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Oral Med BONES, GERIATRICS, MRONJ > MRONJ > Flashcards

MRONJ Flashcards

1
Q

Medical Indications for Bisphosphonates

A
  • Osteoporosis
  • Cancer treatment-induced bone loss
  • Skeletal-related events in patients with malignancies that involve bone
  • Giant cell tumor of bone
  • Hypercalcemia of malignancy
  • Paget disease of bone
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2
Q

Bisphosphonates are ____ absorbed in the GI tract

A

Poorly

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3
Q

Bisphosphonates are excreted _____ by the kidneys

A

Unchanged

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4
Q

Bisphosphonates have a high affinity for ______ within the bone

A

Hydroxyapatite

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5
Q

Bisphosphonates are ____ within the bone

A

Inactive

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6
Q

Bisphosphonates are released during ____ ____

A

Bone resorption

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7
Q

Bisphosphonates ____ osteoclast activity and ____ osteoclast apoptosis

A

Inhibit; promote

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8
Q

Two classes of bisphosphonates

A

Non-nitrogen containing BPs

Nitrogen containing BPs

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9
Q

Non-nitrogen containing BPs function

A

Osteoclast apoptosis

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10
Q

Nitrogen containing BPs: ____ mevalonate pathway and has ____ effects

A

Inhibits; antitumor

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11
Q

Nitrogen containing BPs: What three processes do these affect?

A

Affect osteoclastogenesis, apoptosis and cytoskeletal dynamics

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12
Q

Nitrogen containing BPs: Function of Zoledronate

A
  • Inihibits human endothelial cell proliferation

- Modulates endothelial cell adhesion and migration

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13
Q

Denosumab/Prolia: Function

A

Acts against RANKL and inhibits osteoclast function

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14
Q

Function of Antiangiogenic medications

A
  • Interfere with the formation of new blood vessels

- Used for various tumors/malignancies

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15
Q

Antiangiogenic Inhibitors:

Function of Tyrosine Kinase Inhibitors

A

-Reduce the blood supply to the tumor thereby impacting the tumor’s ability to grow.

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16
Q

“-nib”=

A

Tyrosine kinase Inhibitors

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17
Q

“-mab”=

A

Monoclonal antibody

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18
Q

Definition of MRONJ

A

Bone necrosis associated with pharmacologic therapies

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19
Q

First criteria to establish diagnosis of MRONJ

A

Current or previous treatment with BMA or angiogenic inhibitor

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20
Q

Second criteria to establish diagnosis of MRONJ

A

Exposed bone or bone that can be probed through an intraoral or extraoral fistula in the maxillofacial region and that has persisted for longer than 8 weeks.

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21
Q

Third criteria to establish diagnosis of MRONJ

A

No history of radiation therapy to the jaws or metastatic disease to the jaws

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22
Q

MONJ can be caused by a _____ of bone resportion

A

Supression

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23
Q

MONJ can be caused by soft tissue ______

A

Toxicity

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24
Q

MONJ can be caused by ___-angiogenesis and subsequent _____ vascularity

A

Anti; decreased

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25
Q

MONJ can be caused by a local infection, with the presence of _______

A

Biofilm

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26
Q

MONJ can be caused by an exposure of the oral cavity to the _____ _____ through the teeth and PDL

A

Outside environment

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27
Q

High dose therapy for treatment of malignancy accounts for ___% of MRONJ cases

A

90%

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28
Q

The incidence of patients taking BP for osteoporosis is low, and 100 times lower with ____ patients

A

Cancer

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29
Q

What are the top two medical comorbidities leading to MRONJ

A

Chemotherapy and corticosteroids

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30
Q

What is the most common dental reason for MRONJ

A

Extractions

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31
Q

What are the two most offending meds leading to MRONJ

A

BPs and denosumab

32
Q

A longer duration (>___ years) increases risk for MRONJ

A

2 years

33
Q

Which route increases risk for MRONJ? IV or oral?

A

IV

34
Q

What type of surgery is a major risk factor for MRONJ

A

Dentoalveolar surgery

35
Q

Is the mandible or maxilla more at risk for MRONJ? Which parts specifically?

A

Mandible; mylohyoid ridge, lingual tori, palatal tori

36
Q

There is a ___ fold increase in risk for developing MRONJ in patients receiving IV therapy for cancer and have inflammatory dental disease

A

7

37
Q

What immune suppressing conditions increase risk for MRONJ?

A

Diabetes, autoimmune diseases, renal dialysis

38
Q

What type of chemotherapeutic agents increase risk for MRONJ?

A

Corticosteroids, cyclophosphamde

39
Q

What are two genetic factors that increase risk for MRONJ?

A
  • Single nucleotide polymorphism in the cytochrome P450-2C gene
  • MHC Class II polymorphism
40
Q

MRONJ: Worse with ____ vs osteoporosis

A

Cancer

41
Q

MRONJ: Worse with ___ meds vs. oral meds

A

IV

42
Q

Stage 0 MONJ

A
  • No clinical evidence of necrotic bone

- Nonspecific symptoms or clinical or radiographic findings present.

43
Q

Stage 1 of MRONJ

A
  • Exposed and necrotic bone present

- Asymptomatic with no evidence of infection

44
Q

Stage 2 of MRONJ

A

Exposed and necrotic bone present

Painful and clinical evidence of infection

45
Q

Stage 3 of MRONJ

A

Exposed and necrotic bone present.

46
Q

Non-exposed bisphosphonate-related osteonecrosis of the jaw

A
  • History of BP use
  • Lack of bone exposure
  • Deep periodontal pockets
  • Drainage with or without sinus tracts
  • Pain
  • Advanced bone loss around involved teeth
  • Radiographic involvement: osteolytic changes
47
Q

What can a pano show with MRONJ?

A

Can identify sequestra

48
Q

MRONJ: When is CT helpful?

A

Useful when MRONJ is suspected in the differential diagnosis; allows for 3D reconstruction

49
Q

MRONJ: The CBCT has ____ radiation than CT

A

Less

50
Q

MRONJ: MRI can detect what?

A

Histopathologic changes of necrotic bone

51
Q

MRONJ: What are some goals for management?

A

Elimination of pain
Control infection
Reduce progression of bone necrosis
Prevent of reinfection

52
Q

MRONJ: What procedure do we want to avoid if possible with active MRONJ?

A

Dental extractions

53
Q

MRONJ: Stage 0 Suggested Treatment Strategy

A
  • Patient education

- Systemic management, including the use of pain medication and antibotics

54
Q

MRONJ: Stage 1 Suggested Treatment Strategy

A
  • Antibacterial mouth rinses

- Clinical follow up on a quarterly basis

55
Q

MRONJ: Stage 2 Suggested Treatment Strategy

A
  • Patient education and review of indications for continued BP therapy
  • Symptomatic treatment with oral antibotics.
56
Q

MRONJ: Stage 3 Suggested Treatment Strategy

A
  • Pain Control
  • Debridement to relieve soft tissue irradiation and control the infection
  • Antibacterial mouth rinse
  • Antibiotic therapy and pain control
  • Surgical debridement or resection for long-term palliation of infection and pain
57
Q

Three ways to prevent MRONJ

A
  • OHI
  • Patient Education: MRONJ
  • Dental Exam and Treatment
58
Q

Prevention of quality of life with patients with MRONJ include

A
  • Patient education and reassurance
  • Control of pain
  • Control of secondary infection
  • Prevention of extension of lesion and development of new areas of necrosis
59
Q

For patients initiating or receiving therapy for osteoporosis or a nonmalignant bone disorder for >3 years (low-dose therapy)

A
  • Recommend non-surgical perio but modest bone recontouring may be done if needed
  • Prefer endo vs extraction
  • Dental implants are not contraindicated
60
Q

For patients initiating or receiving therapy for a malignancy (high-dose therapy)

A
  • Avoid elective surgical procedures
  • Consider nonsurgical endo or perio therapy for symptomatic teeth
  • Procedures that involve direct osseous injury should be avoided. non-restorable teeth may be treated by removal of crown and endodontic treatment of remaining roots
61
Q

Treatment recommendation for those receiving oral antiresportive meds: Elective treatment is _____ contraindicated; what should we inform the patient of?

A

Not; small risk

62
Q

There are ___ studies to show benefits of drug holidays in reducing MRONJ risk

A

No

63
Q

Half life of BP drugs exceeds how many years

A

10

64
Q

Treatment recommendation for those receiving oral antiresportive meds: What if I have to perform an extraction?

A
  • Informed consent
  • Atraumatic technique
  • Primary closure
  • use of semipermeable membrane
  • CHX twice daily one week prior and continue afterwards depending on healing
  • Consider administration of antibiotic beginning one day prior to ext extending until completion of 7-10 day course
65
Q

Oral or IV BP use is not an absolute contraindicating to placing _____

A

Implants

66
Q

Which biomarker stood out in assessing risk for developing MRONJ?

A

PTH

67
Q

What is the CTX test?

A

A potential diagnostic blood test that could be used to predict risk for MRONJ

68
Q

What is looked for in CTX test? Which marker?

A

C-terminal cross-linking telopeptide level in blood; the first marker

69
Q

What is correlated in the CTX test?

A

The c-terminal cross-linking telopeptide and the osteoclastic activity with clinical healing or response to surgical debridement

70
Q

How is the CTX test conducted

A

With the morning fasting blood test

71
Q

What value indicates a high risk for oral MRONJ with the CTX test?

A

100 pg/ml or less

72
Q

CTX Test Moderate risk value

A

100-150 pg/ml

73
Q

CTX testing minimal risk

A

Greater than 150 pg/ml

74
Q

FOr patients taking oral BP >3 years, get CTX:

If value is below 150, what should be done?

A

Drug holiday
After 4-6 months, repeat CTX
If still below 150 -> extend drug holiday

75
Q

Rate of osteoclast activity averages ____ pg/ml per month

A

25

76
Q

Level of CTX in blood recovers to value in excess of 150 pg/ml in how many months?

A

6 to 9 months

Oral Med BONES, GERIATRICS, MRONJ (10 decks)

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