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Oral Surgery > Day 3-Osteonecrosis of the Jaw > Flashcards

Day 3-Osteonecrosis of the Jaw Flashcards

1
Q

What did Dr. C not want us to confuse with medication related osteonecrosis of the jaw?

A

osteoRADIOnecrosis of the jaw from H&N radiation

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2
Q

MRONJ Definition: 1) Exposed bone or bone that can be probed through an intraoral or extraoral fistula(e) in the MF region that has persisted for more than
___ weeks.

A

8

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3
Q

MRONJ Definition: 2) No h/o ______ therapy (XRT) to the jaws.

A

radiation

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4
Q

MRONJ Definition: 3) Current or previous treatment

with ________ or ________ agents

A

antiresorptive or antiangiogenic

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5
Q

WHEN were the first cases of MRONJ coming about and what was the common thread of all of them?

A

2003….all pt were in IV bisphosphnates

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6
Q

Whats a REALLY common area for MRONJ to manifest?

A

Lingual of posterior mandibular molar

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7
Q

What was the main pathogen in MRONJ that the pathologist found>?

A

actinomyces

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8
Q

________ oxygen restores vascularity to marginal bone does it have a significant impact on improving MRONJ?

A

hyperbaric..NO

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9
Q

What is the MOST COMMONLY Rx’d ORAL bisphosphonate that started to manifest as MRONJ?

A

ALEN-DRON-ATE

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10
Q

Now, other types of medications used in the treatment of osteoporosis and cancer have been shown to cause osteonecrosis, eg. _______ inhibitors and monoclonal ______, and anti-_______ drugs

A

RANK-L….monoclonal antibodies…. anti-angiogenesis

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11
Q

IMPORTANT! What are the three types of ANTI-RESORPTIVE meds associated with MRONJ?

A
  1. IV Bisphosphonates 2.Oral Bisphosphonates 3.RANK-ligand inhibitor-a human monoclonal antibody
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12
Q

IMPORTANT besides anti-resorptive meds, what other class of drugs are associated with MRONJ?

A

Anti-Angiogenic meds

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13
Q

What are the three most common cancers that metastasize to bone and therefore are treated with MRONJ associated medS?

A

BREAST, PROSTATE, LUNG

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14
Q

What conditions are treated with these anti-angiogenic medications? Bone lesions of _________

A

multiple myeloma

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15
Q

What are the three common ORAL bisphosphonates?

A
  1. ALEN-DRON-ATE (Fosamax) 2.RISE-DRON-ATE (Actonel) 3.I-BAN-DRONATE (Boniva)
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16
Q

What are the two common IV bisphosphonates?

A

1.PAM-I-DRON-ATE (Aredia) 2.ZOLE-DRON-ATE (Zometa)

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17
Q

Recast is crazy- whats its unusual dose?

A

5mg/1yr

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18
Q

What are the names of the 2 Rank-L inhibitors?

A

1)Denosumab 2)ProLia

19
Q

What are the two SubQutaneous bisphosphonates? How often are these administered to the Pt?

A

1)Denosumab 2)Prolia…1x/6months

20
Q

Bisphosphonates and RANK-L inhibitors act by inhibiting ________ activity.

A

osteoclast

21
Q

Osteoclasts resorb bone, releasing ______ and growth factors that stimulate circulating stem cells to differentiate into osteoblasts and create new bone.

A

BMP

22
Q

Inhibition of ________ prevents normal bone turnover, remodeling, and healing of bone when wounded.

A

osteoclasts

23
Q

_________ medications interfere with formation of blood vessels and interrupt vascular supply causing avascular necrosis

A

Anti-angiogenic

24
Q

A common indicator for MRONJ is a thick or sclerotic _________.

A

Lamina Dura (around the root of the tooth)

25
Q

Another good indicator of MRONJ is a _____ blood test which is an index of blood turnover. What is a HIGH risk result of the test?

A

CTX (Collagen Type I C-telopeptide)…less than 100 is high risk

26
Q

Dang! Our CTX blood test to look for MRONJ is not useful in these three patients:

A

1.Cancer patients 2.Methotrexate pt’s 3.steriod pt’s

27
Q

Are there SYSTEMIC tests to indicated MRONJ validated by OS yet?

A

NO

28
Q

What is IDEAL for treating a dental patient when they are going to go on IV bisphosphonates for cancer tx? What happens if MRONJ is already present?

A

Treat patient to control infection and inflammation in the oral cavity BEFORE going on the meds…if present prevent/control secondary infection (life long abx)

29
Q

Cessation of at-risk meds (drug ______) for patients with extended exposure (>___ years) of oral bisphosphonates or denosumab for osteoporosis/osteopenia

A

holiday…more than 4 years

30
Q

The patient has already started anti-angiogenic meds how am I going to Tx? “Nonrestorable teeth may be treated by _______ and ______ treatment of the remaining roots”

A

removal of the crown…endo (so were not messing with alveolar bone)

31
Q

INTERESTING!!! Patients who have taken an oral BP for LESS than ___ years and have NO CLINICAL RISK FACTORS: no alteration or delay in planned surgery is necessary.

A

4 years

32
Q

Patients who have taken an oral BP for LESS than 4 years and have taken CORTICOSTEROIDS or ANTIANGIOGENIC medications concomitantly: contact the prescribing provider to consider a drug ______ for at least ______ months before oral surgery. Do not restart the drug until osseous healing is complete.

A

HOLIDAY….2 MONTHS

33
Q

Patients who have taken an ORAL BP for more than 4 years with or without any concomitant medical therapy: contact the prescribing provider to consider a drug ______ for ____ months before oral surgery. Do not restart until after osseous healing is complete.

A

HOLIDAY…. 2 MONTHS

34
Q

Is the Pt on PROLIA (denosumab)? Drug holiday of ___ months recommended before surgery.

A

3 months

35
Q

Is the Pt on RECAST (Zol-En-Dron-Ate)? Its taken once per year, so what time in the year cycle do you perform dental Tx?

A

Surgery 9 months after dose, so 3 months before dose.

36
Q 
Indications for \_\_\_\_\_\_\_\_:
1) Symptomatic and refractory to nonsurgical
treatment
2) Pathologic fractures
3) Direct sinus communication
A

RESECTION of the jaw :(

37
Q

____% of patients who have MRONJ, are or can be maintained pain-free!

A

90%

38
Q

For those on _____ meds, the disease appears to be rare, less severe, and reversible with discontinuation of the med

A

ORAL

39
Q

New approaches to treatment of established MRONJ Low level _____ therapy, radiotherapy

A

LASER

40
Q

3 of the 4 diagnostic criteria for MRONJ are from the __________!

A

historical data

41
Q

What is the magic number for patients taking oral bisphosphnates?

A

4 years

42
Q

Why are IV bisphosphonates so much more likely to cause MRONJ?

A

they are 5-10x more potent!

43
Q

What are the three bisphosphonates (2 IV, 1 SQ) commonly Rx’d with chemo? (and therefore cancer Pt’s may not know their whole cocktail)

A

1.Zometa (Zol-en-dron-ate…IV) 2.Aredia (Pam-i-dron-ate…IV) 3.Xgeva (Denosumab…SQ)

Oral Surgery (9 decks)

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