Bisphosphonates

Question 1

what is MRONJ

Answer 1

medication related osteonecrosis of the jaw - side effect of anti-resorptive and anti-angiogenic drugs defined as exposed bone or bone that can be probed through a fistula

Question 2

do cancer patients or patients on osteoporosis drugs have higher risk for MRONJ

Answer 2

cancer patients

Question 3

what do anti-resorptive drugs do

Answer 3

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

Question 4

how do bisphosphonates reduce bone resorption

Answer 4

by inhibiting enzymes essential to the formation, recruitment and function of osteoclasts

Question 5

what are bisphosphonates used for

Answer 5

reduce symptoms and complications of metastatic bone disease

Question 6

what conditions are bisphosphonates indicated for

Answer 6

osteoporosis
pagets disease
osteogenesis imperfecta
fibrous dysplasia
prophylactic against steroid effects

Question 7

aside from bisphosphonates what other drug can give MRONJ

Answer 7

denosumab

Question 8

what are the risk factors for MRONJ

Answer 8

the underlying medical condition for which the patient is being treated
dental treatment
duration of bisphosphonate therapy
other concurrent medication
dental implants

Question 9

what do you do if a patient with implants is about to start bisphosphonates

Answer 9

inform them that they have a small risk of spontaneous MRONJ at the implant sites

Question 10

if a patient is on bisphosphonates and wants to get implants what would you advise

Answer 10

they have a risk of compromised bone healing and MRONJ following the procedure and risk of long-term implant failure

Question 11

if a patient is on six monthly injections of denosumab what should you do for their dental treatment

Answer 11

delay non-urgent invasive treatment until the month prior to the patients next scheduled drug administration

Question 12

how long does denosumab’s effect on bone turnover remain within the body after treatment completion

Answer 12

9 months

Question 13

who is in the low risk category for MRONJ

Answer 13

patients being treated for osteoporosis with oral or intravenous bisphosphonates for less than 5 years and not on steroids

patients on denosumab not being treated with steroids

Question 14

who is in the higher risk category for MRONJ

Answer 14

patients on oral or IV bisphosphonates for more than 5 years or any length of time with steroids

patients on anti-resorptives as part of cancer treatment

patients with previous diagnosis of MRONJ

Question 15

what is the best practice for determining risk of a patient for MRONJ

Answer 15

ask about past, current or possible future use of anti-resorptive drugs
assign a risk level based on assessment of medical condition patient being treated for
assign them to a risk category based on previous treatment

Question 16

what is the best thing to do BEFORE a patient starts anti-resorptive drug therapy

Answer 16

aim to get the patient as dentally fit as possible

Question 17

if a patient needs treatment and has started drug therapy what do you do

Answer 17

advise there may be a risk of MRONJ
give personalised preventative advice
prioritise care that will reduce mucosal trauma
seek advice if struggling

Question 18

what type of preventative advice do we give patients at risk of MRONJ

Answer 18

have healthy diet
maintain OH
use fluoride toothpaste and mouthwash
stop smoking
limit alcohol intake
regular dental check ups
report symptoms as soon as they happen

Question 19

what is included in the continuing management of patients at risk of MRONJ

Answer 19

carry out all routine dental treatment and provide preventative advice in primary care
adopt conservative approach in high risk patients

Question 20

if you do an extraction on a patient and the socket has not healed in 8 weeks and you suspect the patient has MRONJ what do you do

Answer 20

refer to oral surgery/special care

Question 21

how do you treat a low risk patient after you have them as dentally fit as possible

Answer 21

carry out treatment as normal
discuss risks and benefits of treatment
advise to contact practice if they have concerns after treatment
refer if you suspect spontaneous MRONJ

Question 22

how do you treat a high risk patient after you have them as dentally fit as possible

Answer 22

carry out treatment as normal
seek advice regarding clinical assessment and treatment planning
if extraction needed explore alternatives where you could retain the roots
if suspect MRONJ refer