Medication-Related Osteonecrosis of the Jaw

Question 1

what drugs could potentially make a patient more at risk of suffering MRONJ

Answer 1

anti-resorptive or anti-angiogenic

Question 2

how should a patient who is low risk of MRONJ be reclassified as if they continue to take bisphosphonate drugs after 5 year medication review

Answer 2

higher risk

Question 3

how should patients who have taken bisphosphonates in the past be allocated to risk group

Answer 3

allocate them to a risk group as if they are still taking the drugs

Question 4

if a patient has taken denosumab in the past nine months how should their risk be classified

Answer 4

as if they are still taking the drugs

Question 5

what is the initial management of patient at risk of MRONJ

Answer 5

get patient as dentally fit as possible before commencement of the drugs through prevention

Question 6

should straightforward extractions and other bone impacting treatment be done if a patient is low risk in primary care

Answer 6

yes

Question 7

should antibiotic or antiseptic prophylaxis be prescribed to patients following extractions or other bone impacting treatments to reduce risk of MRONJ

Answer 7

no

Question 8

how should low risk patients of MRONJ be treated in primary care

Answer 8

carry out all routine dental treatment as normal and review healing

Question 9

what should happen if at 8 weeks the socket has not healed and you suspect patient has MRONJ

Answer 9

refer to oral surgery/ special care dentistry
report to MHRA via yellow card scheme

Question 10

what is MRONJ

Answer 10

rare side effect of anti-resorptive and anti-angiogenic drugs that results in exposed bone that has persisted for more than 8 weeks with NO history of radiation therapy to the jaw

Question 11

what are signs of MRONJ

Answer 11

delayed healing following extraction
pain
soft tissue infection and swelling
numbness
paraesthesia
exposed bone

Question 12

how do anti-resorptive drugs work

Answer 12

they inhibit osteoclast differentiation and function which leads to decreased bone resorption and remodelling

Question 13

what two anti-resorptive drugs have been associated with osteonecrosis of the jaw

Answer 13

bisphosphonates
denosumab

Question 14

what is the action of bisphosphonates

Answer 14

they reduce bone resorption by inhibiting enzymes essential for formation of osteoclasts

Question 15

what is the half life of alendronate (bisphosphonate)

Answer 15

10 years

Question 16

what are bisphosphonates used to treat

Answer 16

osteoporosis
Paget’s disease
osteogenesis imperfecta
fibrous dysplasia

Question 17

when might bisphosphonates be used as a prophylaxis

Answer 17

when a patient is taking glucocorticoids to counteract the osteoporotic effects

Question 18

what is denosumab

Answer 18

monoclonal antibody which inhibits osteoclast function and bone resorption by binding to receptor activator nuclear factor kB ligand (RANKL)

Question 19

how is denosumab administered

Answer 19

subcutaneously every 6 months

Question 20

how do anti-angiogenic drugs work

Answer 20

they target processes by which new blood vessels are formed - used to restrict tumour vascularisation

Question 21

what would be suggested by a patient taking an anti-angiogenic drug in combination with bisphosphonates

Answer 21

higher MRONJ risk

Question 22

what is MHRA

Answer 22

medicines and healthcare products regulatory agency

Question 23

what is the most significant risk factor for MRONJ

Answer 23

the underlying medical condition for which the patient is being treated

Question 24

what is the higher risk group for MRONJ - cancer patients or patients with osteoporosis

Answer 24

cancer patients

Question 25

irrespective of underlying medical condition, which group of patients are also deemed high risk

Answer 25

patients who have had a previous episode of MRONJ

Question 26

what dental aspects are considered risk factors for MRONJ

Answer 26

dento-alveolar surgery any surgery that impacts on bone dental trauma (including dentures)

Question 27

how does duration of bisphosphonate therapy affect risk of MRONJ

Answer 27

increases as the cumulative dose of drug increases

Question 28

what should patients with dental implants placement prior to commencement of anti-resorptive or anti-angiogenic drugs be informed

Answer 28

the small risk of spontaneous MRONJ

Question 29

what are the four factors to consider when assessing a patient's risk for MRONJ

Answer 29

medical condition type duration of drug therapy any other complicating factors

Question 30

how often should bisphosphonate therapy be reviewed

Answer 30

every 5 years

Question 31

what is classified as low risk for MRONJ

Answer 31

patients who have been treated for osteoporosis or other non-malignant diseases of bones with bisphosphonates for less than 5 years and not taking concurrent systemic glucocorticoids

Question 32

what is classified as high risk for MRONJ

Answer 32

cancer patients and those treated for osteoporosis or other non-malignant diseases of bone who have other modifying risk factors

Question 33

what risk factor group would this patient be in - Patient is being treated for osteoporosis with oral bisphosphonates for less than 5 years and is not currently being treated with systemic glucocorticoids

Answer 33

low risk

Question 34

what risk factor group would this patient be in - Patient being treated for osteoporosis with quarterly/ yearly infusions of IV bisphosphonates for less than 5 years and not currently being treated with systemic glucocorticoids

Answer 34

low risk

Question 35

what risk factor group would this patient be in - patient being treated for osteoporosis with denosumab who are not being treated with systemic glucocorticoids

Answer 35

low risk

Question 36

what risk factor group would this patient be in - Patient being treated for osteoporosis with oral or IV bisphosphonates for more than 5 years

Answer 36

high risk

Question 37

what risk factor group would this patient be in - patient being treated for osteoporosis with bisphosphonates or denosumab for any length of time and are taking systemic glucocorticoids at the same time

Answer 37

high risk

Question 38

what risk factor group would this patient be in - patient is being treated with anti-resorptive or anti-angiogenic drugs (or both) as part of cancer management

Answer 38

high risk

Question 39

what risk factor group would this patient be in - patient has previously been diagnosed with MRONJ

Answer 39

high risk

Question 40

where can straightforward extractions and other bone impacting treatments be carried out in low risk individuals

Answer 40

primary care

Question 41

what is alendronic acid used to treat (bisphosphonate)

Answer 41

osteoporosis

Question 42

what is denosumab (RANKL inhibitor) used to treat

Answer 42

osteoporosis and cancer

Question 43

name two anti-angiogenic drugs

Answer 43

bevaxizumab sunitinib