteonecrosis of the Jaw

exposed bone that has persisted for more than 8 weeks

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3
Q

What are the symptoms of MRONJ?

A
  • swelling
  • numbness
  • pain
  • altered taste or sensation
  • signs of infection
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4
Q

What are the signs of MRONJ?

A
  • delayed healing following extraction
  • Exposed bone
  • soft tissue infection
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5
Q

What are the risk factors for MRONJ?

A
  • medical conditions affecting bone turnover (e.g. osteoporosis)
  • malignancy
  • chemotherapy/radiotherapy
  • Previous diagnosis of MRONJ
  • antiresorptive or antiangiogenetic drugs
  • Duration of drug treatment
  • concurrent treatment with systemic glucocorticoids
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6
Q

What is indicative of high risk for MRONJ?

A
  • previous diagnosis of MRONJ
  • if the patient is taking anti-resorptive or anti-angiogenic drugs
  • undergoing cancer treatment
  • if the patient was/is taking RANKL inhibitor (denosumab) AND steroids
  • If the patient has been taking/ has taken bisphosphonates for 5 years or more
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7
Q

How do anti-resorptive drugs work?

A

they inhibit osteoclast differentiation and function, leading to decreased bone resorption and remodelling

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8
Q

What is the function of bisphosphonates?

A

They inhibit osteoclast formation decreasing bone resorption

Bisphosphonates have a high affinity for bone minerals and bind strongly to hydroxyapatite in bone

They persist for a period of time (half life of 10 years)

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9
Q

How does bisphosphonates affect soft tissues ?

A

They inhibit proliferation and increase apoptosis which can lead to delayed soft tissue healing

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10
Q

What conditions are treated by bisphosphonates?

A

non malignant conditions - Osteoporosis and Paget’s disease

malignant conditions - myeloma and breast cancer

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11
Q

What type of drug is Denosumab?

A

A Monoclonal Antibody

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12
Q

What is the function of Denosumab?

A

it inhibits osteoclast function and associated bone resorption by binding to RANKL

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13
Q

What conditions are treated by Denosumab?

A
  • osteoporosis
  • metastatic disease (cancer)
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14
Q

What is an advantage of Denosumab compared to a bisphosphonate?

A

it does not bind to bone so its effect on bone turnover diminish within 9 months of treatment completion

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15
Q

How do anti-angiogenic drugs work?

A

they target the processes which create new blood vessels

they are used in cancer treatment to restrict tumour vascularisation

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16
Q

What three anti-angiogenic drugs are associated with MRONJ risk?

A

bevacizumab - vascular endothelial growth factor inhibitor (VEGF)
aflibercept - VEGF inhibito

sunitinib - receptor tyrosine kinase (RTK) inhibitor

17
Q

What conditions in children are treated by bisphosphonates?

A
  • osteogenesis imperfecta
  • fibrous dysplasia
  • crohn’s disease
  • bone dysplasia
  • juvenile osteoposrosis
  • rheumatologic disorders
18
Q

Why is temporarily stopping bisphosphonates not successful in reducing MRONJ risk?

A

the drug persists in the skeletal tissue for years after due to long half life

19
Q

What risk group for MRONJ are patient being treated for cancer?

A

High Risk

20
Q

What risk group for MRONJ are patients taking bisphosphonates for <5 years?

A

Lower Risk

21
Q

What risk group for MRONJ are patients taking denosumab

A

Lower risk

22
Q

What risk group for MRONJ are patients that took denosumab > 9 months ago with no systemic glucocorticoids

A

Lower risk

23
Q

What risk group for MRONJ are patients taking denosumab and concurrent systemic glucocorticoids?

A

High Risk

24
Q

What risk group for MRONJ are patient taking bisphosphonates for > 5 years?

A

High Risk

25
Q

What risk group for MRONJ are patient taking bisphosphonates for < 5 years and taking systemic glucoscorticosteroids?

A

High Risk

26
Q

What risk group for MRONJ are patients who have previously had MRONJ?

A

High Risk

27
Q

How do you assess MRONJ risk in patients who previously took bisphosphonates?

A

Assess as though they are still taking the medication and determine risk from duration of medication

28
Q

If a patient has MRONJ who do you refer them to?

A

Oral surgery

OR

Special care dentistry

29
Q

What are the key elements of a treatment plan for patients at risk of MRONJ?

A

Ideally make patients dentally fit before medications starts

Extraction is a last resort - try every other option first

Prevention is essential to prevent future treatment

30
Q

What are modifiable factors to reduce risk of MRONJ?

A
  • oral hygiene
  • smoking
  • alcohol consumption
  • diet

SDCEP guidelines (4 decks)

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