MRONJ Flashcards
Name 3 criteria a person must fulfil to be considered to have MRONJ
- Current or previous treatment with anti resorptive drugs
- Exposed bone persisting for over 8 weeks
- No history of radiotherapy or metastatic bone disease in jaws
Name 2 common drugs which cause MRONJ
- Bisphosphonates
2. Denosumab
Describe 5 theories of the pathogenesis of MRONJ
- Inhibition of bone remodelling (cannot remove necrotic bone)
- Inflammation / Infection
- Anti-angiogenesis (bisphosphonates)
- Soft tissue toxicity (bisphosphonates)
- Immune dysfunction (reduction of blood supply)
Name 6 common signs and symptoms of MRONJ
- Pain
- Exposed bone
- Bad taste
- Numbness / paraesthesia
- Swelling / sinus formation
- Delayed healing following surgery
Describe stage 0 of MRONJ
- No clinical evidence of necrotic bone
- Non specific clinical findings, radiographic changes and symptoms
Describe stage 1 of MRONJ
- Exposed and necrotic bone, or fistula that probes into bone
- Asymptomatic and no evidence of infection
Describe stage 2 of MRONJ
- Exposed and necrotic bone, or fistula that probes into bone
- Infection evidenced by pain and erythema in region of exposed bone
Describe stage 3 of MRONJ
- Exposed and necrotic bone, or fistula that probes into bone, extending beyond region of alveolar bone
- Pathogenic fracture
- Extra oral fistula
- Oral nasal / Oral antral communication
- Osteolysis
Describe the treatment for stage 0 MRONJ
Systemic management including use of antibiotics and pain medication
Describe the treatment for stage 1 MRONJ
- Antibacterial mouth rinse
- Clinical follow up on quarterly basis
- Patient education
Describe the treatment for stage 2 MRONJ
- Symptomatic treatment with oral antibiotics
- Pain control
- Debridement to relieve soft tissue irritation and infection control
- Oral antibacterial mouth rinse
Describe the treatment for stage 3 MRONJ
- Antibacterial mouth rinse
- Antibiotic therapy and pain control
- Surgical debridement for long term palliation of infection and pain
- Surgical resection for long term palliation of infection and pain
What is the current guidelines used for management of MRONJ?
Best Practice Guidelines - Belfast Trust
Why may previous bisphosphonate treatment be a risk factor for MRONJ?
Linger in the system as they bind to the skeleton and remain after treatment has finished
What is a concurrent condition which may increase a patient receiving bisphosphonates risk of developing MRONJ?
Immunosuppression
Why may anatomical site be a risk factor for MRONJ?
Mandible is less vascular than maxilla so more likely to develop MRONJ
Describe the components of preventative care of patients on bisphosphonates or denosumab
- Advise patients on risk of MRONJ
- Oral hygeine and diet advice
- Fluoride mouthrinses
- Smoking cessation
- Ensure patient is dentally fit before treatment commences
Describe 4 steps taken to ensure a patient is dentally fit before undergoing treatment which may carry the risk of MRONJ
- Extract teeth with a poor prognosis
- Reduce periodontal infection
- Adjust or replace poorly fitting dentures
- Undertake all remedial dental work
What is the initiating event in most MRONJ?
Dental extraction
Name 4 things which make a person high risk for MRONJ
- Patients being treated with oral bisphosphonates or infusions for non malignant diseases for more than 5 years
- Patients being treated with bisphosphonates or RANKL inhibitors for non malignant diseases and immunosuppressants for any time
- Patients taking anti-resorptive drug as part of cancer management
- Previous diagnosis of MRONJ
Name 3 things which make a person low risk for MRONJ
- Patients being treated with oral bisphosphonates for non-malignant diseases for less than 5 years with no concurrent immunosuppressants
- Patients being treated with IV bisphosphonates for non-malignant diseases for less than 5 years with no concurrent immunosuppressants
- Patients being treated with bisphosphonates or RANKL inhibitors for non malignant diseases with no immunosuppressants
What is the major difference in dental therapy which impacts on bones between low and high risk patients?
- Low risk is discuss risks, proceed with treatment, no prophylaxis, review healing at 8 weeks
- High risk is explore all alternatives possible then discuss risks, proceed with treatment, no prophylaxis, review healing at 8 weeks
Discuss “drug holidays” for patients on bisphosphonates or RANKL inhibitors when needing dental extractions
- Guidance varies
- Tends to have some indications for small benefits
- Write to physician prescribing treatment and ask if patient can have holiday
- Most patients may be able to come off for 2 months without risk of fracture
Name 2 types of anti-angiogenic medications with examples of both
Tyrosine Kinase Inhibitors - Sunitinib
Vascular Endothelial Growth Factor Inhibitors - Bevacizumab / Aflibercept
