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SDCEP, IADT Guidelines > Management of patients at Risk of Medication-Related Osteonecrosis of Jaw > Flashcards

Management of patients at Risk of Medication-Related Osteonecrosis of Jaw Flashcards

1
Q

What does MRONJ stand for?

A
  • Medication related osteonecrosis of the jaw
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2
Q

What is MRONJ?

A
  • Rare side effect of anti-resorptive and anti-angiogenic drugs
  • Exposed bone or bone that can be probed through an intraoral or extraoral fistula in maxillofacial region that has persisted more than 8 weeks
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3
Q

What are the signs and symptoms of MRONJ?

A
  • Delayed healing following dental extraction or other oral surgery
  • Pain
  • Soft tissue infection or swelling
  • Numbness
  • Paraesthesia
  • Exposed bone
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4
Q

What are the current hypotheses of MRONJ mechanisms?

A
  • Suppression of bone turnover
  • Inhibition of angiogenesis
  • Toxic effects on soft tissues, inflammation or infection
  • Likely cause is multifactorial with both genetic and immunological elements
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5
Q

What are the risk factors for MRONJ?

A
  • Underlying medical condition the patient is being treated for
  • Cumulative drug dose (and duration of drug treatment)
  • Concurrent treatment with systemic glucocorticoids
  • Dentoalveolar surgery and mucosal trauma
  • Cancer patients
  • Osteoporosis patients being treated with oral anti-resorptive drugs
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6
Q

How do anti-resorptive drugs work?

A
  • Osteoclasts break down (resorb) bone tissue
  • Inhibit osteoclast differentiation and function
  • Leads to decreased bone resorption and remodelling
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7
Q

What anti-resorptive drugs have been linked to MRONJ and what are they used for?

A
  • Bisphosphonates
  • Denosumab
  • Used for management of osteoporosis and other non malignant and malignant conditions
  • Delays onset of disease or treatment complications like bone fractures and bone pain
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8
Q

How do bisphosphonates work?

A
  • Reduce bone resorption by inhibiting enzymes essential to formation, recruitment and function of osteoclasts
  • Have high affinity for hydroxyapatite and persist in skeletal tissue for sig length of time
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9
Q

What is the half life of alendronate?

A
  • Approx 10 years
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10
Q

What are bisphosphonates used for?

A
  • Reduce symptoms and complications of metastatic bone disease (breast cancer, prostate cancer and multiple myeloma) - high dose Intravenous
  • Osteoporosis
  • Paget’s disease
  • Osteogenesis imperfecta
  • Fibrous dysplasia
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11
Q

What is denosumab?

A
  • Human monoclonal antibody
  • Inhibits osteoclast function and associated bone resorption
  • By binding to receptor activator nuclear factor kB ligand (RANKL)
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12
Q

What is denosumab used for?

A
  • Prophylaxis and treatment of osteoporosis
  • Reduce skeletal -related events related to metastasis ( breast cancer etc)
  • Subcutaneously every 6 months for osteoporosis
  • Higher dose monthly in metastatic disease
  • Effects on bone turnover diminish within 9months after treatment completion
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13
Q

What are anti-angiogenic drugs?

A
  • Target the processes by which new blood vessels formed
  • Used in cancer treatment to restrict tumour revascularisation
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14
Q

How are some anti-angiogenic drugs related to MRONJ?

A
  • Vascular endothelial growth factor (VEGF) inhibitors bevacizumab and aflibercept
  • Receptor tyrosine kinase inhibitor sunitinib
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15
Q

What are bisphosphonates used for in children?

A
  • Osteogenesis imperfecta
  • Fibrous dysplasia
  • Neuromuscular disorders
  • Bone dysplasia
  • Idiopathic juvenile osteoporosis
  • Rheumatologic disorders
  • Crohn’s disease
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16
Q

What is considered low risk of patient getting MRONJ?

A
  • Patient treated for osteoporosis or other non-malignant diseases of bone (Paget’s disease) with oral bisphosphonates for less than 5 years and not concurrently treated with systemic glucocorticoids
  • Patient treated for osteoporosis or other non-malignant diseases of bone (Paget’s disease) with quarterly or yearly IV infusions bisphosphonates for less than 5 years and not concurrently treated with systemic glucocorticoids
  • Treated with denosumab and not being treated with systemic glucocorticoids
17
Q

What is considered a high risk patient?

A
  • Patients being treated for osteoporosis or other non-malignant disease of bone with oral or IV infusions of bisphosphonates more than 5 years
  • Patients on bisphosphonates or denosumab for any length of time if concurrently treated with systemic glucocorticoids
  • Patients treated with anti-resorptive or anti-angiogenic drugs (or both) as part of management of cancer
  • Patients with previous diagnosis of MRONJ
18
Q

What questions can you ask a patient to prompt them if the drug is anti-resorptive or anti-angiogenic?

A
  • Have you ever been prescribed medicine for you bones?
  • Do you take medicine once a week?
  • Have you ever had drug infusion for your bones?
  • Do you take long-term steroids for any condition?
19
Q

What is the key recommendation for patients before commencement of anti-resorptive or anti-angiogenic drug therapy?

A
  • Aim to get patient as dentally fit as feasible
  • Prioritise preventative care
  • Higher risk cancer patients undergo a thorough dental assessment
20
Q

What is the advice you should give to patient about to commence anti-resorptive or anti-angiogenic drugs or those who have recently started?

A
  • Advise patient that due to medication they are at risk of developing MRONJ but risk is small
  • Don’t discourage form taking the medication or undergoing dental treatment
  • Record advise
  • Healthy diet and reduce sugary snack and drinks
  • Maintain excellent oral hygiene
  • Using fluoride toothpaste and mouthwash
  • Stopping smoking
  • Limiting alcohol intake
  • Regular dental checks
  • Report an symptoms such as exposed bone, loose teeth, non-healing sores or lesions, pus or discharge, tingling, numbness or altered sensations, pain or swelling as soon as poss
21
Q

What are some examples of care you can do that will reduce mucosal trauma or help avoid future extractions or any oral surgery that may impact bone?

A
  • Use appropriate radiographs to identify possible areas of infection and pathology
  • Undertake any remedial dental work
  • Extract any teeth of poor prognosis without delay
  • Focus on minimising periodontal/dental infection or disease
  • Adjust or replace poorly fitting dentures to minimise future mucosal trauma
  • Consider prescribing high fluoride toothpaste
22
Q

What to do for low risk patient if they require extraction and have been made as dentally fit as feasible?

A
  • Discuss risks and benefits
  • Proceed with treatment as clinically indicated
  • Don’t prescribe antibiotic or antiseptic prophylaxis unless required for other clinical reasons
  • Advise patient to contact practice if any concerns like unexpected tingling, pain, numbness, altered sensation or swelling in extraction area
  • Review healing
  • If extraction not healed in 8 weeks and suspect MRONJ = Refer to special care dentistry/oral surgery
  • Reporting to yellow card scheme and encourage patient to as well
23
Q

What are some bisphosphonates and their indication?

A

Alendronic acid = Binosto = Osteoporosis

Risedronate sodium = Actonel = Osteoporosis / Paget’s disease

Zoledronic acid = Aclasta = Osteoporosis/ Paget’s disease/ Treatment of cancer

Ibandronic acid = Osteoporosis/ Treatment of cancer

Pamidronate disodium = Paget’s disease/ Bone pain/ Treatment of cancer

Sodium clodronate = Bone pain/ Treatment of cancer

24
Q

What is the RANKL inhibitors and their indication?

A

Denosumab = Prolia = Osteoporosis/ Treatment of cancer

25
Q

What are some anti-angiogenic drugs and their indication?

A

Bevacizumab = avastin = Treatment of cancer

Sunitinib = Sutent = Treatment of cancer

Aflibercept = Zaltrap = Treatment of cancer

26
Q

What can you do before treatment for medically complex patients?

A
  • Consider seeking advice from oral surgery/ special care dentistry specialist with regard to clinical assessment , treatment planning and ongoing management
27
Q

What are the benefits of anti-resorptive or anti-angiogenic drugs and why should the patient not stop the drugs?

A
  • Anti-resorptive drugs reduce risk of fractures and subsequent chronic pain in pts treated for osteoporosis
  • Anti-angiogenic drugs restrict growth of tumour blood vessels and important in some cancer treatments/ Reduce bone pain and risk of fractures
  • Drug holidays not recommended as drugs benefits likely to outweigh risk of MRONJ and in case of bisphosphantes and denosumab it doesn’t affect risk

SDCEP, IADT Guidelines (8 decks)

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