Day 3-Osteonecrosis of the Jaw Flashcards
What did Dr. C not want us to confuse with medication related osteonecrosis of the jaw?
osteoRADIOnecrosis of the jaw from H&N radiation
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.
8
MRONJ Definition: 2) No h/o ______ therapy (XRT) to the jaws.
radiation
MRONJ Definition: 3) Current or previous treatment
with ________ or ________ agents
antiresorptive or antiangiogenic
WHEN were the first cases of MRONJ coming about and what was the common thread of all of them?
2003….all pt were in IV bisphosphnates
Whats a REALLY common area for MRONJ to manifest?
Lingual of posterior mandibular molar
What was the main pathogen in MRONJ that the pathologist found>?
actinomyces
________ oxygen restores vascularity to marginal bone does it have a significant impact on improving MRONJ?
hyperbaric..NO
What is the MOST COMMONLY Rx’d ORAL bisphosphonate that started to manifest as MRONJ?
ALEN-DRON-ATE
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
RANK-L….monoclonal antibodies…. anti-angiogenesis
IMPORTANT! What are the three types of ANTI-RESORPTIVE meds associated with MRONJ?
- IV Bisphosphonates 2.Oral Bisphosphonates 3.RANK-ligand inhibitor-a human monoclonal antibody
IMPORTANT besides anti-resorptive meds, what other class of drugs are associated with MRONJ?
Anti-Angiogenic meds
What are the three most common cancers that metastasize to bone and therefore are treated with MRONJ associated medS?
BREAST, PROSTATE, LUNG
What conditions are treated with these anti-angiogenic medications? Bone lesions of _________
multiple myeloma
What are the three common ORAL bisphosphonates?
- ALEN-DRON-ATE (Fosamax) 2.RISE-DRON-ATE (Actonel) 3.I-BAN-DRONATE (Boniva)
What are the two common IV bisphosphonates?
1.PAM-I-DRON-ATE (Aredia) 2.ZOLE-DRON-ATE (Zometa)
Recast is crazy- whats its unusual dose?
5mg/1yr
What are the names of the 2 Rank-L inhibitors?
1)Denosumab 2)ProLia
What are the two SubQutaneous bisphosphonates? How often are these administered to the Pt?
1)Denosumab 2)Prolia…1x/6months
Bisphosphonates and RANK-L inhibitors act by inhibiting ________ activity.
osteoclast
Osteoclasts resorb bone, releasing ______ and growth factors that stimulate circulating stem cells to differentiate into osteoblasts and create new bone.
BMP
Inhibition of ________ prevents normal bone turnover, remodeling, and healing of bone when wounded.
osteoclasts
_________ medications interfere with formation of blood vessels and interrupt vascular supply causing avascular necrosis
Anti-angiogenic
A common indicator for MRONJ is a thick or sclerotic _________.
Lamina Dura (around the root of the tooth)
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?
CTX (Collagen Type I C-telopeptide)…less than 100 is high risk
Dang! Our CTX blood test to look for MRONJ is not useful in these three patients:
1.Cancer patients 2.Methotrexate pt’s 3.steriod pt’s
Are there SYSTEMIC tests to indicated MRONJ validated by OS yet?
NO
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?
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)
Cessation of at-risk meds (drug ______) for patients with extended exposure (>___ years) of oral bisphosphonates or denosumab for osteoporosis/osteopenia
holiday…more than 4 years
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”
removal of the crown…endo (so were not messing with alveolar bone)
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.
4 years
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.
HOLIDAY….2 MONTHS
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.
HOLIDAY…. 2 MONTHS
Is the Pt on PROLIA (denosumab)? Drug holiday of ___ months recommended before surgery.
3 months
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?
Surgery 9 months after dose, so 3 months before dose.
Indications for \_\_\_\_\_\_\_\_: 1) Symptomatic and refractory to nonsurgical treatment 2) Pathologic fractures 3) Direct sinus communication
RESECTION of the jaw :(
____% of patients who have MRONJ, are or can be maintained pain-free!
90%
For those on _____ meds, the disease appears to be rare, less severe, and reversible with discontinuation of the med
ORAL
New approaches to treatment of established MRONJ Low level _____ therapy, radiotherapy
LASER
3 of the 4 diagnostic criteria for MRONJ are from the __________!
historical data
What is the magic number for patients taking oral bisphosphnates?
4 years
Why are IV bisphosphonates so much more likely to cause MRONJ?
they are 5-10x more potent!
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)
1.Zometa (Zol-en-dron-ate…IV) 2.Aredia (Pam-i-dron-ate…IV) 3.Xgeva (Denosumab…SQ)
